Josh writes:
Thank you for this very interesting case!
I suspect this is a case of localized cutaneous leishmaniasis.
Thank you,
Josh Gray
PGY-3, Department of Medicine
Duke University Medical Center
Steve writes:
botfly
Jason writes:
Greetings TWiP hosts!
I am writing from within the confines of the Amazon Spheres botanical building in Seattle, in which it is a humid 22 degrees C. Outside the massive geodesic structure it is 12 degrees C and unusually dry for this time of the year.
In episode 249’s Case of the Facial Ulcer in a Returning Traveler, the patient appears to present with cutaneous leishmaniasis.
A parasite-focused differential diagnosis in a patient presenting with a cutaneous lesion and history of exposure to the flora and fauna of Belize includes cutaneous leishmaniasis, tungiasis, cutaneous larva migrans, onchocerciasis, myiasis caused by the New World screwworm fly, myiasis caused by the human botfly, and arthropod bites such as fleas and ticks.
In the current case, the geographic exposure coupled with a persistent painless skin ulcer is highly suggestive of cutaneous leishmaniasis.
This disease is caused by infection with one of the many species of Leishmania protozoa. In the New World, these flagellated parasites are spread via the bite of Lutzomyia species sandflies, which are prevalent throughout central and South America.
Diagnosis of cutaneous leishmaniasis is best done via PCR; if PCR technology is unavailable, then a diagnosis can be made via microscopy of a skin scraping. In the case of the latter technique, the border of the ulcer is sampled via needle aspiration, a Brock curette, or a biopsy punch. The sample is then applied to a slide and stained with both May-Grunwald and Giemsa stains to achieve a panoptic effect. Presence of Leishmania amastigotes confirms the diagnosis of leishmaniasis.
Treatment for cutaneous leishmaniasis includes pharmaceutical options such as sodium stibogluconate or pentamidine.
Worm regards,
Jason
(returning champion)
Courtney writes:
Hi all,
First, I want to thank you for all you do and for providing such interesting discussions! This is my first ever guess, and apologies if I am way off base — I am an accountant by trade. I came to Microbe TV and TWIP by chance because I didn’t feel very good at all for about a year and no medical practitioner I saw was able to quite pin it down. So, without answers, I, of course, went to the internet… and here we are. (I am feeling better now, thanks).
Anyway, enough about me. In TWIP 249, I am going to guess cutaneous leishmaniasis caused by leishmania. My research lead me to this conclusion based on the description of the painless facial lesion, and this parasite being endemic to South America and Belize where the subject traveled.
Thanks again, and see you all next TWIP,
Courtney
Elhadi writes:
The description on the patients face sounds like an insect bite. The fact that it developed from a papule and eventually into an ulcer makes me think of a potential infectious cause but cutaneous leishmaniasis comes to the forefront.
I hope to hear the answer soon, and thanks for this interesting case.
Elhadi
Margaret writes:
CL Cutaneous Leishmaniasis
Crypto grandma writes:
Cutaneous leishmaniasis
Sherry writes:
Hi Vincent and Daniel,
My guess for this case #249 re lesion on the face after visiting Belize is:
Leishmania mexicana
Let me know if I am correct, please.
Thanks.
Go Big Red!
Sherry
Ben writes:
Hello all,
Cutaneous leishmaniasis.
Miltefosine. Local therapy, either putting liquid nitrogen on it or microwaving it.
Also go kill the sandflies to protect the next person.
-Ben in New Haven (returning champion)
https://www.cdc.gov/leishmaniasis/hcp/clinical-care/index.html
Not directly related:
If you are handling liquid nitrogen get gloves with grip. Tempshield calls theirs Cryo-Grip. Too many labs have the standard slippery gloves several sizes larger than the largest lab member’s hands. I realize this is a niche topic to have strong feelings about. However if you try to screw shut a (perforated) cryo vial cap with standard gloves on, you may develop a similar view. Feel free to omit this part from the audio.
Leo writes:
Greetings Distinguished Professors,
I am going to go out on a limb here with our intrepid Belize traveler. Although I do not have any medical training, I have played a doctor on TV. Based on my nonexistent training and underwhelming reviews as a television doctor, my guess is that our subject has contracted Echinococcus granuloses, also known as cystic echinococcosis.
I would treat our patient with Albendazole, 400 mg orally BID for at least four weeks. In addition to the Albendazole, I might throw some Praziquantel at it “Just Because” and just in case surgery may be required.
A treatment of “Do Nothing” and “Wait And See” are another valid treatment options. The chemotherapeutic treatment could be administered later depending on how the patient responds.
My diagnosis is a little out of the box, but they don’t call me “Longshot Leo” for nothing.
Very Truly Yours,
Leo
Mendocino, California
Christian writes:
Dear TWIP Team,
Greetings from Austria. Where temperatures have now reached below zero.
Just saw the short, a very nice format for a case.
My guess would be cutaneous leishmaniasis after a bite from a new world sandfly.
As new world leishmania can cause mucocutaneous spread, additional investigations by a ENT doctor would be recommended.
Diagnosis should be done with PCR as the treatment is species specific and the area is endemic to at least 2 different species.
Because the lesion is in the face a lesion aspirate would be prefered to a punch biopsy.
Treatment is then depending on the species, but most likely will be systemic as local infiltration in the face is not nice, and the species in the area have a certain risk of systemic spread.
Treatment options would be pentavalent antimonials, liposmal amphothericin B or Miltefosin.
Merry Christmas and a Happy New Year to the Team,
Christian
Stacy writes:
Hi all,
This is about the new case study in TWiP 249: Woman returns from Belize and discovers a facial lesion.
I’m not a medical person, so I first did a Google search to get my bearings. I searched for parasitic diseases that cause facial ulcers and are endemic to Belize. Google A.I. brought up Cutaneous Leishmaniasis. I then typed the question of why a facial ulcer caused by Leishmaniasis would not heal on its own. The A.I. Response was that a slow immune system response along with persistence of the parasite in skin immune cells made it difficult to eradicate.
Having just listened to TWiP 249, I then looked at my downloaded copy of Parasitic Diseases, Volume 7, and gasped at the photos of lesions. If Leishmaniasis is the cause, the woman returning from Belize would have picked up her infection from the bite of a sandfly. Given that no immune compromising co-infection, medication or autoimmune disease was mentioned, and given that no further lesions developed, I am assuming that the infection had not spread to the mucosa.
A test to determine the exact species of Leishmaniasis would be necessary before determining a course of therapy, and Parasitic Diseases recommends NAAT techniques. In a case study of a boy from Belize with two lesions (published by the Journal of Pediatrics), biopsies looking for amastigotes and PCR determined the infection to be Leishmaniasis mexicana.
The current therapies offered for a Leishmaniasis infection can have severe side effects and I’m no doctor, so I’m not going to attempt to choose one for this patient. The boy with Leishmaniasis mexicana improved after three months of careful wound care, and I am hoping the same turned out to be true for the traveler to Belize. I am looking forward to what therapies were chosen, and what you-all consider to be the best.
My guess for this case study is: Leishmaniasis mexicana.
Since I already downloaded the book, please don’t include me when you draw a number.
I rarely try to solve cases, but I always listen and enjoy your discussions. This and TWiV remain my all-time favorite podcasts. Thank you!
Stacy
https://www.jpeds.com/article/S0022-3476(18)31231-9/pdf
Steve writes:
Hi Parasitastic Purveyors of Pertinent Podcast knowledge,
It has been quite a while since I submitted an answer, mostly because I’m usually occupied while listening to TWIP and forget to go back later to submit one.
My first thought for the 30s-40s female with a 6 month facial lesion after travel to Belize was cutaneous leishmaniasis, due to the persistence of the lesion without spread to other areas or tissues.
Just for fun, I fed a copy of PD6 (for some reason I didn’t see my 7th edition pdf on my phone and was lazy) into chat gpt as well as the patient history to see what it would give me.
While it did give a parasitic differential, none of the other suggestions matched, since all of these suggestions involved the spread of the parasites to other tissues or to other skin regions on the body.
Tinea rashes likely would have resolved with topical ointment, as would most other common causes of dermatitis, while chronic skin diseases would be unlikely to stay isolated to one area and would either spread, or resolve and recurr in other areas.
As she was in an endemic region, spent a great deal of time outdoors, and was bit by insects, CL seems the most likely diagnosis. Treatment would most likely be liposomal amphotericin B, or miltefosine. I’m not a clinician, but I would imagine miltefosine would be the first line treatment, since it is available as an oral drug rather than requiring IV infusion. From what I read, both have some nephrotoxicity, but I was unable to determine which had a higher incidence.
I have not yet received any physical copies of parasitic diseases and would love to have a pd7 copy if I win the drawing.
Thank you from this long time lurker,
Steve in the Eastern Sierra
John writes:
Still hoping to win the book
After hearing this case presentation I was excited because I felt like I could recall cutaneous leishmaniasis from memory and even hear a bit of Dickson’s dialogue in my head from the videos and course. I had to drive my parents a distance over the holiday so I even told them what I knew and how I knew, plus that the sandfly rang a bell as the vector. I was pleased to confirm that in the textbook later.
CL mexicana is endemic to Belize and drawing from the textbook, NAAT would be the testing which I think we would call PCR now. Treatment was less clear so I will look forward to find out what was actually done. CL can clear without treatment and good hygiene for some, other methods are cryotherapy, thermotherapy and topical paromomycin however there is a note that side effects can accompany the types of drugs that apply to CL.
Humans are a dead end host and it appears for most that immunity is attained after initial infection so she should be able to go back and enjoy her next trip after this hopefully clears up.
Happy New Year everyone!
—
John
Rich writes:
As a retired MD from UMass Health Service in Amherst, I am now a vaccinator for the town and found the twiv utube very informative. Out of curiosity , I watched this episode of twip
Over the years I saw patients that traveled Internationally, that had single skin lesions. They often had bacterial infections, but occasionally unusual lesions such as bot flies larva, and cutaneous leishmaniasis. Since this a parasitology video and lesion is long duration, I will go with leishmaniasis as a cause of this woman’s lesion.
Happy New Year
Rich
Good health is true wealth
Ed writes:
New Case: “Fly” bite?
Cutaneous Leishmaniasis seems best bet. Bx diagnostic. Treatment varied but i’ve had good response with heat alone.
Re: 249
BTW …other very significant “pockets” of HTLV1 are present in the Windward Islands with 1-3% of the population infected. Therefore this must exist in Brooklyn with the great number of West Indians in that area near Downstate (Also London and Toronto). Saw many cases of Hyperinfection Syndrome in the Grenadines. Devastating disease.
Thanks for the great educational site and fun!
Ed
Justin writes:
Hello dear hosts,
For the patient with a painless lesion on her face after returning from Belize, my guess is cutaneous leishmaniasis. This is due to Leishmania being endemic in Belize and the very typical symptoms.
As for treatment, since this case seems to be cutaneous and not visceral, amphotericin B would not likely be used due to the side effects. Miltefosine may have been used, but warning should be given to the patient since it can cause birth defects if the patient becomes pregnant within three months. Knowing what species of Leishmania is present would be helpful since Miltefosine may not cure L. major or L. braziliensis infections. Perhaps this was determined via a PCR test.
Thanks as always for a wonderful podcast,
Justin
Eyal writes:
Dear Vincent and the sages of the microscopic eukaryotes.
Happy new year from Sydney Australia where the Cicadas never stop serenading.
Non-healing ulcer after visiting Belize? My immediate intuition would be Leishmaniasis.
After a quick google search I would even refine my guess to L.braziliensis.
Considering that L.braziliensis is somewhat resistant to treatment I would assume Daniel would want her on the new generation of treatments such as Amphotericin B.
Hope the treatment is successful and the lady makes a full recovery.
Wish you all a year of peace, happiness, love, joy, good friends, and healthy family.
Eyal
Kimona writes:
Happy 2025 to all of you at TWiP!
I think this woman was subjected to a sandfly bite (of Lutzomyia spp.) while in Belize and developed a cutaneous leishmaniasis (CL) infection, endemic to the region.
Giemsa stain of a skin biopsy from the edge of the ulcer may reveal intracellular amastigotes.
PCR also has great specificity and would allow species ID and tailoring of treatment options.
L. mexicana appears to be a common cause of cutaneous disease in Belize whereas L. braziliensis also has propensity to cause muco-cutaneous disease. Perhaps the friends at Columbia helped with the PCR and species ID?
Treatment is determined by location and extent of lesions, species ID, but also drug availability and cost. Not sure how long she has been trying various topical creams, but I suspect it is not resolving on its own. Since this is a facial lesion on a young woman, a more aggressive systemic choice (like lipo-amphotericin B or miltefosine) may be in order.
Warmest New Years wishes,
Kimona
Dr. Paul writes:
Hi all,
My diagnosis for the facial ulcer in the visitor to Belize: Cutaneous Leishmaniasis
Thanks to all of you for your continued work! I have a copy of Parasitic Diseases so take me out of the draw.
Dr. Paul