A 52-year-old male farm worker from Ceará state, northeast Brazil, presented with a 4-month history of skin lesions. Lesions appeared first on the face and legs, than spread across much of his body, including the genitalia, soles of feet, and scalp. He reported daily fevers for the first 2 weeks of illness. On examination the patient had 178 lesions of different sizes and aspects1–3; ulcerated, crusted (Figure 1A and B), papular, nodular, and pustular. Many had apparent bacterial superinfections (Figure 1C). The remainder of the physical examination was normal. A complete blood count and liver and kidney function tests were within normal limits. Serological tests for syphilis and human immunodeficiency virus were negative. A skin biopsy imprint revealed amastigotes. Skin culture in Novy-MacNeal-Nicolle medium grew promastigotes characterized as Leishmania (Viannia) braziliensis by isoenzymes. The leishmanin skin test was positive. Bacterial superinfection of the ulcers was treated with cephalexin. Because of a contraindication to treatment with pentavalent antimony (individual > 50 years of age), and lack of medical infrastructure where he lived for providing amphotericin B, the patient was treated with oral fluconazole, 9 mg/kg per day.4 Over the following 6-month period of treatment, the lesions healed completely, many leaving no scars (Figure 1D). Disseminated cutaneous leishmaniasis is an uncommon presentation of Leishmania (V.) braziliensis infection. Most of the lesions are thought to be due to bloodstream dissemination, not to multiple sand fly bites. The reason that some people develop disseminated cutaneous leishmaniasis is not fully understood.3
Costa JM, Marsden PD, Llanos-Cuentas EA, Netto EM, Carvalho EM, Barral A, Rosa AC, Cuba CC, Magalhães AV, Barreto AC, 1986. Disseminated cutaneous leishmaniasis in a field clinic in Bahia, Brazil: a report of eight cases. J Trop Med Hyg 89: 319–323.
Turetz ML, Machado PR, Ko AI, Alves F, Bittencourt A, Almeida RP, Mobashery N, Johnson WD Jr, Carvalho EM, 2002. Disseminated leishmaniasis: a new and emerging form of leishmaniasis observed in northeastern Brazil. J Infect Dis 186: 1829–1834.
Machado PR, Rosa ME, Costa D, Mignac M, Silva JS, Schriefer A, Teixeira MM, Bacellar O, Carvalho EM, 2011. Reappraisal of the immunopathogenesis of disseminated leishmaniasis: in situ and systemic immune response. Trans R Soc Trop Med Hyg 105: 438–444.
Sousa AQ, Frutuoso MS, Moraes EA, Pearson RD, Pompeu MML, 2011. High-dose oral fluconazole therapy effective for cutaneous leishmaniasis due to Leishmania (Vianna) braziliensis. Clin Infect Dis 53: 693–695.