1. Case presentation I2 蔡哲楷

2. Case A previously healthy 19-year-old woman, who had spent several months of the previous year as a student in Brazil, presented at an emergency department complaining of stuffy nose and painful ulcers on her lips and mouth, as well as on her nasal mucosa. When she returned from Brazil the previous year, she had noted multiple skin lesions on her arm, which had since disappeared. Lymphadenopathy was noted on physical examination. A biopsy specimen was taken from the edge of an ulcer.

3. Biopsy A section stained with hematoxylin and eosin showed macrophages containing small, oval parasites, measuring 2 to 3 um

4. QUESTION(1) Which infection does this patient have? What is the name of the hemoflagellate causing her infection? Ans: (1)Mucocutaneous Leishmania (2) Leishmania braziliensis

5. QUESTION(2) Name the four main species belonging to this complex Ans:L. (V.) braziliensis (Espundia) L. (V.) guyanensis (Painbois 痛癤 ) L. (V.) panamensis L. (V.) peruviana (Uta)

6. QUESTION(3) Which vector is responsible for the transmission of this infection? Ans:Lutzomyia sandfly

7. QUESTION(4) How does the life cycle of this parasite differ from that of other species?

8. QUESTION(4)

9. QUESTION(5) How is the diagnosis of this infection made? Ans: (1)Hx:travel Hx,contact Hx (2)P.E.:Cutaneous lesions Mucosal lesions

10. QUESTION(5) (3)Biopsy with microscopy (4)Culture(often scant)

11. QUESTION(6) Do you think there is a connection between the patient ’ s previous skin lesions on her arm and the mucosal lesions she now has? What course does this infection take if untreated?

12. QUESTION(6) Ans: (1)Mucocutaneous leishmaniasis can be the primary manifestation of the disease, but the primary lesions may also be limited to cutaneous manifestations, with mucosal lesions appearing only later in the course of disease when untreated cutaneous lesions progress to involve the oral and nasal surfaces. Initial symptoms related to mucosal lesions may include nasal obstruction and bleeding.

13. QUESTION(6) (Without treatment, the entire nasal mucosa and palates become deformed with ulceration and erosion of the nasal septum, lips, and palate.

14. QUESTION(7) Where is this hemoflagellate usually found? Where is the risk of exposure to infection greatest? Ans: Brazil, Peru, Ecuador, Bolivia, Venezuela, Paraguay, and Columbia

15. QUESTION(8). How is this infection treated? Antimony sodium gluconate IV, IM 10 mg kg qd (max:600mg qd) for 6~10 days Pentavalent antimony b b IV20 mg Sb V /kg qd for 28 days Amphotericin B (deoxycholate) IV0.25~1 mg/kg qod or qd Alternative Pentamidine isethionate IV, IM 2 – 4 mg/kg qod or thrice weekly for ≥15 doses

16. Thank you ……… ^_^