Eustachian tube blockage with consequent middle ear infection in mucosal leishmaniasis.

Mucosal leishmaniasis is the most difficult type to diagnose and treat successfully in the New World1. Usually caused by Leishmania (viannia) braziliensis this parasite metastasises to the cartilaginous nasal septum and is limited to this site in two thirds of our patients. Multiple mucosal surface involvement occurs in the remainder. Here we report for the first time Eustachian tube blockage with middle ear infection in such a patient. The patient J.S.S. (LTB-300) had cutaneous leishmaniasis at the age of seven and a year later developed epistaxis and nasal blockage, signs of mucosal disease. He was briefly reported at the age of 152 when he had septal perforation and partial nasal collapse and extensive granuloma of the mouth throat and laryny; severe multiple lesions for a boy of his age. L. v. braziliensis was isolated and characterised. We reported him as an example of cure with prolonged antimonial therapy (20mg Sbv/ kilo per day continously for 62 days) but he subsequently relapsed. He has continued to have incurable persistent mucosal granuloma for fifteen years. These improve on treatment only to relapse. He has a strong cellular immune response. He forms part of a small group of such patients we will report in the near future. Recent evaluation before two maximal pentamidine courses using fibro optical instrumentation showed anterior nasal septal perforation, granuloma on both soft and hard palates, and epiglottial granuloma. The larynx while fibrosed appeared quiescent but his voice is still hoarse. Nasopharyngeal visualisation showed a blocked left pharyngeal opening of the Eustachian tube by granuloma. Inspite of treatment he has subsequently developed bilateral otitis media. Although the audiograms show little impairment tympanometry showed Eustachian tube dysfunction on both sides. We report this finding to show the importance of careful ear examination when evaluating the effects of nasopharyngeal granulomata in mucosal leishmaniasis.