Delayed skin healing of cutaneous leishmaniasis after clinical cure of mucosal surfaces.

In our endemic area of Leishmania (Viannia) braziliensis (L(V)b) transmission4 we ocasionally see disseminated disease without anergy1. Sometimes this is associated with mucosal involvement3. Here we report the observation of mucosal recovery with residual skin lesions activity in two such patients. Skin biopsy histology showed the parasite in both cases. Patient LTCP 10061, a 42 year old male presented with a band of cutaneous lesions across his central face involving both ears, cheeks and external nares. Mucosal involvement was thought to be by contiguous spread. He failed to respond to 30 days 20 mg Sbv/kg/day glucantime® but the majority of his lesions resolved with l6mg/kg/day aminosidine for 20 days. Nostril granuloma were healed 3 months later but a skin lesion on the left external ear was still active. Patient LTCP 8896, a 55 year old male presented with 48 active skin ulcers. The mucosal lesion involved the upper lip with bilateral nasal involvement without septal perfuration. He was treated five times with 30 days glucantime® in the dose above stated with partial resolution of lesion activity. Subsequently he was given aminosidine in the dose stated. Three months later his mucosal surfaces were normal and only one skin ulcer persisted on the underside of the scrotum involving the midline. The unusual distribution of lesions in the first patient suggest he had his face to the g rou nd w h en he w as d runk in a rich transm ission site o f L(V)b by Lutzomya whitmani. This species is not a high flyer. Ear lesions prove difficult to heal in Leishmania mexicana and Leishmania braziliensis infections in Central America2 probably because of the poverty of the cellular immune response at such a cartilaginous site. However such an explanation will not serve to explain the second patient since the scrotum is rich in lymphatic supply. Perhaps friction was responsible in this case for the persistent scrotal ulceration. In this patient blood stream dissemination is the likely explanation of such widespread disease.