An ulcer that will not heal

A 26 year old British man presented with a seven week history of an ulcer over his left elbow that was slowly increasing in size (fig 1). It had not improved with a course of oral flucloxacillin prescribed by his general practitioner. The man was otherwise systemically well with no fever, night sweats, or weight loss, and he had no skin lesions elsewhere. He did not recall any bites or trauma to the area.

His medical history included an overactive bladder and removal of a bot fly from his scalp. He had acquired the fly during a five week trip to the Peruvian Amazon three months before his attendance.

On examination, he had a 2×3 cm ulcer over his left elbow with indurated edges and associated lymphangitis ascending to the axilla. No other clinical signs were evident.

Full blood count, liver function tests, urea and electrolytes, and C reactive protein were within the normal ranges.

Punch biopsy of the ulcer showed “florid acute and chronic inflammation including foci of granulomatous inflammation” as well amastigotes of leishmaniasis, which were found to be of the L viannia complex on polymerase chain reaction testing. A diagnosis of new world cutaneous leishmaniasis …