Delay in diagnosis: trauma- and coinfection-related cutaneous leishmaniasis because of Leishmania guyanensis infection.

Trauma can trigger the onset of some lesions of cutaneous leishmaniasis (CL). In this study, we present the case of a 65-year-old man who developed persistent, ulcerative, nodular lymphangiitis at the site of elbow abrasions from a fall during a trip to northeastern Brazil. Skin and lymph node biopsy showed tuberculoid granulomatous inflammation and Grocott-methamine silver-positive yeast forms consistent with Sporothrix and Staphylococcus lugdunensis was identified from tissue culture. Antibacterial and antifungal treatment produced short-term healing. Crusted papules recurred at the sites of injury 3 months later and persisted despite therapy. After 15 months, two punch biopsies showed scarring and granulomatous inflammation; cultures and histochemical stains were negative for microorganisms. Because of refractory disease, multiple polymerase chain reaction (PCR) assays for infectious agents on DNA extracted from the biopsy specimens were performed, and Leishmania guyanensis was detected in all specimens. The patient refused pentavalent antimonial therapy and elected for excision of the CL lesions. After 2 years of follow up, he is without disease. CL should be considered in the differential diagnosis in patients who present with ulcerative, nodular lymphangiitis; have a history of travel to endemic regions; and describe a traumatic insult to the affected region. PCR methods for infectious agents increase the sensitivity and specificity of detecting causative agents in these patients who are negative by routine methods. In some, leishmaniasis may be an occult infection whose presence is heralded by trauma. Coinfection, by altering the immune response, may have facilitated the clinical acquisition of CL.