A 25-year-old traveler returning from Bolivia presents with a painless, non-healing ulcer on his left forearm. The lesion started as a red papule that enlarged over two months into a well-defined ulcer with a raised erythematous border and a central depressed area. He denies systemic symptoms like fever, weight loss, or night sweats. There is no history of animal bites or trauma. Differential Diagnosis . Cutaneous Leishmaniasis . Bacterial/fungal skin infection (e.g., Mycobacterium ulcerans, sporotrichosis) . Skin malignancy . Autoimmune ulcers Diagnosis Skin lesion biopsy → Amastigotes seen inside macrophages (Leishman-Donovan bodies). PCR or culture (Novy-MacNeal-Nicolle medium) for species identification. Management . Mild/localized lesions Topical therapy (e.g., paromomycin, cryotherapy with liquid nitrogen). Intralesional sodium stibogluconate (pentavalent antimony). . Extensive/multiple lesions or mucosal involvement Systemic therapy: Liposomal amphotericin B (1st-line in severe cases). Pentavalent antimonials (sodium stibogluconate or meglumine antimoniate). Oral miltefosine (effective for many Leishmania species). . Prevention Vector control (sandfly repellents, insecticide-treated nets). Protective clothing in endemic areas.
