Disseminated cutaneous leishmaniasis: a patient with 749 lesions.

A 46 year-old man, agriculturist, presented with an eight-month history of skin lesions all over his body. Patient did not refer systemic symptoms; however he was a heavy alcoholic drinker until three months after the beginning of disease, when he stopped drinking. Physical exam was inconspicuous except for multiples skin lesions (papular, crusted or ulcerated) on face, trunk (Panels A and B), scalp, arms, legs, genitalia and nasal mucosa. Complete blood count, liver and renal tests, glucose as well as chest x-ray were normal. Tuberculin (PPD) test was 5mm, Montenegro test (leishmanin) was non reactive, VDRL and anti-HIV test were negative. Three 2mm punch skin biopsies were done: for imprint, leishmania culture (NNN) and histopathology. Imprint showed amastigotes in many fields (100X) (Panels C, D and E Arrows). Culture grew Leishmania. Histopathology showed moderate infiltrate of vacuolated macrophages with few lymphocytes, no granulomas were seen. Amastigotes were present in some macrophages. Patient was treated with intravenous pentavalent antimony (Glucantime®) 850mg per day for 30 days and all lesions healed. Leishmanin skin test at end of treatment was 8mm. Disseminated Cutaneous Leishmaniasis is seen in a small percentage of patients with cutaneous leishmaniasis in all endemic areas of Ceará State, northeastern Brazil. This patient was from one of these areas. Even though the Leishmania species was not characterized, the parasite in this case was probably Leishmania (Viannia) braziliensis, because this is the only species identified so far causing cutaneous leishmaniasis in Ceará.