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Boomer-61
10-02-2008, 20:20
Gentlemen,
I was in Sepecue, Costa Rica this past June and had three patients with cutaneous lesions which I had not seen the likes of before. One was on the face, old scar, one nodular lesion (1 x 1.5 cm) on a fore arm and one on the ventral ankle midline which was actively being treated by the local "clinic". The treatment process was multiple intra lesional injections. The cure rate was abysmal. We were providing care for an indigineous indian tribe called the BriBri in very rural Costa Rica. A Costa Rican (new graduate) MD described the lesions being caused by a mosquito, Papalomoyo, that lives in the deep jungle areas on the under surface of the leaves of certain plants. Upon my return to the states, I did some research on this site, the net and a book or two. I think the lesions were more consistant with leishmaniasis. The sand fly is indicated as the vector which seems more consistant with what I saw. The locals live mostly in stilt houses with their live stock below (chickens, pigs) and some mangy looking mutts. Seems like the perfect set up for a host vector environment. My Spanish is lousy at best, and the young Costa Rican Dr.'s English was just as bad so maybe I misunderstood what he was describing to me. I plan to return to an even more remote area in April 2009 and I would like to be able diagnose and treat this disease. So my question is, is this some evil mosquito or misdiagnosed Leishmaniasis? If it is Leishmans, is IM Pentamidine the treatment of choice or is there a PO option? I can treat the secondary infections were needed. Sorry, I did not take any pictures.

AF Doc
10-03-2008, 10:01
Boomer --

It would be helpful if you could describe the lesions a bit more. Raised? Red or discolored? Surrounding features? nodules hard? With or without ulcerations? oozing? pus? scabbing? Associated pain or itching? Any associated systemic symptoms such as fever, sweats, chills, itching, jaundice? Enlarged lymph nodes, liver, spleen?

Cutaneous lesions can be caused by a host of agents, so a mosquito bite isn't out of the question. Any idea why the locals think it could be a mosquito? Patient associates lesion with specific bite? What is the time course of these lesions, e.g. appear overnight or develop progressively over the course of days?

I realize that there were language limitations that may have made a full history difficult to obtain. Do you know what they were injecting into the lesions?

Are there any other indigineous ID Doc's with whom you could consult (they are likely to be more aware of the typical presentation and prevalence of Leishmaniasis in CR).

Good luck!

Boomer-61
10-03-2008, 12:32
AF,
Thank you. The facial lesion I saw was old, scarred and healed. It had an irregular border as if it had been an ulcerated area at one time. The nodule was about 1x1.5 cm raised about .5cm. It was hard but not fixed to deep tissue. This lesion was a bit atypical from the other two. The lesion on the ventral ankle was in a healing ulcerated state, still a bit moist at it's center like a healing scab, no secondary infection. No lyphs on any of these pt.s. I appologize but I do not know what the lesions were being injected with but I don't think it was truly effective. I think the lesions/process was just running it's course. None of them had any systemic complaints, no mucosal lesions, no abdominal pain or organomegally appreciated. The onset seemed to be about a week give or take. And this is very unclear to me. The pt.s denied having any lesions prior to these specific lesions/eruptions yet they all seemed to have various cuts, scratches etc from working in the plantations. In my opinion the locals think it is a mosquito more out of lore than anything. Ie, any bad skin lesion is blamed. What I understood the locals to say about the lesions is that they start with a bump that grows and then opens. They believe the mosquito lays eggs in the skin which hatch, grow and open the skin. Sounds "Alienoid". There is no mention of the infestation going systemic, only local. The lesions are painful, oozey or itchey depending on its stage. The Costa Rican Dr. that was with us for two days was convinced that all three lesions were from the mosquito. I did not have access to an ID man in country but when I got home I did speak with an ID guy from the CDC who told me all about Leishmans and that is what is sounded like to him. I have to agree. What is confusing to me is that the Costa Rican Dr. believes it was a mosquito. I gotta assume he knows what he is talking about. After all I've read, pictures I've seen, and folks I've spoken with I'd have to go with Leishmans. I started this thread to a. see if my suspicions are correct, b. provide information about this so the next time a team hears the term "papalomoyo" they'll know what they're dealing with.
Thanks again.
Boomer

Boomer-61
10-15-2008, 13:39
I found a study which ran from 2/2003-3/2003 conducted by International Health Central American Institute by, Jean Lee, Harvard Medical school. The study was conducted in the northern half of the country, Los Chiles, San Rafael and Puerto Viejo. The study was conducted to determine the incidence of Leishmans in this area of Costa Rica, to understand the various manners of disease presentation, diagnosis, and responses to treatment, and to understand patients' knowledge about the disease, their treatment preferences, and their sources of leishmans education. It looks like a reasonably done study. There is a section about patients knowledge of their disease. This part of the study revealed that 3 out of 6 had suspicions that their symptoms were consistant with "papalomoyo", the colloquial term for Leishmaniasis. Most of the patients interviewed believed that the disease came from a mosquito. None were familiar with the sand fly. For those of you who are interested in this presentation the link is: www.ihcai.org.

csquare
10-15-2008, 15:20
Boomer,
I would send an email to NMCI (formerly known as Armed Force Medical Intelligence Center AFMIC) and send them your questions. They may already written a report on the subject. If not, you can give them all the data and one of the analysis can run down your RIF and give you an answer.

Boomer-61
10-16-2008, 12:01
CSquare,
Will do. Great reference. Thanks.
Boomer

Boomer-61
04-23-2009, 12:07
I'm back from Las Penitas, Costa Rica, in the S.W. tip on the country, where I met a Costa Rican Dr. there (from San Jose) who cleared some things up for me. Papalomoyo and cutaneous Leishmans are the same entity. The lesions of that region typically go untreated and heal spontaneously, usually with some scaring due to secondary infection. There does not appear to be a standard treatment protocol. I did not see any lesions on this trip as I did last year. The locals in this region seemed a bit more savvy on field hygeine and the like. I know this is an obscure topic but I thought it may be of interest.