- Algeria. A patient has a skin ulcer that has already been present for 4 months. You find amastigotes in the scrapings from the edge of the wound. His wife’s grandmother has advised him to eat more vegetables and fruits. Two months later the lesion has indeed healed. What do you think?
- A 29-year-old Dutch veterinary practitioner has lived in northern Kenya for 2 years and has had persistent malaise and general weakness for several months. You observe a pale man with a large spleen (6 cm below the left edge of the rib cage). He does not drink any alcoholic beverages. Before his arrival he was successfully vaccinated against hepatitis B (how can this be checked ?). The edge of the liver is scarcely palpable and is smooth. What do you think and do ?
- A woman in a valley village in Ethiopia has several nodules on her face. There is a painless, persistent wound on her right hand, possibly because she has repeatedly burned herself. What do you do ?
- Algeria. In a village the headman of the village dies of visceral leishmaniasis. The traditional healer is called in and after some ritual he says that all stray dogs and all sick domestic dogs must be killed. What do you think? What would be your opinion if this happened in India? Would all goats also have to be slaughtered?
- In Mexico a 25-year-old "chiclero" has developed an ulcer on the left ear. It began small but became progressively larger and has now already destroyed half the earflap. You do not see any amastigotes in a smear. What now?
- In Oman (Middle East) you see a local man with necrosis of the nose and palate. Could this be espundia? Justify your answer.
- India, Calcutta. 6 months ago a 30-year-old man left the village where he was born, went to the city and has ended up in the slums. He was picked up by the mission sisters. You see a very emaciated, pale person with fever, enlarged spleen and liver, nosebleed and heavy cough, sometimes with bloody sputum. The small laboratory at the dispensary finds a haemoglobin of 4 g/dl, 14,000 blood platelets/mm3 and a white blood cell count of 2000/mm3. The bone marrow contains amastigotes. What do you think and do?
- A bridge-builder in Uganda develops a very painful, evil-smelling, progressive, deep ulcer in the calf of the right leg. He does not remember being injured at all. There are no undermined edges and no acid-fast bacilli are present. What now ?
- Two years ago a farmer from Amazonia moved to Sao Paulo, Brazil and has had no contact with rural areas since then. He gets a chronic wound on his upper lip. Could this be leishmaniasis ?
- Draw an amastigote and a white blood cell beside each other (correct proportions / size ratio!).
- A female patient comes to the clinic with numerous chronic skin lesions on her left arm, distributed according to the lymph drainage pattern ("sporotrichoid lesions"). Which organisms would be included in the differential diagnosis: Leishmania major, Leishmania braziliensis, Sporothrix schenckii, Cryptococcus neoformans, Histoplasma capsulatum, Blastomyces dermatitidis, Nocardia sp., atypical mycobacteria, Streptococcus pyogenes, Staphylococcus aureus, Francisella tularensis, Pseudomonas pseudomallei? Is the geographical location of any significance ?
