RESIDENT CASE PRESENTATION:
ARNOLD W. GUREVITCH AWARD RECIPIENT

Caught at the Border: Five Prisoners and the Dermatologic Surprises Found Beneath their Uniforms

Over a three day period, I was called to see five different prisoners in the emergency room and/or inpatient wards of UCSD Medical Center, all with similar and unusual dermatologic findings. The five patients were Somalian men in their mid-twenties, otherwise healthy who had been arrested together as they tried to cross the U.S./Mexico border illegally. During their medical evaluations in prison, each was noted to have a large, ulcerative mass. Locations for the masses included the hand, leg, foot and earlobe. The patients reported having visited numerous different countries, including Russia, Columbia and several other South American nations, prior to registering with a smuggler for transport into the United States through Mexico. Each man denied a history of trauma to his affected area, but one thought he may have been bitten by a sandfly while traveling through the jungles of the Amazon. The ulcerative masses were minimally painful to touch and none of the men were febrile or showed any systemic signs or symptoms. On histopatholic examination, findings were consistent with cutaneous leishmaniasis. Systemic work-up including blood cultures and CXR were negative for all five men. Cultures later grew New World leishmaniasis. The CDC reported that these were “among the most florid cases they had ever seen in terms of disease burden.” All five men were started on IV amphotericin and transported to and from prison on a regular basis for infusions upon discharge. Two men were deported relatively early into treatment and lost to follow-up, two continued to return for infusions and improved, and one man developed a new lesion elsewhere, despite treatment, and was recently re-admitted to the hospital for further treatment. Interestingly, we also received word from the CDC that a similar strain was cultured in recent months in a man of African descent captured in Oregon. This man also reported using a smuggling operation to travel across the border. The Department of Homeland Security has now become involved in investigating this case. I hope to contribute this case to the PDA resident forum as an interesting manifestation of New World leishmaniasis in five travel companions.

REFERENCES
1. Lawn SD, Whetham J, Chiodini PL et al. New world mucous and cutaneous leishmaniasis: an emerging health problem among British travelers. QJM 2004; 97: 781-88.
2. Schwartz E, Hatz C, Blum J. New World cutaneous leishmaniasis in travelers. Lancet Infect Dis 2006; 6:342-9.