2 
the “chiclero ulcer/' so named after the gum pickers of Central America. Most 
skin lesions are found on the limbs, the face, and auricles. Characteristic scars often 
result (Fig. 2). In the majority of the cases only the cutaneous lesions develop. 
Mucosal lesions of the nose, mouth, and even pharynx, larynx, and trachea (rarely 
of the eye and genitals) develop only in a minority, but in some endemic regions, 
like Paraguay and Sao Paulo, the percentage may be high among forest and planta¬ 
tion workers, who are exposed to the bite of the sandflies (Strong 5 ). There are 
no differences in age, race, or sex among equally exposed people. Most mucosal 
lesions appear from 6 months to 15 years after those of the skin. In about 10% 
of the cases the cutaneous lesions appear simultaneously with lesions of the mucosa 
(Pessoa 0 ). In only 5 of 1,791 cases which Villela 7 reported from Brazil did the 
patients declare that the intranasal lesions developed first. The dissemination from 
Fig. 1 (Case 8).—“Chiclero ulcer” of the auricle, healed. 
Fig. 2 (Case 3). Scar over the right eye. Sequela of cutaneous leishmaniasis. 
the skin to the mucosa probably occurs through lymphogenic and/or hematogenic 
extension. Autoinoculation by the scratching finger has also to be considered. 
According to Pessoa, 6 cutaneous lesions occur in regions up to 2,800 meters above 
sea level and mucocutaneous lesions in the low regions in the forests. The initial 
lesion in the nose consists in hyperemia and, later, ulceration. The ulcers may spread 
and lead to extensive destruction. The external appearance of the nose may remain 
normal for a relatively long period, although internally a great deal of destruction 
may take place. Further progress may reduce the external nose to the apertura 
piriformis. Mattos Barretto f gives the following classification of the nasal lesions: 
1. Ulcerous-destructive form 
2. Atrophic form 
3. Infiltrative form 
4. Polypous form 
t Cited by Pupo. 11 
3 
The ulcerous-destructive form is, of course, the most dangerous one. The 
atrophic form is characterized by dry mucosa and the formation of crusts. It may 
develop in the course of time or as a result of treatment. The infiltrative form may 
reach the middle turbinate but seldom surpasses it. The polypous form is charac¬ 
terized by tumor-like formations originating from the anterior part of the septum; 
it is usually unilateral. The polyps may be pedunculated, diffuse, or sessile (Fig. 3). 
HISTOLOGICAL FINDINGS 
Klotz and Lindenberg 8 reported from Brazil on histological examinations of 
15 cases of leishmaniasis of the nasal mucosa. In their experience, the most striking 
features were (1) the primary perivascular lymphocytic infiltration of the submu- 
Fig. 3 (Case 8).—Polypous form of nasal leishmaniasis. 
cosa; (2) the gradual dominance in numbers of the plasma cells and the endothelial 
cells; (3) the development of endothelial nodules, which become aggregated about 
the vascular channels; (4) the appearance of three types of nodules: (a) endothelial, 
( b ) necrosing, and ( c ) fibrous; (5) the presence of marked endarteritis, with occlu¬ 
sion of many vessels, and (6) the presence of the parasite within the endothelial 
cells in all stages of the disease. However, they were not able to find Leishmania 
organisms if the material had been fixed in formalin. For the demonstration of the 
parasite they recommend fixation in Zenker's solution or in mercury bichloride and 
alcohol. According to Pessoa and Barretto, 9 the parasites are numerous in the early 
stages of mucosal lesions but become increasingly difficult to find as the lesions 
become old and secondarily contaminated. The authors state that the parasite is 
nearly always intracellular but that it may lie extracellularly between cells which 
have been separated by edema resulting from subjacent inflammation. The type 
