4 
of cell most commonly infected is the histiocyte, but parasites may occur in many 
other types of cells, including polymorphonuclear leucocytes and fibroblasts. Rudolf 
Jaffe 10 reported from Venezuela on the histological studies of 25 cases of nasal 
mucous membrane leishmaniasis. He observed epithelial proliferation and granula¬ 
tion tissue with infiltration of round cells, plasma cells, and typical Langhans giant 
cells, which were not found in nodules, as is the case in tuberculosis. Parasites were 
found more easily by Rudolf Jaffe in tissue smears after removal of the blood from 
the excised piece than in histological sections. In a personal communication to me, 
Prof. R. Jaffe confirmed Klotz and Lindenberg’s experience of the difficulty in 
finding parasites in formalin-fixed tissues. He recommends Bouin’s or Zenker’s 
solution. In his article, Rudolf Jaffe points out that the histological picture alone 
Fig. 4.—Cutaneous leishmaniasis of the nostril and upper lip. Leishmania braziliensis found 
in smear. Kahn test also positive. Possible mixed infection with syphilis or yaws. 
does not allow one to make a definite diagnosis, but that the pathologist with experi¬ 
ence in the condition may be able to suspect leishmaniasis. The less experienced 
may mistake the findings for tuberculosis. 
DIAGNOSIS 
In the highly endemic areas the diagnosis seldom is difficult. In other regions, 
where the condition is less common, or in the case of persons who come from tropical 
countries to the temperate zone, it is important that the examiner think of the dis¬ 
ease. One has to remember also the fact that under tropical conditions not only one 
but several diseases may be present, for instance, syphilis and leishmaniasis or a 
malignant growth and blastomycosis. Other conditions which have to be considered 
in differential diagnosis are leprosy and yaws. Figure 4 shows a dermal lesion of 
5 
the nostril and upper lip. Leishmania organisms were found in the smear. However, 
the Kahn reaction was also positive. Lupus vulgaris of the skin and the mucosa of 
the upper respiratory tract is practically nonexistent in tropical countries but may 
be considered in persons who originally come from the temperate zone or who have 
resided there for a prolonged period of time. On examination of the nose, one should 
remember the changes described under pathology. Perforation of the septum is one 
of the commonest consequences of nasal leishmaniasis (Pessoa 6 ). In the mouth, 
the palate is the localization site of preference (Aguiar Pupo 11 ). In many cases of 
mucosal involvement a scar on the limbs or face, as sequelae of previous cutaneous 
lesions, will be present. The parasite may be found in scrapings from the lesions, in 
smears from excised tissue, or in histological sections, or it may be absent, as has 
been discussed above. Serological reactions are not reliable (Pessoa 6 ). Very help¬ 
ful in making the diagnosis is the intracutaneous Montenegro test. This is an allergic 
reaction which was introduced by Montenegro in 1926 12 and was based on the work 
of Wagener. 13 From 0.1 to 0.2 cc. of a suspension of a culture of Leishmania 
braziliensis in 0.4% phenol is injected intradermally. Within 48 hours there is a 
sharp local reaction, which persists up to several days. A moderately severe reaction 
and formation of a pustule are seen with greater frequency in Negroes. Such a 
positive reaction proves that the patient suffers or has suffered once from a Leish¬ 
mania infection. The allergy tends to remain for life; i. e., it persists in clinically 
cured cases. In very early infections the test is not reliable, but in such cases it is 
usually easy to find the parasite. As a rule, strong positive reactions are found in 
lesions of the mucosa and in old cases. False reactions are weak and disappear early 
(Pessoa)4 The test cannot be used to distinguish different forms of Leishmania, 
e. g., L. braziliensis from L. tropica (Wagener, 13 Montenegro, 12 Fasal and 
Gradow 1 ). 
TREATMENT 
Modern therapy began in Brazil with the introduction of antimony potassium 
tartrate by G. Vianna in 1912. This drug has to be given by intravenous injection, 
and untoward effects are common. At present stibophen (Neoantimosan), a triva- 
lent antimony compound developed originally in Germany by Bayer as Fuadin 
and sold now in Latin America under the name of Repodral by Winthrop Products, 
Inc., New York, is much used. It has the advantage that it is given by the intra¬ 
muscular route. Untoward effects are, in my experience, less pronounced than with 
antimony potassium tartrate, but they are not uncommon. The dosage for my 
patients usually conforms to the original manufacturer’s advice. For adults of 
average build the first dose is 3.5 cc., followed every second day by an injection of 
5 cc. until 10 injections are completed. If necessary, the course of injections is 
repeated after a lapse of one or more months. If general malaise, pains, etc., are 
too pronounced, the treatment is interrupted for several days, and/or the daily dose 
is reduced. Another preparation which is used in South America is dioxydiamido- 
arsenobenzol (Eparseno). It is made by Poulenc Freres, Paris. I have had no 
experience with this drug. 
Local treatment may be only symptomatic. For the removal of crusts, washing 
with sodium bicarbonate has been recommended. Local application of 1 to 2% 
i Personal communication to the author from the Instituto Oswaldo Cruz, Rio de Janeiro, 
Brazil. 
