6 
antimony tartrate solution and cauterization with trichloroacetic acid or phenol have 
also been advised. Involvement of the larynx may necessitate tracheotomy. In my 
cases local treatment of the nasal lesions is omitted as much as possible in order to 
facilitate a therapeutic test. 
PROPHYLAXIS 
Prophylaxis consists in protection and measures against the vector: the use of 
chlorophenothane (DDT) and other insecticides, screening of houses, and the use of 
mosquito nets. Under primitive conditions it is often difficult to apply these meas¬ 
ures. Pessoa 6 reported on success with preventive vaccination. 
PROGNOSIS 
The prognosis depends upon timely and proper chemotherapy. Advanced ' j 
mucosal lesions sometimes respond poorly to treatment, and death may occur as a j 
consequence of respiratory complications and cachexia. 
gj • 
PERSONAL OBSERVATIONS 
All cases reported here were observed from 1944 to the time of writing in the 
hospital of the Chiriqui Land Company, Bocas Division, a subsidiary of the United 
Fruit Company, in Almirante, Panama. The Almirante area is almost entirely a 
settlement of company employees and their families and is situated on the Atlantic 
coast of Panama, near the border of Costa Rica. A part of the company’s farms is 
located on Costa Rican territory. The company is growing bananas, abaca (Manila 
hemp), and cocoa. Employees and their dependents number about 12,000. However, 
the approximately 2,000 inhabitants of the provincial capital, Bocas del Toro, and 
the people from private farms, as well as the Indian tribes of the province, all depend 
a great deal upon the hospital. Ethnically, the patients are mostly mestizos and 
Negroes, with Indians and Caucasians in the minority. The climate is that of a 
tropical lowland—hot and damp. Antimalaria measures have reduced the malaria 
morbidity among company employees and their families to less than 1%. Other 
hygienic measures conform also to the standards of American industrial medicine in 
the tropics. It is important to note that 35 species of Phlebotomus sandflies were 
identified in the Almirante area by the Gorgas Memorial Laboratory. 14 
Cutaneous leishmaniasis is frequently seen in people who live or have lived in 
the bush. The lesions correspond to those which have been described under pathol¬ 
ogy. In most cases they consist in ulcers of the skin of the exposed parts, nearly 
always old, neglected, and contaminated. Thus, the parasites are rarely found. In 
former years confirmation of the diagnosis of leishmaniasis depended mostly on the 
therapeutic test; the lesions were covered with an indifferent dressing, and, after 
exclusion of yaws and syphilis by the Kahn or V. D. R. L. test, antimony treatment ^ 
was instituted. The prompt healing under only this form of therapy clinched the \ 
diagnosis. One of the cutaneous cases was that of a young man who had a large 
ulcer, with raised edges on one foot. Almost the whole dorsal aspect of the foot was 
covered with large discolored granulations. A biopsy specimen was taken and sent 
to a laboratory in Panama City. The histological diagnosis was “tuberculosis.” 
General examination, including a roentgenogram of the chest and serological tests, 
7 
gave normal findings. No antituberculosis treatment was given, but antimony 
therapy was instituted. The lesions healed rapidly, with the exception of a small 
area, which later on was treated by plastic repair. This case is mentioned only 
because the error m the histological diagnosis has some bearing on two of the nasal 
cases to be reported below. The biopsy specimens taken in these cases were exam¬ 
ined in the same laboratory. The differentiation from tuberculosis in the histological 
picture has been discussed fully in Rudolf Jaffe’s article. 10 
Through Prof. Olimpio da Fonseca Filho, Director of the Instituto Oswaldo 
Cruz, Rio de Janeiro, Brazil, and Dr. Julio Muniz, Chief of the institute’s Depart¬ 
ment of Protozoology, the hospital procured in 1951 an antigen for the intradermal 
Montenegro test. Since then the test has proved to be as valuable here as elsewhere. 
REPORT OF CASES 
Case 1 . —An elderly West Indian Negro complained of a sore on the upper lip. On exami¬ 
nation, the interior of the nose was found to be filled with discolored granulations. The whole 
cartilaginous and cutaneous septum was destroyed. The tip of the nose was sagging downward. 
The lesions were spreading continuously to the upper lip. There was also an ulcer upon the 
uvula. 
The interior of the nose was swabbed, and the smear gave a negative result. Material obtained 
by biopsy from the intranasal granulations was sent in formalin to the above-mentioned labora¬ 
tory in Panama City. The histological diagnosis was tuberculosis. A roentgenogram of the 
chest was normal. The Kahn test was negative. All lesions disappeared promptly after 12 
injections of stibophen (Fuadin), all together 58.5 cc. Rhinoscopy after two years revealed a 
smooth mucosa with only a few crusts. 
Comment .—This patient was seen when I was less acquainted with leishmaniasis. 
Instead of swabbing the granulations, I should have done a tissue smear. Fixing 
the material in formalin has to be done, for external reasons. The error in diagnosing 
the histological findings as tuberculosis has already been discussed. The clinical 
findings, the mistaken diagnosis of tuberculosis, and the prompt and permanent heal¬ 
ing under antimony treatment leave no doubt about the diagnosis mucocutaneous 
leishmaniasis. The antigen for the Montenegro test was not available at that time. 
Case 2.—Mestizo boy. 
Family History .—Father operated on by me for chronic pansinusitis. 
Personal History .—Seen first by another doctor in 1944, when the patient was 9 years old. 
An ulcer in the nose was encountered. Kahn test was negative. Smear for Leishmania negative. 
Examined first by me in February, 1945, when rhinitis sicca was diagnosed. A smear for 
Leishmania was negative. The sinuses were normal. Kahn test again negative. Antimony treat¬ 
ment (stibophen [Repodral]) and application of an indifferent nose ointment resulted in improve¬ 
ment. In January and February, 1946, the patient was seen again for mild rhinitis sicca. In 
October, 1946, rhinitis anterior with formation of some granulation tissue was encountered. 
Histological Examination .—A biopsy specimen examined in the laboratory mentioned above 
showed tuberculosis but was negative for acid-fast bacilli. Roentgenogram of the chest normal. 
Kahn test negative. In April, 1947, the findings were noted as chronic rhinitis, with small 
granulations on the anterior part of the septum and the lateral wall of the nose. Smears for 
Mycobacterium leprae and Leishmania were negative. In May a right-sided dacryocystitis was 
found and improved after stibophen treatment. In November, 1947, the nose was entirely normal. 
In February, 1953, the patient complained about a catarrh of two weeks’ duration. Granulations 
were again encountered in the right vestibulum. The Montenegro test resulted strongly 
positive. V. D. R. L. test negative. Again, stibophen treatment was started, but had to be inter¬ 
rupted because of general malaise and pains in the limbs. It was resumed with a smaller dosage. 
In March of the same year the nose appeared normal. 
