8 
Comment .—The case shows the tendency to recurrence in mucosal lesions and 
a certain resistance to treatment, which has been reported also by Pessoa. G Never¬ 
theless, there was always a response to antimony treatment. The diagnosis of tuber¬ 
culosis, always by the same laboratory, and the strongly positive reaction of the 
Montenegro test are to be noted. Of interest also is the affection of the lacrimal sac. 
Case 3.—A 14-year-old mestizo girl. 
History. _Had a skin lesion on the right cheek in early childhood. Complained of obstruction 
and bleeding from the nose for an undetermined period of time. 
General Examination ,—Large old scar over the right eye (Fig. 2), like a sequela of leish¬ 
maniasis. Otherwise, no findings of significance. Roentgenogram of the chest normal. V. D. R. L. 
test negative. 
0tolaryngotogical Examination .—Pus and many crusts in both nostrils. Granulations upon 
the anterior part of the septum, the lateral wall, and the floor of the right nasal cavity. These 
granulations had partly grown into small tumors. There were also very fine granulations on 
the anterior part of the septum in the left nasal cavity. Otherwise, upper respiratory passages 
normal. Roentgenogram of the sinuses normal. Smears from excised tissue negative for leish- 
mania. Montenegro test strongly positive. 
Biopsy .—Histological examination of formalin-fixed material by Prof. Rudolf Jaffe, M.D., 
Director of the Pathological-Anatomical Institute of the University of Caracas, Venezuela, was 
reported as follows: “Pieces of mucosa. The pavement epithelium is much broadened and forms 
large and small papillae toward the deeper layers, with epithelial pearls in some places. The 
subepithelial tissue consists of granulations with numerous capillary vessels and dense infiltration 
by all kinds of round cells. Among the latter there are in some places also numerous poly¬ 
morphonuclear leucocytes and plasma cells. Irregularly distributed giant cells similar to those 
of the Langhans type are also present. There is no formation of nodules. In some of the capil¬ 
laries and about them many polymorphonuclear leucocytes are encountered. This morphological 
picture is frequently found in leishmaniasis, and this diagnosis is the most probable one. Parasites 
were not found in the sections, but this happens very often.” 
Treatment .—Antimony therapy (stibophen) resulted in prompt healing of the lesions. Only 
some crusting remained, which was treated with an indifferent nose ointment. 
The patient was seen again six months after her discharge. Some crusting of the anterior part 
of the septum was encountered but no granulations or ulcerations. Eight months after her first 
admission, the results of examination were not remarkable. 
Comment .—In this case the biopsy specimen was examined by another pathol¬ 
ogist and the structures were found suspicious for leishmaniasis. The strongly posi¬ 
tive Montenegro test and the prompt healing under antimony therapy tally with the 
histological findings. As has been stated before, parasites are seldom found in sec¬ 
tions of old lesions. Also, the material had been fixed in formalin. 
Case 4.—A Talamanca Indian woman about 50 years old. 
History .—Nasal obstruction for five months. Pain and deafness in the left ear for one month. 
General Examination .—General examination, including roentgenogram of the chest, normal. 
No scars on the skin. V. D. R. L. test negative. Thick smear for malaria negative. Hypo¬ 
chromic anemia. Urine normal. 
Otolaryngological Examination .—Right nostril narrowed by scarring and some crusting; 
endoscopic examination impossible. Left nasal cavity contained hemorrhagic crusts. An ulcer¬ 
ation extended from the vestibulum backward on the lateral wall. This lesion made a full inspec¬ 
tion of the cavity impossible during the early period of observation, because of considerable pain. 
Only later on a moderately large perforation of the anterior part of the septum could be seen. 
There was slight reddening and possible thickening of the soft palate. The left drum membrane 
was moderately retracted. Roentgenogram of the sinuses was normal. Smears from excised 
tissue and from swabbing the nose showed Staphylococcus albus and were negative for Leish- 
mania and Klebsiella rhinoscleromatis. 
9 
Histological Examination .—Histological examination of a specimen fixed in formalin by Prof. 
Rudolf Jaffe, of Caracas, Venezuela, was reported as follows: “Granulation tissue infiltrated by 
leucocytes, round cells, and plasma cells. Many translucent cells which look like Mikulicz’ cells 
but are not quite typical. Scleroma? Malignancy can be ruled out.” 
Penicillin and, afterward, streptomycin treatment was without effect on the nasal lesions. 
Probably both drugs were dissolved in pyrogenic water, because fever was present during the 
first week, and the patient’s temperature dropped to normal after the discontinuation of this 
kind of therapy. The Montenegro test was strongly positive, with a pronounced inflammatory 
reaction. A full course of stibophen was now given, and prompt healing of all nasal ulceration 
resulted. Only slight crusting remained. The palate became normal, and the patient was dis¬ 
charged, free from all complaints. 
Comment .—The histological findings were not conclusive. Extensive ulceration 
speaks against scleroma. The strongly positive Montenegro test and the prompt 
healing under antimony therapy established the diagnosis of leishmaniasis. 
Case 5.—A 84-year-old West Indian Negro. Old large perforation in the cartilaginous and 
cutaneous nasal septum. Ozena of long duration, possibly secondary and due to the perforation. 
Two whitish scars on the left forearm and wrist. Kahn test negative in 1945 and 1949. 
The patient had been kept for several years in the “chronic ward” of the hospital because 
of old age, when a crusting lesion appeared in a reddened area near the tip of the nose. The 
Montenegro test was strongly positive, with formation of a blister. Under stilbophen treatment 
(37 cc. in 18 days) the skin lesion healed promptly. The ozena remained unchanged. 
Comment .—The strongly positive Montenegro test and the prompt healing of 
the skin under antimony therapy leave no doubt that the patient suffered from leish¬ 
maniasis. The large perforation in the cartilaginous and cutaneous septum was in 
all probability also due to the same condition. The dermatosis was a relapse of an 
old infection. A fresh infection in the screened hospital ward, which is treated with 
DDT at regular intervals, appears to be out of the question. 
Case 6.—A 65-year-old Negro woman from Jamaica, B. W. I. Admitted for influenza. The 
patient was not able to give a concise history. In former years, possibly in childhood, she suffered 
from a mutilating nose disease. 
Examination .—The anterior part of the external nose was partly destroyed and scarred. The 
scarring made inspection through the left nostril impossible; only a thin probe could be intro¬ 
duced. The anterior part of the septum was destroyed. There were no signs of an active patho¬ 
logical process in the nose. Montenegro test moderately positive. V. D. R. L. test negative. 
Roentgenogram of the chest normal. Leucoma of both eyes. Skin not remarkable. 
Comment .—The nasal lesions, together with the positive Montenegro test, speak 
for leishmaniasis. Yaws in which the serological reaction had become negative is a 
more remote possibility. 
Case 7.—A 20-year-old white Panamanian youth. Crusting in the anterior part of both nasal 
cavities, resistant to treatment with indifferent nose ointment. Slight swelling of the mucosa of 
the anterior part of the septum. Roentgenogram of the sinuses normal. V. D. R. L. test negative. 
Large old scar on the right leg. Montenegro test strongly positive. 
One series of stibophen injections was given. The dose had to be reduced partly to 4 cc. 
per injection because of untoward effects. One month after termination of the antimony therapy, 
to which, later on, application of the former nose ointment had been added, the nose appeared 
normal. 
Comment .—The scar on the leg together with the strongly positive Montenegro 
test do not leave any doubt that the patient had been infected by Leishmania. The 
only slight intranasal lesion was in all probability also due to leishmaniasis. 
