Cutaneous leishmaniasis — DTM&H MCQ
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Correct answer: E — Cutaneous leishmaniasis
The correct answer is E, Cutaneous leishmaniasis. A painless, indurated ulcer with satellite papules acquired in Afghanistan (a sandfly-borne Leishmania tropica/major endemic area), unresponsive to antistaphylococcal antibiotics, is classic for cutaneous leishmaniasis, and the demonstration of amastigotes (Leishman-Donovan bodies) on slit-skin smear is the confirmatory diagnostic step used in UK tropical medicine referral centres. Sandflies inoculate promastigotes that transform into intracellular amastigotes within dermal macrophages, producing a chronic granulomatous ulcer that classically fails to respond to conventional antibacterials because the pathology is parasitic, not bacterial. UK travel and tropical medicine guidance identifies leishmaniasis as an established risk for personnel deployed to Afghanistan, and slit-skin smear microscopy for amastigotes remains a core part of the diagnostic protocol in specialist centres. Why the other options are wrong: D. Tropical phagedenic ulcer: this is a rapidly progressive, painful, necrotic ulcer caused by synergistic bacterial infection (fusobacteria/spirochaetes), not a painless indurated lesion, and no amastigotes are seen. A. Buruli ulcer: caused by Mycobacterium ulcerans, this produces a painless but characteristically undermined ulcer with necrotic slough; diagnosis rests on acid-fast bacilli or PCR, not slit-skin amastigotes, and it is geographically linked to West/Central Africa, not Afghanistan. B. Yaws: due to Treponema pallidum pertenue, yaws causes papillomatous skin lesions (mother yaw) diagnosed by dark-field microscopy or serology, not amastigotes on slit-skin smear. C. Chromoblastomycosis: a chronic fungal infection producing verrucous, cauliflower-like plaques, confirmed by finding pigmented sclerotic (Medlar) bodies on skin scraping, not amastigotes. Key point: an indolent, painless ulcer with satellite lesions in a returnee from an endemic sandfly area, confirmed by amastigotes on slit-skin smear, is diagnostic of cutaneous leishmaniasis.
Reference: TravelHealthPro (NaTHNaC) / UK clinical literature on cutaneous leishmaniasis in returning travellers: Clinical features and diagnosis of cutaneous leishmaniasis, describing slit-skin smear and amastigote microscopy as part of the UK specialist Tropical Medicine diagnostic protocol. https://www.sciencedirect.com/science/article/abs/pii/S1477893904001231