Derm Cases · Dermatology / Infectious disease / Tropical medicine
OSCE — returned traveller with a volcano ulcer: cutaneous leishmaniasis work-up and when to treat systemically
An 8-minute OSCE station on recognising cutaneous leishmaniasis (volcano ulcer), Old World vs New World risk of mucosal disease, diagnostic Giemsa/PCR pathway, and escalating from local therapy to systemic miltefosine/antimonials/amphotericin when indicated.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on recognising cutaneous leishmaniasis (volcano ulcer), Old World vs New World risk of mucosal disease, diagnostic Giemsa/PCR pathway, and escalating from local therapy to systemic miltefosine/antimonials/amphotericin when indicated.
Brief (to candidate)
A 28-year-old returned from rural Latin America with a painless chronic ulcer on the forearm with a raised indurated border (“volcano”). He has mild nasal congestion. You have 8 minutes to diagnose cutaneous leishmaniasis, arrange speciation-aware work-up, and decide local vs systemic therapy including mucosal-risk species.
[3]Candidate instructions
- Recognise classic cutaneous leishmaniasis morphology and sandfly transmission.
- Take a travel/species geography history (Old World vs New World).
- Order smear/biopsy Giemsa (LD bodies), culture/PCR for speciation.
- Escalate for mucosal (espundia) or visceral red flags.
- Outline local vs systemic treatment options (including miltefosine / antimonials / liposomal amphotericin frameworks).
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Clinical recognition | Chronic painless ulcer, raised indurated border (volcano sign), exposed sites; consider sandfly exposure in endemic travel/residence[1][3] |
| Spectrum | Cutaneous ± mucocutaneous (esp. L. braziliensis complex New World); visceral (kala-azar: fever, massive splenomegaly, pancytopenia); PKDL after treated VL in South Asia/East Africa[1][5][7] |
| Diagnosis | Giemsa smear/biopsy for intracellular amastigotes (LD bodies); PCR/speciation guides therapy and mucosal risk; culture (e.g. NNN) where available; rK39 for visceral context[1][3] |
| Mucosal red flags | Nasal stuffiness, epistaxis, septal/palatal destruction after New World exposure → urgent systemic therapy + ENT input — do not observe as simple Old World CL[1][3] |
| Treatment ladder | Simple Old World CL may use local physical/topical measures or watchful waiting when appropriate; New World / mucosal / complex / visceral → systemic therapy (species- and region-guided: pentavalent antimonials, miltefosine, liposomal amphotericin B, paromomycin per protocols)[1][3][5] |
| Public health | Not person-to-person via casual contact; vector control counselling; HIV co-infection worsens VL course |
| Communication | Explain delayed diagnosis risk if treated as bacterial ulcer alone; need for specialist tropical/ID-dermatology pathway |
Model key actions
- Diagnose volcano-type CL and request parasitology + PCR speciation.[1][3]
- Treat New World / mucosal-risk disease systemically, not with antibiotics alone.[1][3]
- Screen for visceral features when systemic symptoms present.[5]
Common errors
- Treating only with antibiotics/topical steroids without parasitologic testing.
- Assuming all CL is self-healing Old World disease after Latin America travel.
- Missing early mucosal symptoms (nasal stuffiness/epistaxis).
- Starting systemic antileishmanials without confirming diagnosis when sampling is feasible.
- Forgetting PKDL as a post-VL dermatologic syndrome in endemic patients.
References4ShowHide
- [1]Burza S, Croft SL, Boelaert M. Leishmaniasis. Lancet, 2018.PMID 30126638
- [3]de Vries HJC, Schallig HD. Cutaneous Leishmaniasis: A 2022 Updated Narrative Review into Diagnosis and Management Developments. American Journal of Clinical Dermatology, 2022.PMID 36103050
- [5]van Griensven J, Diro E. Visceral Leishmaniasis: Recent Advances in Diagnostics and Treatment Regimens. Infectious disease clinics of North America, 2019.PMID 30712769
- [7]Zijlstra EE, Musa AM, Khalil EA, et al. Post-kala-azar dermal leishmaniasis. The Lancet Infectious Diseases, 2003.PMID 12560194