Case Presentation: A 30-year-old man with no medical history presented to infectious disease (ID) clinic with 6-months of diffuse and progressive hypopigmented, erythematous, non–purulent, pruritic papules on bilateral hands, fingers, ears, testicles, and anterior sinuses. He didn’t report other symptoms but had recently immigrated from Peru.He was initially seen in dermatology clinic and diagnosed with keloid scarring. Months later when seen in ID clinic, the lesions had worsened and were concerning for mucocutaneous leishmaniasis as he reported many insect bites during travel through endemic areas. He was admitted directly from clinic for IV Amphotericin treatment given a high degree of clinical suspicion. Punch biopsies of the nasal turbinates and dorsal hand lesions were negative for leishmaniasis, but AFB and Fungal stains were consistent with mycobacterium lepromatosis. After conversations with the patient and ID, he was started on rifampin, moxifloxacin, and minocycline for a 12 month course.
Discussion: Climate and sociopolitical conditions have led to increased migration from Central and South America. In particular, the Darién region on the southern border of Panama, is associated with a high prevalence of infectious diseases that are rare in destination countries.1,2 After surviving the journey, migrants face many barriers to care: language differences, fear of deportation, lack of insurance, and care delays due to lower suspicion for “tropical” diseases among clinicians in North America. This patient’s initial misdiagnosis underscores the importance of a comprehensive social and travel history. Insurance and legal status posed further challenges in accessing specialized care. Additionally, after identifying his lesions as likely infectious, he was empirically treated for leishmaniasis with IV amphotericin before an official diagnosis. It is worth recognizing that US-trained physicians receive limited education on tropical diseases, which can have varied symptoms and mimic conditions from malignancy to rheumatologic.3 ID colleagues should be consulted early when a patient’s history contains risk factors for these diseases. Historical treatment of Leprosy is dapsone, rifampin, and clofazimine for 24 months.4 However, clofazimine may cause non-reversible skin discoloration, compounding the stigma and psychosocial distress associated with this condition.5 An alternative regimen of rifampin, moxifloxacin, and minocycline for 12 months has been demonstrated to be non-inferior to standard treatment and was chosen to avoid non-reversible skin pigmentation.4,6
Conclusions: When caring for migrant patients, maintaining a high degree of suspicion for unusual infectious diseases is vital. Additionally, it is crucial to recognize the vulnerability of these patients and the psychosocial trauma they may carry, to practice in a way that preserves patient autonomy and prioritizes their values and concerns.