The Gorgas Courses in Clinical Tropical Medicine

Selected Cases Seen by 2007 Course Participants

During the past week the Gorgas Course in Clinical Tropical Medicine concluded with a 4-day field trip to Iquitos on the banks of the Amazon River.  Iquitos, with a population of approximately 500,000, is the largest city in the world that is reachable only by air and by river.  The nearest road ends over 400 km away.  The following case was seen in the outpatient department of the Iquitos Hospital in Iquitos, Peru.  We thank Dr. Pedro Legua from our institute for his advice on this patient.

Publishing a case report for 9 consecutive weeks would not be possible without the assistance of an extremely dedicated group of people.  We would like to thank in particular: Dr. Carlos Seas, Clinical Rounds Coordinator for the Gorgas Courses for case selection, coordination of case summaries and images; Drs. Jaime Cok and Juan Ferrufino for preparation and discussion of pathologic specimens, and Adam Plier of the UAB Center for Geographic Medicine for all publishing on the Gorgas Course web site.

We hope you have enjoyed this year’s cases.  In August 2007 we will be running the 2-week Gorgas Expert Course and will present 2 more cases during that time.  We will also be in touch in February 2008 at the beginning of next year’s case series.

These cases will be re-formatted to meet CME guidelines and will be available for online CME credit later this year.  We look forward to providing more cases during the 2008 Gorgas Course.

Please send any suggestions or comments for these cases to info@gorgas.org.

David O. Freedman & Eduardo Gotuzzo
Course Directors

History:  Male patient, 47 years old, lives in the jungle, worked in agricultural activities.  First manifest his illness at age 14 with numbness on the dorsal aspect of his right foot and on the lateral aspect of the right leg.  At age 17 he noticed “hypopigmented macules” on his trunk that had reduced sensation.  At age 23 years there was pain in the nerves of both arms that curled the fingers of both hands.  He never sought medical attention but took herbal remedies.  At age 26 years there was edema of the ankles and pain in the internal aspect of both ankles, and then the toes of both feet curled.  Since the age of 30 years old he has had recurrent episodes of erythematous painful nodules in the skin all over his body.  In the last year he has noticed swelling of his face and earlobes.

Epidemiology:  Lifelong resident of a remote area of the jungle in the Loreto department.  No contact with anyone with a similar illness.

Physical Examination:  Afebrile.  Infiltrative diffuse lesions of the skin of his forehead, malar areas, cheeks, nose and chin, with loss of eyebrows and eyelashes present [Image A].  In addition, the infiltrative lesions of the ear had overlying ulceration [Image B].  The skin of his trunk and limbs had numerous tender erythematous nodules of varying sizes from 1 to 1.5 cm in diameter and several papules (note right arm, Image C).  There was mild enlargement of both ulnar nerves, more marked on the left side; of both common peroneal nerves, more marked on the left side; and of both posterior tibial nerves.  There was bilateral glove and stocking anesthesia with loss of sensation to the elbows and mid-calf.  There was bilateral corneal anesthesia (loss of blink reflex as tested with a wet tissue, Image D).  There was complete clawing of all digits on both hands with cutaneous ulceration, loss of tissue, bone resorption, and loss of the fifth finger of the right hand [Image E].  Similar changes on feet, and plantar ulcers on the left foot [Image F, G].

Laboratory Examination:  Diagnostic material was obtained from the earlobes.

Click here for Diagnosis & Discussion about this case