CASE STUDY

The patient was a 27-year-old male student who presented with ulcerated, raised lesions on his neck, back, and foot. The lesions began as raised red areas that spontaneously drained, ulcerated, healed, and then began to "grow" again. On presentation, the neck lesion had a raised, erythematous border with an ulcerative crater in the center (Fig. 1, left). His history was significant for travel in the Middle East the previous summer. He worked on an Israeli irrigation project in June and July and spent a week in the Sinai Peninsula in August, followed by several weeks along the Nile in Egypt. During his travel in Israel and Egypt, he experienced bites from multiple flying incests. While in Egypt, he suffered 8 days of watery diarrhea and a 20-lb (ca. 9-kg) weight loss and first noticed the neck lesion. This occurred 5 months prior to presentation. At presentation, he had a normal complete blood count including eosinophil count. The infecting organism was detected by direct examination and culture of the neck lesion (Fig. 2 right).

1. What is the organism causing his illness?

Why doesn't he have systemic symptoms?

2. What is the natural history of his illness?

Was the presence of multiple lesions unusual?

3. How is the disease spread? How can infection be prevented?

4. Why are infections with this organism typically seen on the head and neck?

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