Step 1: View clinicals

A 25-year-old man presents with a painless, non-healing ulcer on his left thumb for six weeks. This commenced as a small papule which progressively grew larger and then ulcerated. There is no bleeding or discharge. He is otherwise healthy, and reports no previous injuries to his hand. His medical, surgical, and family histories are unremarkable, and he is not on any medications, or over-the-counter supplements. There is no history of recreational drug use. He works as a gardener, only drinks socially, and does not smoke. Close questioning reveals that he traveled to Brazil for a two-week long holiday around three months ago, although he denies experiencing any insect bites. A complete blood count is found to be within normal parameters.

Step 2: Order all relevant investigations

Skin scrapings for leishmania

The skin scrapings are negative for Leishmania amastigotes.

Skin biopsy

The skin biopsy reveals central ulceration of the epidermis with hyperkeratosis at the edges, as well as mild epidermal hyperplasia. There are also mixed granulomatous cellular infiltrates. Subsequent cultures of the biopsy materials reveal Sporothrix schenckii.

Autoimmune screen

The autoimmune screen is negative.

X-Ray chest

The chest x-ray appears completely normal.

Step 3: Select appropriate management

Amphotericin B
Meglumine antimoniate

Score: ★★☆