Cutaneous leishmaniasis and rickettsial African tick-bite fever: A combination of exotic traveler's diseases in the same patient

Background Cutaneous leishmaniasis and rickettsial African tick-bite fever are two zoonoses increasingly diagnosed in industrialized nations due to more international travel to endemic areas. Methods A 52-year-old American nurse was evaluated for a 0.5cm well-demarcated, tender, shallow ulcer on her wrist, nonproductive cough, fever, chills, and night sweats, all of which began threeweeks after travel to Botswana and a visit to a game reserve, where she reported being scratched on the ankle by a cheetah. Results This cutaneous finding was strongly suggestive of leishmaniasis, but the systemic symptoms were perplexing. Although excisional biopsy showed only nonspecific changes, a specimen sent to the United States Centers for Disease Control revealed leishmania promastigotes of L. tropica. Initial Rickettsia typhi titers and many other serologic tests were negative. However, fourweeks after admission, R. typhi IgG titer was 1:64 and R. rickettsii IgG was 1:1024. Conclusion Thus, our patient had two tropical diseases simultaneously.