Atypical cutaneous leishmaniasis in Central America: possible interaction between infectious and environmental elements.

Biopsies of 71 cases of atypical cutaneous leishmaniasis from Costa Rican patients were evaluated by histopathological procedures and attempts were made to culture Leishmania from nine biopsies. Leishmanin skin tests were carried out in 31 patients and 112 healthy individuals. Additional biopsies from 19 patients from Nicaragua were evaluated by routine histopathology. Ten biopsies were studied by confocal and nine by scanning electron microscopy. Inorganic material was analysed using an electron probe for microanalysis. Leishmania parasites were isolated from only two biopsies, but 90.3% of the patients from Costa Rica were leishmanin-positive, as were 27.7% of healthy individuals. Routine histopathological studies revealed naked granulomas formed by differentiated macrophages. Abundant inorganic material was observed in sections examined by confocal microscopy. Electron probe analysis revealed that silica and aluminium were the predominant elements in large particles. We postulate that the presence of this inorganic material, possibly of volcanic origin, in the skin may modulate the immunological response to Leishmania and may inhibit visceralization in the cases caused by Leishmania chagasi.