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Marmara Medical Journal 2011; 24 (1):81-82 DOI: 10.5472/MMJ.2010.01687.2Photo-QuizA 53-year-old Brazilian Woman With a Malleolar Ulcer After anInsect BiteVitorino Modesto SANTOS 1 , Liliane Aparecida SOARES 2 , Natália Polidorio MACHADO 1 ,Fernanda Gama Neves SILVA 1 , Valéria Araújo Nascimento SANTOS 31Catholic University (UCB) and Armed Forces Hospital (HFA), Internal Medicine, Brasília-DF, Brezilya 2 Armed Forces Hospital,Internal Medicine Department, Brasília-DF, Brezilya 3 Armed Forces Hospital, Pathology Division, Brasília-DF, BrezilyaPHOTO-QUIZA 53-year-old woman, who was submittedto saphenectomy 20 years ago, was admitted with apainful ulcer over the right medial malleolus. Shewas tobacco-smoker (16 pack-years) and had highblood pressure. The skin change appeared 30 daysbefore, following an insect bite. Firstly, there was apapule, which evolved as an ulcer in three weeks.She related that her domestic dog was recentlysacrificed by the Zoonoses Control Department dueto visceral leishmaniosis. Physical examinationrevealed an ulcerated lesion (4 cm in diameter) withirregular borders in her right medial malleolus, withhyper pigmented area associated with inflammatorysigns and draining serous secretion (Figures 1A and1B). There were varicose veins in the right lowerlimb, and arterial pulses were normal. Thediameters of the calf were 40 cm on the right and40.2 cm on the left; and the diameters of the ankledistal third were 24.7 cm on the right and 23.2 cmon the left. Laboratory determinations wereunremarkable. The echo-Doppler of the inferior rightlimb detected incompetent perforant veins.Photomicrography features of biopsy samples fromthe border of the ulcer are showed in Figure 1C.Rapid reduction in the lesion size was observed withclinical treatment (Figure 1D). She becameasymptomatic and was discharged to home at daynine of admission.What is the most probable diagnosis?Figure 1. A and B: Shallow ulcer (4 cm) with irregularborders and hyper pigmented area.Figure 1. C: Photomicrography of biopsy showing nonspecificchronic inflammation.Figure 1. D: Evolution of the lesion after one week ofclinical management.Başvuru tarihi / Submitted:23.08.2010 Kabul tarihi / Accepted:26.12.2010Correspondence to: Vitorino Modesto Santos, M.D. Catholic University (UCB) and Armed Forces Hospital (HFA),Internal Medicine, Brasília-DF, Brezilya e-mail: vitorinomodesto@gmail.com81Marmara Medical Journal 2011; 24 (1):81-82