Cutaneous Leishmaniasis ( or Kala-azar): a rare tropical disease
caused by parasites transmitted by the bite of a female sand fly during a certain point in her gustation period.
Symptoms - Physical signs may manifest 2 weeks to 4 months after being infected. Initially, the lesion is a small, red papule up to 2 cm in diameter at the site of the bite. Over several weeks, the papule becomes darker and will crust in the center, eventually ulcerating to present a typical appearance of an ulcer with raised edges and surrounding dusky red skin. The ulcers can be moist or open with seropurulent exudate or dry with a crusted scab. After about 6 - 9 months, the ulcers may heal, leaving a raised border and possible disfiguration. Other consequences, which can manifest anywhere from a few months to years after infection, include fever, damage to the spleen and liver, or anemia.
Cliff Notes: I got this disease on my face. After 30 shots I am healed. Pictures at the end.
After a quick search on the internet one can easily find a more grotesque picture of this disease however this man seemed the most enthusiastic about being its poster child. I will warn you now, some of the description below is a bit detailed and there is a picture of the form I had at the end if you want to read without seeing it.
I think any country where you could possibly get this disease or any other of the liking should, at all points of entry, have clearly labeled signs and pass out pamphlets to each and every person that clearly state the potential risk you take when you step foot on their soil. If this is the kind of information that is handed out on a need to know basis then I needed to know about 7 months ago when I got my passport stamped by a friendly customs official inviting me to enjoy my stay in Costa Rica.
I consider myself an experienced traveler and always do my homework to make sure I have the proper vaccines or necessary preventative measures for my desired geographical location. I never heard of this disease. Now I can say I know more than I would like to about this parasite and had a very close relationship with it.
Sometime last September after I had settled into Playas Del Coco, a small red bump appeared on the right side of my face just below my bottom lip. At first I thought it was a pimple which refused to go away but after weeks of poking and prodding it seemed to just worsen. I decided it was time I see a doctor. The local clinic is easy to find as there is only one on the main street in Coco. I am not sure if is is by design or chance but the clinic is located next to the fast food chain Pollo Crispy where rumors of food poisoning abound. The line outside each and the wait to get service is equal at both. After a brief visit, I walked out with a prescription for an ointment and a lack of confidence in the doctor's diagnosis. After a couple weeks, it was still getting worse and now I had developed 2 large lumps in my throat which had me worrying about something more severe.
So I went back. On this visit another doctor was rotating through the clinic. The new doctor explained I most likely had enlarged lymph nodes due to whatever infection I had under my lip. This gave me a bit of ease about the lumps but his confidence was also lacking in the diagnosis of the now large red node below my lip. He prescribed a different ointment and added some pills for good measure.
After two more weeks of things getting worse, both doctors recommended I see a dermatologist. Of course there is no dermatologist in Coco. The closest dermatologist is a 1.5 hour bus ride away in Liberia and he only comes every other weekend from San Jose. When I asked if they knew which weekend the dermatologist was there, they were about as confident with this as they were with the diagnosis of what was on my face.
At this point the sore had begun turning from a red bump to a crusty ulcer and had enlarged to about the size of a dime. It had what seemed to be a scab over the top which I mistook multiple times to mean it was healing however upon picking the scab off the hole it was leaving in my face was just getting deeper and deeper. It would ooze a clear liquid and reform the scab over the length of a day.
I had to get to Liberia to see a dermatologist but trying to pick a weekend to see a dermatologist that may or may not be there was not something I was looking forward to. It was like trying to get matching numbers on a pair of 30-sided die in a nightmarish game of craps. Luckily for me my parents had planned a trip to visit me in Costa Rica in early December which was now just a week away. Unluckily for them, the awesome itinerary of sights I put together for them would now include a first day of using their rental car to drive to Liberia to search for a dermatologist.
Once again the directions I had were cryptic at best since Costa Ricans don't believe in street addresses. Here is what I had: "Go straight through the main intersection in town that leads to San Jose. Go passed the local bank on your left and before the Pizza Hut on the right there is a road where the clinic is but it is one way so you can't turn right. So you need to go past the Pizza Hut and then around the block to find the clinic. It is difficult to find. There may or may not be a sign outside."
So with the parents loaded up in our compact SUV we made out way to Liberia. After a few wrong turns, asking some pedestrians, knocking on doors we finally figured out that the sign outside the building advertising a hair salon also doubled as the sign for the dermatologist. Of course he was not in this weekend but my mom did get a good deal on some highlights. We asked if they knew of another clinic in town being that it was so small but they said they did not. I figured Liberia is a fairly large town and there had to be something else around so we just began to drive around town searching for anyone that remotely resembled a dermatologist.
The easiest thing to track down was the large public hospital which didn't appear to be located in the best part of town but we had to give it a shot. I parked the car down a dirty side street while the locals stared at the obvious newcomers to see what form of entertainment we may be to them. Having been living in Central America for some time I was used to be being in these situations and hopped out of the car, locked the door, and began walking across the street to the hospital entrance. I turned around to see how far back the parentals were and they were still at the car having some type of mental tug-of-war. One was outside the car staring at the other one through the rolled up glass of the door window securely locked inside. Apparently, one thought the safest route was to get out and stay as close to me as possible while the other thought the safest route was to stay locked in the car and not step food outside. In the end it was agreed upon that the best option was for everyone to stick together however the entire episode ended up being quite hysterical and sent my mother into a fit of uncontrollable laughter. As soon as we entered the hospital the staff thought it was her who had the problem and my Spanish is no where near good enough to explain to them why she could not stop laughing so I turned them around and we headed back to the car.
After a bit more driving my mother redeemed herself and spotted the most convenient clinic I've ever seen. A 25 hour clinic. We couldn't pass this one up. We entered and were told yes they had a dermatologist but of course he was not in this weekend. There was a regular doctor who could see me though and at this point I was willing to see anyone who might have a chance at curing this thing. He had a look and prescribed me some actual antibiotics and a different ointment and told me to check back in a week. This seems like the only thing they teach at medical schools in Costa Rica but for some reason I had a bit more confidence this time.
However after a great week of travel with my parents the sore had gotten much worse. The scab area was easily the size of a quarter. The skin between my lip and chin was inflamed and my lower lip was extremely swollen and bruised. So as is the beginning, shall be the end. My parents and I headed back to Liberia on their last day in the country. Since their were no dermatologists in town last weekend then they should be there this weekend but I am guessing now that every other weekend actually translates into maybe once a month. Both previously visited clinics were
sans dermatologist again.
After leaving the second clinic looking feeling quite hopeless, I began my drive out of town. After one random turn we ran into another clinic. This one the biggest and best looking of the three. I parked the car, told my parents to wait as I did not set my expectations to high. I walked in and asked the receptionist if there was a dermatologist in this weekend. She looked at me like it was a dumb question and said of course. You can see him in 15 minutes. Well the 15 minutes turned into 1.5 hours of waiting along side pregnant women, sniffling children, and old men with urine samples in hand but I finally got to see a real live dermatologist.
On a side note, and maybe this has to do with no one using addresses in this country, but it did strike me as quite strange that all 3 of these clinics are within a 5 block radius of each other yet they didn't seem to know that the others existed. Even if they were in strict competition with one another, if you see a guy with some disease that is eating his face, you direct him in the right direction so he can get some help.
Once inside the doctor's office, he put me on the table and took a look at the infection under his well lit magnifying glass. After a few seconds he said with a slight grimace that he was pretty sure he knew what it was. He asked if I had been down south to the jungle recently and told him I had. He told me it looked like Leishmanias but I would need to go to a bacteriologist in San jose to be sure.
After I asked him repeatedly to pronounce it, I then asked him how bad it was. Now from my previous experience with doctors and what I have seen on tv, when the doctor gives the diagnosis they usually add a phrase consoling you and saying it will be fine. Well I did not get that from him. He just kept grimacing in his chair and moving a bit uncomfortably like he didn't want to be there. I asked him if their was something to treat it and if it would go away. To this he replied that there is a treatment of 20 - 30 shots that usually works. Sometimes it leaves a scar that requires plastic surgery but luckily for me I could just cover it up with my beard. Not the best news I had heard in a while but at this point I was just glad to get a solid diagnosis and was ready to start anything to get this off my face.
So the day after my parents left, I took the first of several bus rides back and forth from Coco to San Jose. The bus ride is touted as a 5 hour trip. I never did it in less than 7, sometimes sitting, sometimes standing, usually sleeping.
I made my way to the bacteriologist who worked out of a cramped office behind a Pawn Shop. After putting an allergen injection in each arm he clamped my head to the wall with his left hand and began hacking away at the sore with the scalpel in his right hand until he was sure he had taken enough of it off for a good sample which felt to me like a good portion of my chin. He then placed the samples in the refrigerator next to his McDonalds bag. I had to hang around for 3 days for the results. As I saw the allergens in my arms swell up I didn't need the bacteriologist to confirm it was indeed Leishmaniasis. The day I went back, he had an assistant there and they both took turns measuring the injection areas on my arms before they gave me the news. I asked them how bad it was just to get another doctor's opinion. They looked a each other with a smirk and said, "Oh it is bad. You will need at least 30 shots."
After this, I met back with the dermatologist with the confirmed results. I was ready to start the shots but there was now a different problem. Since this disease is so rare, the normal pharmacies would probably not have the injections I needed. I could try and go to a government clinic but since I am not a Costa Rican citizen they will probably not give it to me. He then asked if there was anyway I could go back to the States for treatment. I told him this was not really an option. He then basically said I was on my own for figuring out how to get the injections but I should go back to Coco and try there. He wanted to see me after 2 weeks of shots to see my progress and check for side effects. Up to this point he had mentioned nothing about side effects so I asked what these might be. His response was pain.
So I went back to Coco to my clinic and talked to the doctor. He had never heard of the injections I needed much less had it. He told me to check at the government clinic and if they wouldn't give it to me, he would send a local to get the drug under his name. The clinic didn't even have the drug.
I went to the 3 pharmacies in town on the off chance they might have it. None of them had it but one was willing to help me out and order it. The pharmacists there was also a doctor and he could give me the injections. When they said they could order it I was surprised to hear that it would be in the next day as things usually take weeks to get anywhere.
So the next day I would finally be able to start my road to recovery. I walked into the Aloe Farmacia and introduced myself to the man who would see my bare ass more than any other man in the world, Dr. Viales. I obviously became a regular at the pharmacy due to my daily injections. As the days went on, I finally saw signs of retreat from the infection. Along with this however came an extremely sore backside. Even with rotating sides each day, it felt like I had two small breast implants just above each ass cheeks.
