ear mass

A 25-year-old male who was previously healthy presents to the emergency department with a painful left posterior ear mass. The mass began as a “pimple” and has been increasing in size for the last 6 months. He has an associated headache, dizziness, and malaise. He denies fever, trauma, drainage, known insect bite, dysphagia, dyspnea, trismus, and hearing loss. He emigrated to the United States from Honduras 8 months ago. He was seen in the emergency department 4 months prior for a similar complaint, which was diagnosed as lymphadenopathy by point-of-care ultrasound.

Vitals: BP 129/67; HR 55; RR 16; Oxygen Saturation 100%; Temperature 97.9°F


  • Conjunctiva without erythema or drainage
  • Left auricle anteriorly displaced and not tender to palpation, normal auditory canal, and normal tympanic membranes
  • No mucosal erythema or edema
  • Moist mucous membranes, oropharynx is without erythema or edema, uvula is midline and without edema, no trismus noted
  • Left submandibular and submental lymphadenopathy


  • 3×5-centimeter ovoid erythematous hyperkeratotic plaque posterior to the left auricle with raised borders and central desquamation
  • The lesion is soft and tender, but there is no fluctuance or drainage.
  • There is slight erythema tracking inferiorly down the neck and superiorly to the hairline.

The remainder of the exam is unremarkable


Leishmaniasis comprises a complex of vector-borne diseases caused by a group of protozoa of the genus Leishmania.

It is transmitted by bites from the sand fly, which lives close to animal reservoirs.

There are three categories of leishmaniasis: cutaneous leishmaniasis, visceral leishmaniasis, and mucocutaneous leishmaniasis.

Approximately 75% of cutaneous leishmaniasis is reported from ten countries in the Middle East, North Africa, and Central and South America [1]. Clinical manifestations range from cutaneous ulcers to systemic multiorgan disease [2]. Localized cutaneous leishmaniasis consists of cutaneous lesions on exposed areas of the skin. The ear is the area most likely to be affected, followed by the nose, upper lip, cheeks, legs, distal upper extremities, and ankles. It begins as a pink-colored papule that enlarges and develops into a nodule or plaque-like lesion (often with central softening), leading to usually painless ulceration with an indurated border. In the photo, we can see the classic Chichlero’s ulcer, an eponym used for localized cutaneous leishmaniasis involving the ear. A diagnosis is made by a biopsy sent for histology, culture, and polymerase chain reaction (PCR) [3].

Take-Home Points

  • Leishmaniasis is transmitted by the sand fly (which is endemic in multiple parts of the world, including the Middle East, North Africa, Central and South America).
  • The disease has cutaneous, visceral, and mucocutaneous forms.
  • Typical therapy involves topical antifungals, though systemic therapy with azoles or amphotericin may be indicated in refractory or complex cases.
  1. CDC – Leishmaniasis. Centers for Disease Control and Prevention. https://www.cdc.gov/parasites/leishmaniasis/. Accessed March 19, 2020.
  2. Torres-Guerrero E, Quintanilla-Cedillo MR, Ruiz-Esmenjaud J, Arenas R. Leishmaniasis: a review [version 1; peer review: 2 approved]. F1000Research. 2017;6(750). doi:10.12688/f1000research.11120.1 PMID: 28649370
  3. Aronson N, Herwaldt BL, Libman M, et al. Guidelines Diagnosis and Treatment of Leishmaniasis : Clinical Practice Guidelines by the Infectious Diseases Society of America ( IDSA ) and the American Society of Tropical Medicine and Hygiene ( ASTMH ) *. Am J Trop Med Hygeine. 2017;96(1):24-45. doi:10.4269/ajtmh.16-84256 PMID: 27927991

Gabriela Rivera-Camacho, MD

Gabriela Rivera-Camacho, MD

Atrium Health - Carolinas Medical Center
Gabriela Rivera-Camacho, MD

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Adeline Dozois, MD

Adeline Dozois, MD

Assistant Professor of Emergency Medicine
Atrium Health – Carolinas Medical Center
Adeline Dozois, MD

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