A 21 year old female was seen in infectious diseases clinic for persistent non-healing bilateral facial and right neck sores.

She was seen about two months after she had returned from a two month stay in Costa Rica where she had worked on as a volunteer assisting local "organic" farmers. The facial lesions had first appeared approximately one month into her two month stay in Costa Rica. One of the facial lesions is pictured at upper left.

She had found the sores sometimes uncomfortable but otherwise she had felt well. She had had no fevers, chills, or other constitutional symptoms. Topical antibiotic cream, two courses of TMP/SMX, and application of triamcinolone cream had not appeared to provide significant benefit.

In Costa Rica she had spent her days working in small "sustainable" agricultural settings where she assisted local farmers in the cultivation of a variety of fruits and vegetables. Because of concern about possible exposure to dengue fever, she wore protective clothing and made liberal use of insect repellents while working on the agricultural plots. Indeed, she recalled there were a great many flying insects of different varieties. At night she slept in quarters provided by the host farmers. She erected mosquito netting to protect herself from insect exposure.

Prior to her visit to the infectious diseases clinic she had had a biopsy performed of her right neck lesion. A photomicrograph of this biopsy is pictured at lower left.