A forty-five-year-old black male patient from Apucarana,Parana, with one atypical lesion on the right side of his back was attended, in March 2009, in the LEPAC (Laboratorio de Ensino e Pesquisa em Analises Clinicas) of the Universidade Estadual de Maringa, for cutaneous leishmaniasis (CL) laboratory diagnosis. The patient reported that the lesion had been present for approximately one month (Fig. 1A). The lesion was a rounded plaque, with a erythematous violaceous center, descamative ulcerated edges, surrounded by an extensive area of lichenification, measuring 20 cm. Based on clinical appearance, the differential diagnosis of the lesion included chronic simple lichen, psoriasis, squamous cell carcinoma, chromomycosis, cutaneous tuberculosis, syphilis, paracoccidioidomycosis, and sarcoidosis. Before seeking for medical attention, the patient used topical antibiotics, but the lesion persisted without improvement. The performed tests showed a positive Montenegro skin test (MST) with an induration of 10 mm and indirect immunofluorescence (IIF) positive for anti-Leishmania IgG antibodies, reaching a titer of 80.Leishmania amastigotes were detected in the material obtained by scraping of the lesion stained by Giemsa (Fig. 1B) and cultured in blood base agar (BBA). The BBA grown parasites were sent to the Colecao de Leishmania of Instituto Oswaldo Cruz (CLIOC), Rio de Janeiro, Brazil, for identification and the strains were confirmed as L. (V.) braziliensis (MHOM/BR/2009/3476). The species identification was performed by multilocus enzyme electrophoresis (MLEE). To exclude the possibility of coexisting infections, fungi and HIV investigations were performed with negative results. 
The patient was treated with 120 ampoules of intramuscular meglumine antimoniate (approximately 15 mg/kg Sb5+ per day) in three cycles of 20 days each at the Pronto Atendimento Municipal of Apucarana municipality. Approximately 40 days after the end of treatment (August 2009) the lesion was still active and new laboratory tests were performed. The IIF test was positive with a titer of 160 and the direct parasite search was negative. 
About six months later (May 2010) the patient was submitted to another treatment with intravenous pentamidine (4 mg/kg per day) for seven days, which resulted in apparent healing of the lesion. In June 2010, the values of serum amylase (87 U/L) and creatinine (1.0 mg/dL) were normal. However, some months later, new papular lesions emerged, ulcerated and spread to the axillary region. In November 2010, the patient was admitted for treatment with amphotericin B desoxycholate (50 mg/day). The treatment was discontinued after three doses because the values of serum urea (88 mg/dL) and creatinine (3.1 mg/dL) were increased indicating renal failure. One additional course of pentamidine for 10 days was established (April 2011). There was a partial clinical resolution of lesions with the patient still presenting some residual lesions. 
In February 2012, about three years after the onset of the lesion and despite the multiple treatments, the lesion was not healing. The lesion was an ulcerated plaque with erythematous fibrous bottom and verrucous edges, surrounded by a lichenification area in the right scapular region and posterior region of the right arm (Fig. 1C). New laboratory tests were performed. The direct parasite search revealed the presence of characteristic amastigotes of Leishmania spp., the IIF showed titer 320, and the polymerase chain reaction (PCR) for kDNA minicircles of the subgenusLeishmania (Viannia) was positive.
The patient was treated again with meglumine antimoniate by the intravenous route (3 ampoules per day) for approximately 40 days. Following this treatment, the lesion healed. Unfortunately, about a year after the end of the treatment, the patient died of a heart attack.