Facial ulcerations and neurologic symptoms in a farmer

Abstract

A 47-year-old immunocompetent man presented with a 2-month history of ulcers on the face (Fig 1). He worked in a rural area in the state of Pará, northern Brazil, was a smoker, and had an alcohol use disorder. He had a 3-month history of weight loss, tetraparesis, reduced visual acuity, and vertical nystagmus. Magnetic resonance imaging showed multiple bilateral brain lesions with marginal contrast enhancement (Fig 2). Cerebrospinal fluid findings were nonspecific. Skin samples were collected for culture and histopathologic examination and stained with hematoxylin-eosin and Grocott methenamine silver (Fig 3).