isolates of L. amazonensis from any res- ervoir or from sandﬂies. The data avail- able for isolates from humans [4–7], from domestic and wild reservoir hosts [4, 6], and from sandﬂies [4, 6, 8, 9] support our statement: Leishmania (Viannia) braziliensisis is the only known agent of cutaneous leishmaniasis in the state of Ceará. In a large study of 272 human isolates from 39 different municipalities, all were characterized as L. braziliensis [5]. In another report [6], the author studied 354 isolates from humans, rodents, dogs, and sandﬂies; all were characterized as L. braziliensis. Fur- thermore, because the patients in our study were from several different endemic areas, the hypothesis that the response of our patients was due to as- peciﬁc clinical syndrome caused by L. braziliensis from a speciﬁc endemic area is not true. The lymphadenopathy de- scribed in L. braziliensis infection [5] has been documented in other regions of Brazil, and its detection depends on the moment patients seek medical atten- tion and on a comprehensive physical examination because this lymphade- nopathy is an early manifestation of infection and, as a rule, the lymphade- nopathy is painless and abates as the ulcer progresses. There is evidence that 1 strain of L. braziliensis from 1 region may be genetically different from another strain from other regions [10], and it is possible that these strains may respond differently to therapy. Hence, it is critically important that ﬂuconazole be tested in other areas where L. brazil- iensis and other species of Leishmania are endemic, keeping in mind that optimal weight-based dosing is very likely to be an important determinant of therapeutic success [1]. Note Potential conﬂicts of interest. All authors: No reported conﬂicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conﬂicts of Interest. Conﬂicts that the editors consider relevant to the content of the manuscript have been disclosed. Anastácio Q. Sousa,1,2 Margarida M. L. Pompeu,3 Mércia S. Frutuoso,5,6 Elisabete A. Moraes,4 and Richard D. Pearson7 1Hospital São José for Infectious Diseases; 2Department of Internal Medicine; 3Department of Pathology; 4Department of Physiology and Pharmacology; 5School of Medicine, Federal University of Ceará; 6Christus School of Medicine, Fortaleza, Brazil; and 7Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville References 1. Sousa A, Frutuoso M, Moraes E, Pearson RD, Pompeu M. High-dose oral ﬂuconazole therapy effective for cutaneous leishmaniasis due to Leishmania (Vianna)braziliensis. Clin Infect Dis 2011; 53:693–5. 2. Grimaldi G, David JR, McMahon-Pratt D. Identiﬁcation and distribution of new world Leishmania species characterized by sero- deme analysis using monoclonal antibodies. Am J Trop Med Hyg 1987; 36:270–87. 3. Vasconcelos IAB, Vasconcelos AW, Momen H, Grimaldi G Jr, Alencar JE. Epidemiologi- cal studies on American leishmaniasis in Ceará State, Brazil. Molecular characteriza- tion of the Leishmania isolates. Ann Trop Med Parasitol 1988; 82:547–54. 4. Vasconcelos IAB, Vasconcelos AW, Fe Filho NM, et al. The identity of Leishmania isolat- ed from sand ﬂies and vertebrate hosts in a major focus of cutaneous leishmaniasis in Baturite, northeastern Brazil. Am J Trop Med Hyg 1994; 50:158–64. 5. Sousa AQ, Parise ME, Pompeu MM, et al. Bubonic leishmaniasis: a common manifesta- tion of Leishmania (Viannia) braziliensis in- fection in Ceara, Brazil. Am J Trop Med Hyg 1995; 53:380–5. 6. Vasconcelos IAB. Epidemiologie de la leish- maniose cutanée dans un foyer de L’état du Ceara (Bresil). déﬁnitions des parasites impliqués [thèse]. Paris: Universite Paris XII de Marne, Faculte de Medicine de Creteil, 1996. 7. Harms G, Fraga F, Batroff B, Oliveira F, Feld- meier H. Cutaneous leishmaniasis associated with extensive lymphadenopathy during an epidemic in Ceara State, northeast Brazil. Acta Trop 2005; 93:303–10. 8. Azevedo ACR, Rangel EF, Costa EM, David JR, Vasconcelos AW, Lopes UG. Natural in- fection of Lutzomyia (Nissomyia) whitmani (Antunes & Coutinho, 1939,) by Leishmania of the braziliensis complex in Baturité, Ceará State, northeast Brazil. Mem Inst Oswaldo Cruz 1990; 85:251. 9. Queiroz RG, Alencar IAB, Vasconcelos AW, Pessoa FAC, Sousa RN, David JR. Cutaneous leishmaniasis in Ceará State in northeastern Brazil: incrimination of Lutzomyiawhitmani (Diptera: Psychodidae) as a vector of Leish- mania braziliensis in Baturité municipality. Am J Trop Med Hyg 1994; 50:693–8. 10. Gomes RF, Macedo AM, Pena SD, Melo MN. Leishmania (Viannia) braziliensis: genetic relationships between strains isolated from different areas of Brazil as revealed by DNA ﬁngerprinting and RAPD. Exp Parasi- tol 1995; 80:681–7. Correspondence: Anastácio Q. Sousa, MD, PhD, Rua Nestor Barbosa 315, Parquelândia, CEP 60455-610, Fortaleza, Ceará, Brazil (aqsousa@gmail.com). Clinical Infectious Diseases 2012;55(2):309–10 © The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com. This is an Open Access article distribu- ted under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. DOI: 10.1093/cid/cis399 310 CID 2012:55 (15 July) CORRESPONDENCE