A 17-year-old Afghani girl who had lived in the United States for 4 years presented with a 6-month history of bilateral pretibial ulcerations. The patient was born in Kabul, Afghanistan, but soon after was displaced to refugee camps in Northeastern Pakistan. Subsequent to her relocation to the United States, she had no history of travel. The patient denied a history of preceding trauma to the lower extremities but reported a 9.1-kg weight loss over the previous 8-month period. In addition, she reported epigastric and hypogastric pain and extreme fatigue affecting her daily activities and school performance. Examination revealed a thin girl with nontender splenomegaly. A skin examination revealed 2 ulcerations, one 4 × 2 cm, the other 2 × 2 cm, on the pretibial aspects of her lower extremities (Figure 1). Skin biopsy specimens were obtained for routine histologic tests and tissue culture. Findings from a chest radiograph and tests for antinuclear antibody, human immunodeficiency virus, stool guiaic, and urine Histoplasma antigen were reported as within the reference range or negative. Serum aspartate aminotransferase and alanine aminotransferase levels were found to be slightly elevated (36 U/L and 39 U/L, respectively, upper limit of normal range, 32 U/L [to convert to microkatals per liter, multiply by 0.0167]). She had evidence of mild anemia with a hemoglobin level of 10.9 g/dL (reference range, 11.5-14.5 g/dL [to convert to grams per liter, multiply by 10.0]), but other blood cell counts were within the reference range. Tests with tissue fungal and mycobacterial stains and cultures were negative. However, skin histologic findings revealed the presence of predominantly intracellular and few extracellular microorganisms suspicious for amastigotes (Figure 2). Given the high clinical suspicion for leishmaniasis, additional tissue specimens were obtained and sent with serum to the Laboratory of Parasitic Diseases of the Centers for Disease Control and Prevention, Atlanta, Georgia. Findings from a tissue smear demonstrated the presence of amastigotes on light-microscopic examination; tissue culture using Novy, McNeal, and Nicolle media with 10% defibrinated rabbit blood with 15% fetal calf serum was positive, and isoenzyme electrophoresis results yielded L tropica. Serum indirect immunofluorescent antibody (using whole promastigotes of L donovani) titer for L tropica was elevated at 1:64 (diagnostic titer >1:16), which, given her systemic signs and symptoms, was highly suggestive evidence of visceral dissemination of L tropica in this patient.