Leprosy – Old wine in new bottle

Panchatsharam Adithyan, Bittanakurike Narasappa Raghavendra, Anjan Kumar Patra

Department of Dermatology, MVJ Medical College and Research Hospital, Bengaluru, India

Corresponding author: Adithyan Panchatsharam, MD

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How to cite this article: Adithyan P, Raghavendra BN, Patra AK. Leprosy – Old wine in new bottle. Our Dermatol Online. 2022;13(e):e13.

Submission: 27.09.2021; Acceptance: 05.01.2022

DOI: 10.7241/ourd.2022e.13

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ABSTRACT

Leprosy is a public health problem and despite India achieving the goal of elimination of leprosy it is still being transmitted in India. 42 year old male presented with Complaints of red raised lesions all over the body since 1 year. Examination revealed multiple erythematous plaques and nodules over face, trunk, bilateral upper limbs, lower limbs. Erythematous plaques with central necrosis present over left forearm and arm. 28 Year old male presented with complaints of raised lesions over upper limbs, lower limbs, lower back since 6 months. Examination revealed multiple well defined papules, annular plaques over the extensor aspect of forearm, leg, back, buttocks. 22 year old male patient presented with complaints of hypopigmented patches over lower back since 6 months. Cutaneous examination revealed multiple ill defined, hypopigmented, hypoesthetic patches over lower back. Due to variable clinical presentation, lack of clinical suspicion and appropriate investigations such cases may not be diagnosed.

Key words: Leprosy; Communicable; Elimination; Atypical

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INTRODUCTION

Leprosy also known as Hansen’s disease caused by the bacillus Mycobacterium leprae is a chronic infectious disease with various epidemiological characteristics and clinical manifestations. Leprosy predominantly affects the skin and peripheral nerves since M. leprae prefers cooler temperature of <37°C [1]. Despite achieving leprosy elimination at the global level in December 2000 and at national level on January 30,2006 [2] leprosy is still endemic in many developing countries, with majority of cases detected in countries like India, Brazil, Madagascar, and Nepal [3,4]. However, due to decreased clinical suspicion of leprosy and atypical case presentations, such cases may be not be diagnosed. In this report we describe 3 cases of Hansens disease with varied presentation

CASE REPORTS

Case 1

42 year old male presented with Complaints of red raised lesions all over the body since 1 year &amp; fever since 6 days. Previously he was treated with oral methylprednisolone 8mg BD, Azithromycin 500mg, Ofloxacin 200mg BD in local hospital for a period of 6 months. (Diagnosis not documented).Cutaneous examination revealed diffuse infiltration with multiple erythematous, edematous, hypoesthetic, tender plaques and nodules over face, trunk (Figs. 1a and 1b) bilateral upper limbs and lower limbs. Erythematous plaques with central necrosis (erythema necroticans) (Fig. 1c) present over left forearm and arm. Both ulnar nerve, common peroneal nerve, Anterior and posterior tibial nerves was thickened, firm &amp; non tender. Glove and stocking anaesthesia was present. No visible deformity and no muscle weakness was seen. Slit-skin smear for acid-fast bacilli (AFB) (lepromatous) was found to have a bacteriological index of 6+ (Fig. 1d). Skin biopsy for histopathological examination was consistent with lepromatous leprosy. He was diagnosed as a case of Lepromatous leprosy (LL) in Type-II lepra reaction (erythema nodosum leprosum) and was started on WHO multibacillary multidrug therapy (WHO MDT).

Figure 1: (a) Erythematous nodules over face (b) Erythematous plaques over back (c) Erythema necroticans (d) Acid fast bacilli.

Case 2

A 28 Year old male presented with complaints of raised lesions over upper limbs, lower limbs, and lower back since 6 months. There was no history of itching. Cutaneous examination revealed multiple well defined papules, annular plaques over the extensor aspect of forearm, (Fig. 2) leg, back, buttocks. There was no nerve enlargement, visible deformity or muscle weakness. Slit-skin smear for acid-fast bacilli (AFB); (lepromatous) was found to be negative. Skin biopsy for histopathological examination showed features of borderline tuberculoid leprosy. Fite Faraco and Ziehl Neelsen stain was non contributory whereas Auramine Rhodamine stain was positive. CB NAAT was negative for mycobacterium tuberculosis. He was diagnosed as a case of Borderline tuberculoid leprosy and was started on WHO paucibacillary multidrug therapy.

Figure 2: Papules,annular plaques over forearm.

Case 3

A 22 year old male patient presented with complaints of hypopigmented patches over lower back since 6 months. Cutaneous examination revealed multiple ill defined, hypopigmented, hypoesthetic patches over lower back (Fig. 3). Left ulnar nerve &amp; Right posterior tibial nerve was thickened, firm &amp; non tender. There was no visible deformity or muscle weakness. Slit-skin smear for acid-fast bacilli (AFB) (lepromatous) was found to be negative. Skin biopsy for histopathological examination showed features suggestive of chronic non-specific dermatitis. Auramine- Rhodamine stain was positive. Final Diagnosis of Borderline Tuberculoid Hansen’s was made. (Indeterminate downgrading to BT). Patient was started on WHO MDT.

Figure 3: Hypopigmented patches over back.

DISCUSSION

Patients suffering from leprosy exhibit a wide spectrum of presentation ranging from tuberculoid to the lepromatous pole, with the immunologically unstable borderline forms in-between, depending upon the immune status of the individual [4,5]. Tuberculoid leprosy indicates a high cellular immune response and few bacilli in tissues and at the opposite pole lepromatous leprosy indicates an absent cellular immune response to Mycobacterium leprae antigen. The spectrum of leprosy is a continuum and patients may move in either direction according to host response and treatment.

In our first case the patient was treated irrationally with steroids, azithromycin, ofloxacin &amp; was not on classical MB-MDT before coming to our OPD. The second case was misinterpreted as papular variety of granuloma annulare considering the morphology of skin lesions. Skin biopsy and Auramine Rhodamine positivity helped in clinching the diagnosis inspite of slit skin smear and other special stains like fite faraco showing no features. The third case again was diagnosed with Auramine Rhodamine positivity in spite of SSS &amp; HPE showing no features.

CONCLUSION

Variable clinical presentations of leprosy depending on bacterial load and loss of mycobacterium leprae specific cellular immunity make it difficult to arrive at an accurate diagnosis thereby emphasizing the need for appropriate investigations in every suspect case.

Consent

The examination of the patient was conducted according to the principles of the Declaration of Helsinki.

The authors certify that they have obtained all appropriate patient consent forms, in which the patients gave their consent for images and other clinical information to be included in the journal. The patients understand that their names and initials will not be published and due effort will be made to conceal their identity, but that anonymity cannot be guaranteed.

REFERENCES

1. Hastings RC. The microbiology of leprosy. In:Leprosy. 1^st ed. Edinburgh:Churchill Livingstone;1985. 37.

2. Sasidharanpillai S, Reena Mariyath OK, Riyaz N, Binitha MP, George B, Janardhanan AK, et al. Changing trends in leprosy among patients attending a tertiary care institution. Indian J Dermatol Venereol Leprol. 2014;80:338-40.

3. World Health Organization, “Global leprosy update, 2014:need for early case detection,“The Weekly Epidemiological Record, vol. 90, no. 36, pp. 389–400, 2015.

4. Paudel D, Sah BP, Bhandary S. Isolated leprosy of pinna masquerading perichondritis:a rarest entity. Am J Med Case Rep. 2014;2:87-9.

5. Clapasson A, Canata S. Laboratory investigations, in Leprosy:A Practical Guide, E. Nunzi and C. Massone, Eds., pp. 55–82, Springer, Milan, Italy, 1^st edition, 2012.

Notes

Source of Support: Nil,

Conflict of Interest: None declared.