Dermatology Online Journal

Lepromatous leprosy
Alexandria V Booth MD, Olympia I Kovich MD
Dermatology Online Journal 13 (1): 9

New York University Department of Dermatology

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Abstract

A 51-year-old woman presented with a 2-month history of pruritic, erythematous papules and plaques on her arms that were treated as chronic urticaria. Histopathologic examination demonstrated acid-fast bacilli, and a diagnosis of lepromatous leprosy was made. Presentation and treatment of leprosy are reviewed.

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Clinical synopsis

A 51-year-old Ecuadorian woman presented to the Dermatology Clinic at Bellevue Hospital Center with a 2-month history of a pruritic eruption on her arms that has been treated with hydrocortisone cream in the past without improvement. A diagnosis of chronic urticaria was made. Treatment included triamcinolone acetonide cream twice a day and hydroxyzine 10 mg three times a day as needed for itching. On follow-up evaluation, there was no improvement, and a biopsy was performed. Medications were changed to dapsone 50 mg daily and minocycline 100 mg daily with improvement. Her review of symptoms disclosed numbness of the left arm and leg for a year. Past medical history includes chronic urticaria, hypertension, and hepatitis B virus infection.

Erythematous, edematous papules and plaques with slightly hypopigmented centers were present on the upper extremities.

Figure 1	Figure 2

A chemistry panel was normal.

Histopathology reveals a superficial and deep, perivascular and periadnexal infiltrate of lymphocytes, plasma cells, and a few histiocytes. A Fite stain highlights the presence of scattered acid-fast bacilli.

Comment

The clinical presentation of Hansen disease can vary based on the patient's immune status. Traditionally patients were classified according to the Ridley-Jopling scale, which included indeterminate leprosy, tuberculoid leprosy, borderline tuberculoid leprosy, borderline leprosy, borderline lepromatous leprosy, and lepromatous leprosy. Tuberculoid leprosy represents a sufficient cell-mediated immune response. Patients have one or two, hypopigmented, erythematous, and anesthetic macules with a raised margin [3]. Lepromatous leprosy may occur in the setting of immune dysfunction or if the patient is anergic to Mycobacterium leprae. These patients may have widespread disease that involves the skin, upper respiratory tract, anterior chamber of the eye, testes, lymph nodes, periosteum, and superficial sensory and motor nerves [1]. Cutaneous findings include diffuse, erythematous macules, papules, and nodules [3]. A difference in cytokine response also has been demonstrated in subtypes of Hansen disease, with a primarily TH1 profile expressed in tuberculoid leprosy and borderline tuberculoid leprosy tissue specimens and a TH2 profile in lepromatous leprosy tissue specimens [1].

The Ridley-Jopling scale has been replaced by the World health Organization system, which categorizes disease as either paucibacillary or multibacillary. Paucibacillary leprosy is defined as five or fewer skin lesions with the absence of bacilli in skin smears. Multibacillary leprosy is defined as six or more skin lesions and positive skin smear [3]Citation:Dermatology Online Journal 13 (10):

The presentation of Hansen disease can be variable and often is misdiagnosed. Case reports include initial diagnoses of contact dermatitis, tinea corporis, and chronic urticaria [3, 4]. The average time to diagnosis in the United States is two years from presentation.

The World health Organization multidrug regimen has been in use since 1982. Patients with paucibacillary disease receive a six-month course of rifampicin 600 mg monthly and dapsone 100 mg daily. Patients with multibacillary disease receive a 24-month treatment of rifampicin and dapsone at the same dosages in addition to clofazimine 300 mg monthly and 50 mg daily. The WHO technical advisory group noted that patients with multibacillary disease could probably be treated for a 12-month course; however, long-term relapse data are not available, and most healthcare providers continue with the 24-month course. Minocycline, certain macrolides, and some of the fluoroquinolones have shown efficacy in mousepad models [5]. Patients presenting with new muscle weakness or sensory loss should be treated with a course of prednisolone with an initial dose of 30-40 mg daily [7].

References

1. Ooi W, Moschella S. Update on leprosy in immigrants in the United States: status in the year 2000. Clin Infect Dis 2001; 32:930

2. Bureau of Primary Health Care: The National Hansen's Disease Programs. www.bphc.hrsa.gov/nhdp

3. Hartzell J, et al. Leprosy: a case series and review. South Med J 2004; 97:1252

4. Barman KD, et al. Sub-polar lepromatous leprosy presenting as urticarial wheals: a case report. Indian J Lepr 2004; 76:223

5. Ustianowski A, Lockwood D. Leprosy: current diagnostic and treatment approaches. Curr Opin Infect Dis 2003; 16:421

6. Haimanot RT, Melaku Z. Leprosy. Curr Opin Neur 2000; 13:317

7. Lockwood D, Kumar B. Treatment of leprosy. Br Med J 2004; 328:1447

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