“Is that contagious?”

HPI: Previously healthy 16 y/o male on return from a 4 year stay in

Nigeria presented with a rash on his face, back and upper and lower extremities that had become more prominent over the past four months

The rash was first noted on his lower extremities 12 months earlier and was initially pruritic but the involvement of his upper extremities and face was non-pruritic and painless

Seen by physicians in Nigeria 6 months earlier and was given a powder to apply to the rash on his lower extremities which did not improve his symptoms

Applying olive oil to the rash on his face with no relief

Denied fevers, weight loss, visual or neurologic deficits

Denied sick contacts including anyone with tuberculosis

PMH: None Medications: None Immunizations: Up to date Social History: Born in Nigeria and immigrated to the U.S. at age 2 Attending boarding school in Nigeria for the past 4

years. He reported no classmates or teachers with similar dermatologic symptoms. While in Nigeria had had visited a rural village where

there was no running water Exposure to goats, cows, and chickens. Denies sexual

activity, alcohol, or drug use

PE: T: 36.8 °C, BP: 116/67, HR: 67, RR: 18 GEN: Comfortable, pleasant male with obvious

lesions on face EXT: 2 + pitting edema was noted up to his knees

bilaterally. SKIN: Lichenified skin was noted on both shins.

Papules, nodules, and plaques were noted on his face, ears, upper and lower extremities with sparing of the trunk. Some hypopigmented patches were noted on his back.

NEURO: There was prominence of the temporal, ulnar and popliteal nerves. Neurologic exam was grossly intact. All sensation was normal including fine touch and proprioception.

Remainder of exam was normal

Studies: CBC: WBC 6.84 Thou/uL (S-68%, L-22%, M-4%, E-6%) Hgb 12.6 g/dL Hct-37.3% Plt-279 Thou/uL

Chemistries and LFTs: Normal UA: Normal Chest x-ray: Normal HIV ELISA: Negative

Differential Diagnosis

1) Cutaneous leishmaniasis 2) Cutaneous onchocerciasis

(Onchocerca volvulus) 3) Lepromatous leprosy

(Hansen’s Disease) 4) Mycobacterium marinum 5) Human Immunodeficiency

Virus (HIV) type 2 infection 6) Fungal dermatitis 7) Allergic reaction to

homeopathic therapy

Diagnosis and Follow-up Ziehl-Neelsen staining did not

identify acid fast organisms but a modified Fite-Faraco stain demonstrated numerous bacilli within histiocytes consistent with Mycobacterium leprae

He was started on dapsone,

rifampin and clofazimine

Noticeable reduction in size and distribution of lesions after 6 months of therapy

Will undergo a skin biopsy after 12 months of therapy to guide duration of therapy. Plans are for a minimum of 24 months of treatment

Leprosy (Hansen’s Disease) Disease caused by bacillus Mycobacterium leprae

Spectrum of disease manifestations related to cell

mediated immune response

Highly infectious but low virulence - Believed to be spread by direct contact or nasal droplet - Skin and peripheral nerves most affected organs

Incubation period 2-5 Years

Leprosy: Keys to Diagnosis

Diagnosis is Clinical: Hypopigmented or erythematous anesthetic plaque

“Leonine Facies” and madarosis

Peripheral Nerve Thickening

Decrease in peripheral sensation to fine touch and

vibration

Treatment and Prognosis Multi-drug Therapy: Dapsone Rifampin Need to check for G6PD and TB Clofazimine prior to initiating therapy

Recommended length of therapy is minimum of 2 years

Goal of therapy is prevention of permanent nerve damage

Leprosy is curable

Final Diagnosis

Lepromatous Leprosy (Hansen’s Disease) caused by Mycobacterium leprae