|CASE IN POINT: DERMATOLOGY
|Year : 2015 | Volume
| Issue : 1 | Page : 40-41
Unusual presentation of borderline tuberculoid leprosy
Peerzada Sajad1, Iffat Hassan1, Yasmeen J Bhat1, Syed Mubashir1, Syed Imtiyaz2, Waseem Qureshi3
1 Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Pathology, Government Medical College, Srinagar, Jammu and Kashmir, India
3 Department of Registrar academics, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||26-Oct-2015|
Dr. Iffat Hassan
Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sajad P, Hassan I, Bhat YJ, Mubashir S, Imtiyaz S, Qureshi W. Unusual presentation of borderline tuberculoid leprosy. Astrocyte 2015;2:40-1
|How to cite this URL:|
Sajad P, Hassan I, Bhat YJ, Mubashir S, Imtiyaz S, Qureshi W. Unusual presentation of borderline tuberculoid leprosy. Astrocyte [serial online] 2015 [cited 2022 Jul 3];2:40-1. Available from: http://www.astrocyte.in/text.asp?2015/2/1/40/168254
Leprosy also known as Hansen's disease is a chronic infection with the oldest known bacterium (Mycobacterium leprae), which mainly affects skin, peripheral nerves, eyes, and testes. Leprosy mainly affects those areas of skin that have a relatively lower temperature and are more exposed to trauma. Certain sites such as scalp, eyelids, axillae, palms and soles, groins, genitalia, lumbosacral area, midline of the back, and perineum have been described as immune to the development of leprosy lesions, but recent studies have reported the development of lesions at these sites also, hence these sites are relative rather than absolute immune zones in leprosy.,
We report the case of a 28-year-old male patient, normotensive, nondiabetic, nonsmoker, laborer by occupation who presented with chief complaints of reddish raised lesions with decreased sensations over the right hand and right side of face of 25 days duration. There was no history of similar lesions in the past or other family members, and no history of any constitutional symptoms. There was no history of epistaxis, rhinorrhea, nasal stuffiness, cough, chest pain, dyspnea, epigastirc discomfort, dysphagia, constipation, oliguria or anuria, and swelling of hands/feet. On examination, there was a well-defined erythematous indurated plaque over the palmar aspect of right middle finger and adjacent area of palm in an apron distribution. Another erythematous indurated plaque with central blister was present over the distal portion of right middle finger. A small satellite lesion was noticed adjacent to the main plaque over the centre of the palm. Sensations of temperature and fine touch were decreased over the lesions. Less sweating was also noticed clinically over the lesions. A similar well-defined erythematous plaque was present over the right side of face. The sensations and appendages were intact over this lesion [Figure 1] and [Figure 2].
|Figure 1: Erythematous indurated plaques over the right palm and middle finger, with a small satellite lesion over the centre of palm.|
Click here to view
Examination of peripheral nerves revealed enlarged but nontender greater auricular and ulnar nerves on the right side. The motor examination was normal. A differential diagnosis of borderline tuberculoid leprosy, granuloma annulare, cutaneous sarcoidosis, and annular lichen planus was made.
Baseline investigations such as complete blood count (CBC), liver function tests (LFT), renal function tests (RFT), urine examination, chest X-ray, and ultrasonography of abdomen were normal. Slit skin smear was done (from ear lobes, eyebrows, and the lesion over right palm), which was negative. Skin biopsy for histopathological examination was done, which revealed epidermal atrophy and well-defined tuberculoid like granulomas, showing epitheloid cells, Langhan's giant cells, and lymphocytes in dermis [Figure 3]. Thus a diagnosis of borderline tuberculoid leprosy with grade-1 deformity of right hand was made. The patient was put on World Health Organization (WHO) multidrug therapy and is doing well on follow up.
|Figure 3: Histopathological picture of palmar lesion (×100, Fite-Faraco).|
Click here to view
Leprosy is a chronic bacterial infection with M. leprae, which primarily affects skin and peripheral nerves. There are many forms of leprosy that range from mildest indeterminate form to the most severe lepromatous type, and the type of disease an individual develops depends on the host immune status; with tuberculoid type being seen in those with good immunity and lepromatous form in individuals with poor immunity. Leprosy affects mainly those areas of the skin, which have a relatively lower temperature and are more exposed to trauma. The leprosy lesions are found commonly over the face, knees, elbows, gluteal region, dorsal aspect of the extremities, and trunk. But certain sites such as scalp, palms and soles, genitalia, groins, axillae, eyelids, lumboscaral area, and midline of the back and perineum have been described to be immune to the development of lesions in leprosy. The reason for sparing of these zones has been attributed to the relatively high local temperature. But clinical, histological, and bacteriological involvement of these so-called immune zones have been documented. Hence these immune zones are now called as relative immune zones rather than absolute immune zones of leprosy. In fact there are a number of case reports of involvement of these so-called immune zones in leprosy., Fleury et al. and Malaviya et al. have reported involvement of scalp in borderline and lepromatous leprosy.,
Arora et al. have reported cutaneous lesions of male genitalia in 2.9% of all cases examined. Most of them were of borderline type.
Literature search shows palmoplantar involvement in leprosy to be approximately 10% (in few case series), but these lesions are seen more in case of lepra reactions in borderline types of leprosy (with palmar involvement more than the plantar involvement). Hopkins et al. screened 245 leprosy patients for lesions over certain anatomical locations and found palmar involvement in 17 (6.9%) and planter involvement in 13 (5.9%) cases. Indira et al. carried out a study to assess the frequency of lesions over palms and soles. Of the 280 leprosy patients screened, 28 (10%) showed lesions over the palms and/or soles, 12 (42.8%) had only palmer lesions, 6 (21.4%) had only planter lesions, and 10 (35.7%) had both palmer and planter lesions. Palmoplantar lesions were found in borderline tuberculoid, borderline lepromatous, and polar lepromatous types of diseases.
Leprosy has a predilection for cooler and trauma prone areas of the body. Although palms and soles are trauma prone and cooler areas of the body with rich nerve supply, and are categorized as one of the immune zones in leprosy but are less frequently affected because of the thicker skin and fibrofatty tissue, which results in a high nerve bed temperature. Leprosy is very uncommon in Kashmir (northern most part of India), hence a high degree of suspicion is needed to diagnose it in a nonendemic area like ours and especially in case of unusual sites of involvement like palms and soles. Simultaneously, the reporting of this case is testament to the fact that leprosy can affect any site of the body, hence the term relative immune zones in leprosy seems more appropriate.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Katoch VM, Mukherjee A, Girdhar BK. A bacteriological and histopathological study of apparently normal skin in lepromatous leprosy. Lepr India 1980;52:508-12.
Bechelli LM, Silva DA, Oliviera AB. On the histopathological findings in biopsies of apparently normal skin in cases of leprosy. Int J Lepr 1985;13:175.
Jopling WH, McDougall AC. The disease. In: Handbook of Leprosy. 5th ed. New Delhi: CBS Publications; 1996. p. l0-49.
Kaur S, Kumar B. Study of apparently uninvolved skin in leprosy as regards bacillary population at various sites. Lepr India 1978;50:38-44.
Fleury RL, Tolentino MM, Opromolla OV, Tonello C. Inapparent lepromatous leprosy in the scalp. Int J Lepr 1973.p580.
Malaviya GN, Girdhar BK, Husain S, Ramu G, Lavania RK, Desikan KV. Scalp lesion in a lepromatous patient – case report. Indian J Lepr 1987;59:103-5.
Arora SK, Mukhija RD, Mohan L, Girdhar M. A study of cutaneous lesions of leprosy on male genitalia. Indian J Lepr 1989;61:222-4.
Hopkins R, Denney OE, Johansen FA. Immunity of certain anatomic regions from lesions of skin leprosy. Arch Dermatol 1929;20:767-79.
Indira D, Kaur I, Sharma VK, Das A. Palmoplantar lesions in leprosy. Indian J Lepr 1999;71:167-72.
[Figure 1], [Figure 2], [Figure 3]