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CONCISE COMMUNICATION
Year : 2020  |  Volume : 11  |  Issue : 4  |  Page : 632-634  

A masquerading solitary skin lesion: Unusual presentation of multibacillary leprosy with dermoscopic assistance in diagnosis


1 Department of Dermatology and Venereology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Web Publication13-Jul-2020

Correspondence Address:
Naveen Kumar Kansal
Department of Dermatology and Venereology, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_495_19

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How to cite this article:
Kansal NK, Joshi PP, Dhanta A, Hazarika N, Divyalakshmi C. A masquerading solitary skin lesion: Unusual presentation of multibacillary leprosy with dermoscopic assistance in diagnosis. Indian Dermatol Online J 2020;11:632-4

How to cite this URL:
Kansal NK, Joshi PP, Dhanta A, Hazarika N, Divyalakshmi C. A masquerading solitary skin lesion: Unusual presentation of multibacillary leprosy with dermoscopic assistance in diagnosis. Indian Dermatol Online J [serial online] 2020 [cited 2020 Aug 6];11:632-4. Available from: http://www.idoj.in/text.asp?2020/11/4/632/289629



Sir,

A 35-year-old otherwise healthy male presented to the dermatology outpatient department with a single asymptomatic lesion on his left forearm since 1 month. He had no other cutaneous or systemic complaints. On examination, a solitary, well-defined, normoaesthetic, erythematous plaque of about 3 × 2 cm size with prominent follicular openings was present over the distal extensor surface of the left forearm [Figure 1]. The rest of the cutaneous, peripheral nervous system and systemic examination were insignificant. Dermoscopic examination of the lesion (with a Dermlite DL4 third-generation dermoscope, original magnification ×10, polarized noncontact) was performed which revealed diffuse reddish-brown background with multiple ill-defined orange-brown globules at places. Central whitish streaks with multiple arborizing vessels in the periphery were also seen [Figure 2]. Clinical differential diagnoses of extrafacial granuloma faciale, sarcoidosis, and pseudolymphoma were considered. The pathological examination of the biopsy specimen from lesion revealed an atrophic epidermis with a narrow grenz zone. There was a diffuse lymphohistiocytic infiltrate in the papillary and reticular dermis with a diffuse collection of epithelioid cells and foamy histiocytes [Figure 3]. The Wade-Fite stain was strongly positive for acid-fast bacilli. Therefore, the pathological report was consistent with a diagnosis of lepromatous leprosy. At the follow-up visit 1 month later, the patient presented with few erythematous papules on the flanks [Figure 4]. A slit-skin smear from lesions on flanks was positive for acid-fast bacilli with a bacillary index of 3.5. With a final diagnosis of multibacillary (MB) lepromatous leprosy, the patient was started on the World Health Organization multibacillary multidrug therapy (WHO MB-MDT).
Figure 1: Normoaesthetic erythematous plaque on the left forearm

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Figure 2: Dermoscopic examination of the lesion revealed diffuse reddish-brown background with multiple ill-defined orange-brown globules (black circle) at places. Central whitish streaks (red arrow) with multiple arborizing vessels (black arrow) in the periphery are also seen

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Figure 3: Vague collection of epithelioid cells and foamy histiocytes in the dermis. (H and E, original magnification, 40×)

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Figure 4: Asymptomatic erythematous papules on the flank at the follow-up visit after 1 month

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Leprosy (Hansen's disease) is a chronic, granulomatous, multisystem infection caused by the acid-fast bacillus Mycobacterium leprae, and may present with a wide range of clinic-patho-serologic manifestations (especially in the MB patients e.g., lepromatous, histoid variants, etc.), therefore, also known as a great mimicker.[1],[2] Still, the disease is more likely to present with typical manifestations, with a field diagnosis easily considered/possible in the “endemic” regions with the WHO's cardinal signs.[3] However, a number of atypical presentations of the disease have been described, which may sometimes present a challenge even to the trained eyes of an insightful dermatologist.

Classically, the MB lepromatous disease presents as multiple red-brown nodular infiltrates (lepromas) in the skin and mucous membranes occurring symmetrically. The lepromatous pole presenting as a solitary lesion is one of the rarest presentations, with only a few cases reported in the literature.[4],[5],[6],[7] The propensity of leprosy for unusual presentations is likely to lead to an undue delay in the correct diagnosis. The patient described by Yoder et al. had a single erythematous plaque on the left elbow with loss of sensation to touch and to pinprick, which indicated the possibility of leprosy.[4] However, in our case, there was no sensory loss on the lesion or anywhere else in the body and there was no peripheral nerve thickening, further obscuring the clinical diagnosis. Although the precise etiology of this presentation is not known, it has been hypothesized that minor trauma, direct exposure to M. leprae or low temperature could possibly be the pathomechanism.[5],[6] Apart from microbiologic and pathologic examinations, dermoscopy has been useful with certain subtle clues and is likely to expand the armamentarium of diagnostic methodology in leprosy. Under a dermoscope, yellow-orange structures in combination with linear vessels in branching patterns indicate a granulomatous process. In the present case, however, dermoscopy also demonstrated a whitish-yellow area with streaks, which has not been observed in previous observations in granulomatous conditions. The dermoscopic finding of whitish-yellow color with streaks, as seen in our case, is attributable to the peculiar whorled arrangement of histiocytes in the multibacillary granuloma of leprosy.[8]

To conclude, lepromatous (MB) leprosy presenting as a solitary clinical lesion is a rare occurrence. Dermoscopic features as seen in our patient, along with a slit-skin smear certainly help the clinician by providing early vital diagnostic clues. Although many countries have achieved the elimination of leprosy (defined as a public health problem), early diagnosis and management remain essential for the eradication of this chronic and mutilating disease.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Weller RB, Hunter HJ, Mann MW. Clinical Dermatology. 5th ed. Oxford: John Wiley & Sons; 2015 p. 224.  Back to cited text no. 1
    
2.
Kansal NK, Hazarika N, Upadhyaya A, Joshi PP. Umbilicated lesions in a de novo case of histoid leprosy. J Dtsch Dermatol Ges 2019;17:333-5.  Back to cited text no. 2
    
3.
The World Health Organization. [homepage on the Internet]. Available from: https://www.who.int/lep/disease/en/. [Last accessed on 2019 Sep 29].  Back to cited text no. 3
    
4.
Yoder LJ, Jacobson RR, Job CK. A single skin lesion—An unusual presentation of lepromatous leprosy. Int J Lepr Other Mycobact Dis 1985;53:554-8.  Back to cited text no. 4
    
5.
Job CK, Kahkonen ME, Jacobson RR, Hastings RC. Single lesion subpolar lepromatous leprosy and its possible mode of origin. Int J Lepr Other Mycobact Dis 1989;57:12-9.  Back to cited text no. 5
    
6.
Ranjan Kar B, Belliappa PR, Ebenezer G, Job CK. Single lesion borderline lepromatous leprosy. Int J Lepr Other Mycobact Dis 2004;72:45-7.  Back to cited text no. 6
    
7.
Sapkota BR, Neupane KD, Maharjan RK. Single lesion multibacillary leprosy, a treatment enigma: A case report. J Med Case Rep 2009;3:8.  Back to cited text no. 7
    
8.
Ankad BS, Sakhare PS. Dermoscopy of histoid leprosy: A case report. Dermatol Pract Concept 2017;7:63-5.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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