CASE PRESENTATION
We present a case of 20 years old female from the Hilly terrain of
Dolakha presented to out -patient department ofDolakha Hospital, an
outreach center of Dhulikhel Hospital on 15th May, 2021.She presented
with chief complaints of acne like lesions (maculopapular lesions,
pustules and later nodules) on face since 2 years which gradually
progressed to back, and flexor surface of lower limbs bilaterally
(FIGURE 1 ) (FIGURE 2 ) (FIGURE 3 ).The lesions
first noted on her face were comedones, papules,pustules and gradually
developed to nodules on face, back and
flexor surface of lower limbs. Her past medical history was uneventful
and she had neither significant family history nor contact history with
Tuberculosis patients, Leprosy or Sexually Transmitted Infections(STDs).
There was no history of weight loss, loss of appetite, hair fall, loss
of eyebrows, loss of sensation, hypo pigmented areas, thickening of
nerves, loss of motor function, lethargy. She had been using Topical
Retinoic Acid Gel 0.25% on face for acne, based on advice from friends
along with topical application of Herbs from traditional healers for 2
years prior to consultation in our hospital. There was no use of
antibiotics or any other medication.
On examination, her general condition was fair. There were multiple
maculopapular lesions, pustules, nodules, face, lower back and lower
part of lower extremities. Perineal lesions were absent. Lymphadenopathy
was not present, patient was afebrile and there was no organomegaly.
Routine tests CBC(complete blood count), LFT, RFT,UREME, total count,
Culture of sputum, Mantoux tests were sent which all yielded normal
results.However ESR and TSH were raised and differential count showed
lymphocyte predominance. Serology(HbSAg, HIV, VDRL) was non-reactive and
chest radiograph was also within normal limits. Laboratory markers are
presented in the table (TABLE 1 ).
On history taking retrospectively from the past 2 years,treatment with
Topical Retinoic Acid Gel 0.25% with application of herbal pastes had
shown no improvement and there was gradual spread of lesions.The
presenting findings were suggestive of Acne Vulgaris, Cutaneous
Tuberculosis,Leprosy, Sarcoidosis, SLE, Granuloma Annulare, fungal
infection.
Patient was offered Excisional biopsy of skin lesions for HPE which
showed Lepromatous Leprosy.
Skin biopsy specimen consisted of single piece of skin covered tissue
measuring 0.3 cm. Entire specimen was submitted in two sections.
Sections showed orthokeratotic epidermis with basal layer with melanin
pigmentation. Subepithelially, band of collagen fibres forming Grenz
zone were seen(FIGURE 4 ). Underlying dermis showed
lymphohistiocytotic clusters with dense perivascular and periadnexal
lymphocytic infiltrations with neural tissue destruction (FIGURE
5 ). Granuloma was not seen. Stain for AFB Leprae was positive
(FIGURE 6 ). Bacillary Index was 3 (1 to 10 per HPF)
Leprosy though eliminated is fairly common in this part of the world
hence in view of this patient was referred to Anandaban Hospital which
is a national center where state of the art treatment is provided free
of cost to patients.
InAnandaban Hospital, detailed history was taken and examination was
done. Contact and Family history were ruled out. Repeat biopsy was taken
which showed features consistent with Lepromatous Leprosy. On
examination multiple lesions were found on face, back, legs, however
other telltale signs of Leprosy such as hypochromic anesthetic skin
patches, thickening of nerve, loss of sensation, loss of motor function,
amputation of limbs or nasal septum,loss of eyebrows, clawing, visible
deformities were absent. A large number of acid-fast bacilli were
present in the slit skin smears (BI: 3+) taken from left lower limb
.Patient was diagnosed and confirmed as a case of Lepromatous Leprosy
with BI 3+ based on HPE report of skin.
She was given Multibacillary Multidrug therapy which consists of the
following regimen:Rifampicin 600 mg PO once a month, Dapsone 100 mg PO
once a day, Clofazimine 300 mg PO once a month and Clofazimine 50 mg PO
once a day for 12 months. She is doing well and responding well to the
treatment with visible decrement of nodules on face and limbs. There has
been no intolerance to medications provided in course of the treatment.