Volume 49, Issue 1 , Pages 70-72, January 2011
Facial tuberculoid leprosy: case report
Article Outline
Abstract
Leprosy is a chronic, infectious, systemic disease caused by Mycobacterium leprae and is classified as paucibacillary and multibacillary types. It is contagious and has an insidious onset. Clinical presentation is characterised by hypopigmented skin lesions with reduced sensation. Presence of acid-fast bacilli in tissue specimens is regarded as a gold standard for diagnosis. Treatment is based on multi-drug regimens. We report a case of borderline tuberculoid leprosy in a 31-year-old woman.
Keywords: Leprosy, Mycobacterium leprae, Multibacillary, Paucibacillary
Introduction
Leprosy is a chronic infectious disease caused by Mycobacterium leprae.1 Clinically the disease is characterised by erythematous or hypopigmented cutaneous macules with peripheral sensory and motor neuropathies.2
For treatment purposes it is divided into two types.3 Paucibacillary leprosy shows one to five skin lesions and is treated with a regimen of rifampicin and dapsone for 6 months; multibacillary leprosy shows more than five skin lesions and is treated with a regimen of rifampicin, clofazimine, and dapsone, for 12 months.4, 5 The presence of acid-fast bacilli in slit skin smear tests or tissue biopsy specimens is required for definitive diagnosis.6
Case report
A 31-year-old woman 3 months postpartum was referred to the department of oral and maxillofacial surgery with acute painful swelling that involved the midface. She also had double vision, and the symptoms had developed over a period of 10 days. She had immigrated to the United Kingdom from Goa, India, 3 years earlier. Her medical history was unremarkable.
Clinical examination of the face showed symmetrical swelling and erythema involving the cheeks, nose, and central forehead (Fig. 1). The affected skin was warm and tender, and there was anaesthesia of the involved sites, which was particularly marked on the tip of the nose, and at the glabella. She also showed evidence of binocular diplopia and had pain on eye movements. An annular plaque was noted on her right thumb, which also had reduced sensation. Intraoral examination was unremarkable.
Fig. 1.
Frontal view before treatment showing classical bilateral facial involvement in leprosy (published with the patient's consent).
Initially a diagnosis of facial cellulitis was suspected. Treatment with intravenous antibiotics resulted in a slight improvement and she was discharged. She was readmitted within a week with a severe deterioration of her symptoms, which included painful eye movements and diplopia. The symptoms improved moderately with prednisolone 70
mg orally, reduced to 15mg over a week. A dermatological opinion was sought and a clinical diagnosis of borderline tuberculoid leprosy was suggested. Diagnosis was confirmed by examination of a biopsy specimen from the left eyebrow that showed extensive non-caseating granulomatous inflammation. The presence of acid-fast bacilli was confirmed on Wade-Fite staining (Fig. 2).
Fig. 2.
Photomicrograph of a section from skin biopsy specimen showing non-necrotising granulomatous inflammation and few acid-fast Mycobacterium leprae (Wade-Fite stain, original magnification ×600).
She was urgently referred to a regional centre for tropical diseases, and was given multi-drug treatment for paucibacillary leprosy (rifampicin 600mg monthly, dapsone 100mg daily for 6 months, with prednisolone 15mg daily) under the care of a consultant leprologist. She improved considerably within the first 2 months of treatment (Fig. 3). Erythema of the facial lesions had flattened and reduced, and the plaque on her wrist had completely disappeared, but she was left with residual facial numbness.
Fig. 3.
Frontal view after treatment showing resolution of skin lesions (published with the patient's consent).
Discussion
Leprosy is rare in the United Kingdom and must be reported directly to the Health Protection Agency (HPA), but although its incidence is negligible, the presence of diverse immigrant populations underlines the need for clinicians to be aware of the disease. Early diagnosis may avoid permanent neurological damage.7
This case emphasises the importance of involving a dermatologist for all patients with unusual skin lesions. Skin smear tests and histopathological identification are recommended for the classification of lesions. While routine biopsy examination of skin lesions may not always be practical, skin smears can be taken from selected sites in patients with one, or more than one, patch suspected to be of leprosy.
Acknowledgements
We acknowledge the valuable and active contribution made by Professor Diana Lockwood (Hospital for Tropical Diseases, University College London) and Dr DA Buckley, consultant dermatologist, Great Western Hospital, in the management of this case.
References
- . Leprosy. Clin Dermatol. 2007;25:165–172
- . Leprosy: a primer for Canadian physicians. CMAJ. 2004;170:71–78
- . Single lesion multibacillary leprosy, a treatment enigma: a case report. J Med Case Rep. 2009;3:8
- . Borderline lepromatous leprosy presenting as a single cutaneous plaque. Australas J Dermatol. 2005;46:181–183
- . Leprosy. Recognition and treatment. Am J Clin Dermatol. 2001;2:203–211
- . Leprosy pathogenesis – classification – diagnosis—treatment. Hautarzt. 1990;41:126–130(German)
- . Leprosy: a case series and review. South Med J. 2004;97:1252–1256
PII: S0266-4356(10)00018-5
doi:10.1016/j.bjoms.2010.01.011
© 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Volume 49, Issue 1 , Pages 70-72, January 2011
