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Pictures showing H&E, Fite, and AFB staining of skin biopsy A-F: H&E staining. The red arrow indicates grayish granular material, which was proven to be M. leprae globi following acid-fast stain. The green arrow indicates cutaneous never that is entrapped by foamy macrophages loaded with M. leprae. G: FITE staining. H: AFB staining H&E: hematoxylin and eosin; AFB: acid-fast bacillus
Source publication
Leprosy is an infectious disease that is associated with various types of presentations. Diagnosis of the disease can be tricky in cases of atypical presentations. We report a unique case of leprosy characterized by chronic hand swelling, dactylitis, and seropositive laboratory markers, which was diagnosed in a rheumatology clinic.
Contexts in source publication
Context 1
... the sections of the skin biopsy from the arm showed skin extending to the subcutaneous tissue. The sections showed acute and chronic inflammatory infiltrates replacing approximately 80-90% of the dermis and extending into the subcutaneous tissue forming lobular panniculitis ( Figures 3A, 3B). These infiltrates were composed of aggregates of foamy histiocytes with interspersed lymphocytes, eosinophils, and scattered neutrophils (Figures 3C, 3D, 3E) with surrounding blood vessels, adnexal structures, and cutaneous nerves at all levels of the dermis and subcutaneous tissue ( Figures 3D, 3E, 3F). ...
Context 2
... sections showed acute and chronic inflammatory infiltrates replacing approximately 80-90% of the dermis and extending into the subcutaneous tissue forming lobular panniculitis ( Figures 3A, 3B). These infiltrates were composed of aggregates of foamy histiocytes with interspersed lymphocytes, eosinophils, and scattered neutrophils (Figures 3C, 3D, 3E) with surrounding blood vessels, adnexal structures, and cutaneous nerves at all levels of the dermis and subcutaneous tissue ( Figures 3D, 3E, 3F). Within the reticular dermis, there were regions where dermal fibrosis intervened ( Figures 3A, 3B). ...
Context 3
... infiltrates were composed of aggregates of foamy histiocytes with interspersed lymphocytes, eosinophils, and scattered neutrophils (Figures 3C, 3D, 3E) with surrounding blood vessels, adnexal structures, and cutaneous nerves at all levels of the dermis and subcutaneous tissue ( Figures 3D, 3E, 3F). Within the reticular dermis, there were regions where dermal fibrosis intervened ( Figures 3A, 3B). However, no vasculitis or fibrin thrombi were observed in the fat lobules and/or in the overlying dermis ( Figures 3C, 3E). ...
Context 4
... the reticular dermis, there were regions where dermal fibrosis intervened ( Figures 3A, 3B). However, no vasculitis or fibrin thrombi were observed in the fat lobules and/or in the overlying dermis ( Figures 3C, 3E). Histiocytes within the inflammatory infiltrate showed prominent gray-blue granular substance within the cytoplasm ( Figures 3D, 3F). ...
Context 5
... no vasculitis or fibrin thrombi were observed in the fat lobules and/or in the overlying dermis ( Figures 3C, 3E). Histiocytes within the inflammatory infiltrate showed prominent gray-blue granular substance within the cytoplasm ( Figures 3D, 3F). Acid-fast Bacilli and Fite stains revealed large numbers of clumped, intact, as well as beaded acidfast bacilli within vacuolated histiocytes as well as within cutaneous nerves ( Figures 3F, 3G, 3H). ...
Context 6
... within the inflammatory infiltrate showed prominent gray-blue granular substance within the cytoplasm ( Figures 3D, 3F). Acid-fast Bacilli and Fite stains revealed large numbers of clumped, intact, as well as beaded acidfast bacilli within vacuolated histiocytes as well as within cutaneous nerves ( Figures 3F, 3G, 3H). ...
Citations
... Skin involvement in leprosy is frequent, but edema per se due to leprosy is unusual and mostly a symptom of a reactional state [1]. There are reports of patients presenting with edema and dactylitis as the presenting symptoms of lepra reactions and leprosy [2,3]. Such tenosynovitis and edema are reported in the hands and joints. ...
Leprosy has been known for its wide range of peripheral nerve and tissue involvement and causing disabilities. Early diagnosis and treatment with multi-drug therapy can save lives and limbs and prevent disabilities. However, management and drug therapy are usually lengthy and full of ups and downs of side effects. Further, the lepra reaction is frequently noted during management, requiring immunosuppression and leading to associated side effects. Limb edema per se due to leprosy is unusual and mostly a symptom of a reactional state. There is no specific management for edema in such cases, and it subsides with improving reactionary states. Nevertheless, the edema may be persistent and bothersome. The present report highlights one such unusual case in a 40-year-old man, diagnosed with borderline-tuberculoid leprosy and experiencing a type-1 reaction. Owing to ocular complications, steroid therapy for the reaction was tapered abruptly, and his limb edema did not subside with the improving lepra reaction. Compression stockings helped to manage edema. This case also makes us ponder the possible use of compression stockings as an opioid-sparing aid in lepra reaction-related edema.
... The diagnosis of leprosy when it presents as acne vulgaris without the telltale features in skin or nerve involvement is often difficult and remains a diagnostic challenge often inundating physicians. It is because in the post elimination era, leprosy as a differential doesn't strike physicians easily due to significantly decreased incidence [9]. Our patient presented with acne-like lesions (maculopapularlesions, pustules and nodules) on the face which later progressed to different parts of the body. ...
Leprosy affects multiple systems and causes morbidity. However, with attainment of global elimination, and prevalence being 0.89/10000 at national level in Nepal; it is seldom considered a diagnosis when it doesn't manifest telltale signs. Leprosy can masquerade various dermatological, orthopedic or neurological problems thus delaying the diagnosis.
... It is because in the post elimination era leprosy as a differential doesn't strike physicians easily due to significantly decreased incidence. 9 Our patient presented with acne-like lesions (maculopapularlesions, pustules and nodules) on the face which later progressed to different parts of the body. Though papules have been a common presentation, progression of lesions to pustules and nodules has rarely been witnessed. ...
Leprosy affects multiple systems causing morbidity.1 However with attainment of global elimination and prevalence being 0.89/10000 at national level; it is seldom considered a diagnosis when it doesn’t manifest telltale signs. 2,3 Leprosy can masquerade various dermatological, orthopedic or neurological problems thus delaying the diagnosis.
... The associated etiology can either be directly related (intrinsic) or indirectly caused (extrinsic) to the affected hands. Indeed, swollen hands can represent a condition localized to the hands or a specific manifestation of a systemic disorder [1][2][3][4][5][6][7][8][9]. ...
... Swollen hands can either be asymptomatic or associated with pain, pallor, paralysis, paresthesia, and/or pulselessness. Clinically, the edema can be pitting or non-pitting [1][2][3][4][5][6][7][8][9]. ...
... In addition to POTASH, other causes of acute hand swelling include allergic contact dermatitis, compartment syndrome, deep venous thrombosis, erythromelalgia, exercise-induced urticaria, infection, irritant contact dermatitis, medications, nocturnal hand swelling, post coronavirus disease 2019 (COVID-19) puffy hands, Raynaud disease and phenomenon, remitting seronegative symmetrical synovitis with pitting edema, and thoracic outlet syndrome [1,2,5,6,8,[10][11][12]. In contrast, chronic hand swelling can result from acromegaly, carpal tunnel syndrome (tumor associated), complex regional pain syndrome type I, leprosy, lymphedema, mixed connective tissue disease, puffy hand syndrome, rheumatoid arthritis, scleroderma, and systemic organ (heart, kidney, and liver) disease [2][3][4]7,9]. ...
... Hand swelling can result from either intrinsic (such as a tumor) or extrinsic (such as an arthropod assault) causes. The swelling can be limited to only the hands (such as allergic contact dermatitis) or a component of a systemic condition (such as mixed connective tissue disease) [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. ...
... The unanticipated development of hand swelling may be a cause of concern and often requires additional assessment [3]. The initial evaluation should determine whether the onset of hand swelling was acute (for which some of the causes are listed in Table 1 [1][2][3][4][5][6][7][8][9][10][11]) or chronic (for which some of the causes are listed in Table 2 [3,[12][13][14][15][16][17][18][19][20]). In addition, the examination should consider the presence of numbness, pain, pruritus, tingling or warmth (or the absence of symptoms), the color changes of the affected area, and whether the condition persists, or resolves (either spontaneously or following treatment). ...
Post ambulatory swollen hands (POTASH) is a rarely described etiology for hand swelling; to the best of my knowledge, it has only been reported in the medical literature a decade ago in a prospective study evaluating its development in walkers who were either dog owners (who walked or did not walk their dogs) in comparison to non-dog owners. In addition to swelling after initiating ambulation by participating in an activity such as hiking, running, or walking, there are also several other causes of swollen hands; a positive fist sign has only been described in a limited number of conditions observed in individuals with hand swelling. A fist is created when there is clenching of the fingers and the fingertips are in direct contact with the palm of the hand with the thumb lying on top of the fingers between the proximal and distal interphalangeal joints. A positive fist sign is demonstrated by the inability to clench the fingers tightly into a fist; indeed, it is a common--yet not frequently reported--manifestation observed in individuals with a swollen hand. In contrast, a negative fist sign occurs when the patient can form a fist of tightly clenched fingers. The author, a 62-year-old physician and long-distance runner since high school, developed recurrent episodes of POTASH beginning five years ago. He noticed asymptomatic, bilateral, and symmetric swelling of his dorsal and palmar hands--with a positive fist sign--beginning after approximately one hour of running; the degree of swelling was proportional to the duration of time he ran. His hand swelling would completely resolve spontaneously--and his fist sign would be negative--within two hours after he stopped running. Recommendations for hikers and walkers to potentially eliminate or limit the degree of POTASH have been suggested; for dog owners who walked their dog, POTASH was less likely to occur if they regularly walked the dog. Several etiologies for POTASH have been proposed; however, the definitive pathogenesis for hand swelling related to either hiking, running, or walking remains to be determined. Therefore, research to gain additional insight and possibly establish the cause of ambulatory-associated swollen hands is warranted.
... 1,2,3 Following the skin and nerves, bone and joint changes are the third most common manifestation of leprosy. 4,5 The diagnosis of leprosy can be a problem for clinicians when musculoskeletal features constitute the initial presentation with minimal or even none of the skin or nerves involvement. 5 Furthermore, musculoskeletal problems in leprosy can resemble other connective tissue disorders, which may lead to misdiagnosis and mistreatment. ...
... 4,5 The diagnosis of leprosy can be a problem for clinicians when musculoskeletal features constitute the initial presentation with minimal or even none of the skin or nerves involvement. 5 Furthermore, musculoskeletal problems in leprosy can resemble other connective tissue disorders, which may lead to misdiagnosis and mistreatment. 6 Therefore, it is important for clinicians to have good knowledge about several aspects of this condition. ...
... 6 Therefore, it is important for clinicians to have good knowledge about several aspects of this condition. 5 In addition, the examination and early treatment of bone and joint complications can reduce disabilities and deformities in leprosy. 1,4,7 This case report aimed to show a rare finding of abundant Mycobacterium leprae in the synovial fluid of a lepromatous leprosy patients with bone changes and leprosy-related chronic arthritis. ...
Bone and joint involvements are the most common manifestation in leprosy, after cutaneous and neurological manifestations, yet are underdiagnosed and rarely reported. We report a case of lepromatous leprosy in a 41-year-old male with bone and joint changes. Physical examination revealed a leonine face, madarosis, hypesthetic hypopigmented macules on the back, and swelling of fingers and toes. Acid-fast bacilli from slit-skin smear and synovial fluid in an interphalangeal joint of the hand were found. Radiographic features showed osteolysis and destruction of some phalanges of the hands, bone erosion and destruction of some phalanges of the feet, as well as destruction and subluxation of some hand joints. The patient was given multidrug therapy for multibacillary leprosy, resulting in the reduction of swelling in fingers and toes. In conclusion, the examination of bone and joint changes in leprosy patients is important for early detection and management of musculoskeletal complications, to prevent future deformities and disabilities.
Leprosy is an ancient disease which is now evolving in terms of its presentation and behaves like a true chameleon. Although the majority of cases are still diagnosed with classical clinical presentations, there are atypical and uncommon presentations of Hansen’s which may be misleading and pose diagnostic dilemmas. We report a case presenting with isolated dactylitis, without any classical features of Hansen’s, confirmed histopathologically with visualisation of AFB, and a final diagnosis of BT Hansen’s, highlighting the presence of atypical manifestations of Hansen’s in endemic countries like India.KeywordsBT Hansen’sDactylitisAtypical presentation
