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research-article2015

CMSXXX10.1177/1203475415611380Journal of Cutaneous Medicine and Surgery

Clinical Correspondance – Medical

Borderline Lepromatous Leprosy: A Case to Remember

To the Editor: We share a case of a 15-year-old male diagnosed with borderline lepromatous leprosy in Canada to remind our colleagues that patients in North America can present with this curable infection. Our patient, originally from the Philippines, immigrated to Canada 4 years prior to his presentation at the Dermatology Clinic at The Hospital for Sick Children in Toronto, Canada. He had a 5-year history of slow progressive loss of sensation of his face and arms. Four years after the onset of his neurologic symptoms, he developed a nodular skin eruption. On physical examination, the young male had a flexion contracture of his right hand and complete loss of sensation of his hands, arms, and face. Erythematous-infiltrated nodules were distributed on his face, back, chest, and arms (Figure 1), and he was beginning to show signs of a leonine facies. During his time in Canada, his symptoms progressed. After consultations with genetics and neurology, the initial differential diagnoses included a primary sensorimotor polyneuropathy and amyloidosis. In 2013, he was referred to dermatology, and a diagnosis of leprosy was suspected. A skin biopsy revealed intracellular gram-positive bacilli, and polymerase chain reaction (PCR) showed mycobacterium leprae. The diagnosis of borderline lepromatous leprosy was confirmed, making this patient the first case of leprosy diagnosed in Toronto since 2010. Treatment with dapsone, ofloxacin, and rifampin was initiated, and his skin improved (Figure 2). Unfortunately, it is not expected that his sensorimotor deficit will resolve. No family members or close contacts were affected. Leprosy is a global disease caused by mycobacterium leprae. The spectrum of the disease varies from tuberculid (paucibacillary) with few skin lesions to lepromatous (multibacillary) with more than 5 skin lesions.1 When the host cell–mediated immunity is intact, tuberculid leprosy presents; however, when there is low cell-mediated immunity, the spectrum shifts toward lepromatous leprosy. Borderline lepromatous leprosy presents as symmetric papules and plaques with infiltration, notably diminished sensation and multiple bacilli found in the skin.2 The World Health Organization guidelines suggest dapsone, ofloxacin, and minocin for the treatment of paucibacillary disease and dapsone, rifampin, and clofazamine for multibacillary disease.3 Treatment for leprosy can be challenging, especially when neurological disability has occurred. A 2014 study in North India noted that children are possibly the most vulnerable group for leprosy. Of the 1225 cases,

Journal of Cutaneous Medicine and Surgery 2016, Vol. 20(2) 176­–177 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1203475415611380 jcms.sagepub.com

Figure 1.  Skin lesions prior to treatment.

Figure 2. Posttreatment.

borderline tuberculoid was the most common clinical presentation (67.8%). Lepromatous leprosy was diagnosed in 11.9% of the cases and borderline lepromatous leprosy in 10.1%. The mean time to diagnosis was 18.5 months despite the study having being conducted in a region with a higher rate of leprosy than Canada.4 The authors stressed the importance of early detection to prevent the sequelae of this curable disease. While leprosy is not endemic in North America, Canadians have great diversity in their countries of origin and exposures. Therefore, as highlighted by our case, in patients who present with loss of sensation and skin findings, a diagnosis of leprosy should be considered and ruled out.

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Mussani Farheen Mussani Division of Dermatology, University of Toronto, Toronto, Ontario, Canada [email protected] Roberto Mendoza-Londono Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada Irene Lara-Corrales Division of Pediatric Dermatology, The Hospital for Sick Children, Toronto, Ontario, Canada Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References 1. Boggild A, Correia J, Keystone J, et al. Leprosy in Toronto: an analysis of 184 imported cases. CMAJ. 2004;170(1): 55-59. 2. Kamath S, Vaccaro S, Rea T, et al. Recognizing and managing the immunologic reactions in leprosy. J Am Acad Dermatol. 2014;71(4):795-803. 3. Boggild A, Keystone J, Kain K. Leprosy: a primer for Canadian physicians. CMAJ. 2004;170(1):71-78. 4. Dogra S, Narang T, Khullar G, et al. Childhood leprosy through the post-leprosy-elimination era: a retrospective analysis of epidemiological and clinical characteristics of disease over eleven years from a tertiary care hospital in North India. Lepr Rev. 2014;85(4):296-310.

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