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E-IJD CASE REPORT
Year : 2015  |  Volume : 60  |  Issue : 2  |  Page : 214
De novo histoid leprosy: A case report from a post-elimination area


1 Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Pathology, Government Medical College, Srinagar, Jammu and Kashmir, India

Date of Web Publication3-Mar-2015

Correspondence Address:
Yasmeen J Bhat
Department of Dermatology, STD and Leprosy, Government Medical College, Srinagar - 190 010, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.152590

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   Abstract 

Histoid leprosy is an uncommon variant of lepromatous leprosy that usually follows treatment failure. Occasionally it occurs de novo without any history of previous inadequate or irregular treatment. We, hereby, report a case of de novo histoid leprosy in a 25-year-old man from the post-elimination area of Kashmir, where the prevalence rate of the disease was reported to be 0.17/10000 in March, 2013 (NLEP).


Keywords: De novo, histoid leprosy, ROM therapy


How to cite this article:
Bhat YJ, Hassan I, Yaseen A, Wani R. De novo histoid leprosy: A case report from a post-elimination area. Indian J Dermatol 2015;60:214

How to cite this URL:
Bhat YJ, Hassan I, Yaseen A, Wani R. De novo histoid leprosy: A case report from a post-elimination area. Indian J Dermatol [serial online] 2015 [cited 2019 Aug 25];60:214. Available from: http://www.e-ijd.org/text.asp?2015/60/2/214/152590

What was known?
Histoid leprosy is an uncommon variety of lepromatous leprosy that follows treatment failure.



   Introduction Top


Histoid leprosy (HL) is an uncommon variant of lepromatous leprosy (LL) with characteristic clinical, immunological and bacteriological features. It presents with well-defined, smooth, succulent, shiny papules and nodules, [1] mimicking many other dermatosis and can be missed clinically. HL under rare circumstances has been reported to occur in the absence of pervious inadequate or irregular treatment, contrary to the earlier belief in dapsone era. [2],[3] In addition to LL, it may occasionally be seen in unstable borderline lepromatous and indeterminate leprosy groups. [4]


   Case Report Top


A 25-year-old unmarried native Kashmiri man, presented with a 3 months history of raised skin colored lesions over the trunk and limbs with decreased sensations of the right foot. The lesions first appeared over the upper limbs and then progressed to involve the back, chest, abdomen, lower limbs and face in that order. The lesions were asymptomatic. There was history of burning sensation in the eyes, nasal stuffiness and swelling of feet. The patient denied any drug intake, fever, arthralgias, myalgias, spontaneous blistering or ulceration and testicular pain. None of the family members had suffered from leprosy. His general physical examination was normal with no madarosis or lymphadenopathy. Cutaneous examination revealed multiple shiny, soft, hemispherical, non-tender, skin colored to erythematous papules and nodules present bilaterally on the forehead, cheeks, forearms, back, chest, the abdomen in the periumblical distribution, thighs and legs with sparing of palms and soles [Figure 1]. Neurological examination revealed thickened (Grade 2) bilateral greater auricular (left being tender also) [Figure 2], bilateral ulnar and right radial cutaneous nerves. Pain, touch and temperature sensations were markedly diminished along the lateral border of right foot. Rest of the musculo-skeletal and neurological examination was normal. Routine hematological and biochemical investigations including urine, renal and liver function test revealed no abnormality. His retroviral serology was negative. Slit skin smear showed a full field of AFB and globi, with a BI>5+ and MI of 75%. A lesional biopsy revealed focal collections of foamy histiocytes seen beneath the atrophic epidermis [Figure 3]. Fite faraco staining showed cells filled with numerous AFB [Figure 4] which are arranged singly, are longer than the normal bacilli, uniform in length, and are arranged in parallel bundles along the long axis of histiocytes. Findings were consistent with HL (cells contained acid fast organisms on H and E stain). So a diagnosis of de novo HL was made. The patient was given a single dose of ROM therapy as rifampicin rapidly reduces the bacillary load and ofloxacin and minocycline have strong bactericidal action. He was also instructed to take MBMDT for 1 year. The patient is on regular follow up and is free of lesions.
Figure 1: Dome shaped, shiny, skin coloured to erythematous papules and nodules on trunk

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Figure 2: Thickened left greater auricular nerve

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Figure 3: H and E showing focal collections of foamy histiocytes beneath the atrophic epidermis (×100)

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Figure 4: Cells filled with numerous acid fast M. leprae (Fite Faraco stain x 400)

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   Discussion Top


The prevalence of leprosy in Kashmir has been reported to be 0.17/10000 in March, 2013 (NLEP), hence is a non-endemic area. Very rarely has HL been seen in this part of the country. HL is an uncommon variant of LL presenting with well defined, smooth, shiny papules and nodules. [1] In India, its incidence among leprosy patients is estimated to be 2.79% to 3.6%. There is a male preponderance and the average age at diagnosis is between 21 and 40 years. [4],[5] In the era of dapsone monotherapy, HL was associated with dapsone resistance and relapse following dapsone therapy. However, it has also been reported in patients who relapsed on supervised monthly dose of MDT and in those without any treatment. [6]

Rodriguez found that, of 72 relapsed patients, 28 [39%] developed histoid lesions, which occurred much more frequently in men than in women. They have been reported in patients of age 10-84 years. [1] Bhutani et al. found 0 cases of HL among 280 cases of leprosy over 3 years. There were 14 females and 6 males with age range of 22 to 88 years and disease duration ranged from 3 years to more than 14 years. [5] In their study, 7 out of 20 patients developed de novo HL and the remaining developed it following treatment failure. In their retrospective study on 40 HL patients, Kaur et al. found that only 12.5% patients developed de novo histoid lesions. [3]

When HL occurs during early LL/BL leprosy, it presents as transient lesions. However, in the case of relapse, HL lasts longer as dapsone susceptible bacilli have been wiped out and latent bacilli continue to proliferate. [7] Clinically, HL is characterized by cutaneous and subcutaneous papules and nodules which are painless, firm and discrete, smooth, globular, skin colored to yellowish brown, ranging in size from 1.5 to 3.5 cm and are usually 3-50 in number. [8] They occur on the extensor surfaces of extremities, back and buttocks. They may be clustered on the face or localized to the bony prominences over the knees and elbows. In more severe cases, mucosae and genitalia may be involved. Palms and soles are usually not affected. [9] When involving the nerves they present as firm non-tender, freely mobile, nodular swellings along the course of peripheral nerve trunks and cutaneous nerves. HL clinically resembles dermatofibroma, xanthoma, neurofibroma, reticulohistiocytosis, cutaneous metastasis, sarcoidosis, keloid, molluscum contagiosum.

Slit skin smear from HL shows abundant acid fast bacilli. Bacteriological index may be 5+ to 6+ and morphological index may be very high as well. [10] Classical histopathological findings of HL include epidermal atrophy due to dermal expansion by underlying leproma and acellular band (Grenz/Unna band) below the epidermis. Dermis consists of fusiform histiocytes in a whorled, criss-cross or storiform pattern. The histoid nodules expand rapidly forming pseudocapsules of compressed collagen at the periphery. Often there is a central liquefaction necrosis. [11] Within the histiocytes there are numerous acid fast bacilli arranged in parallel bundles along the long axis of spindle histiocytes (histoid-habitus) with or without globus formation. [9] They are well-preserved, solid uniformly staining long rods with tapering ends, distinctly longer than ordinary lepra bacilli.

The enhanced global strategy emphasizes reducing grade-2 disabilities among new cases; thus, it is important that cases are detected early and treated effectively to attain cure with a complete course of MDT and management of complications. [12] HL, as in our case, is treated by giving ROM therapy with 600 mg rifampicin, 400 mg ofloxacin and 200 mg minocycline once, followed by MBMDT therapy. [4]

In our case, the clinical picture of HL was confirmed by slit skin smear and histopathological examination. A high index of suspicion is required in diagnosing such cases for prompt treatment as HL could serve as a reservoir of leprosy and a source of new cases especially in the post leprosy elimination era.

 
   References Top

1.
Sehgal VN, Srivastava G. Histoid leprosy. A review. Int J Dermatol 1985;24:286-92.  Back to cited text no. 1
    
2.
Nair SP, Nanda Kumar G. A clinical and histopathological study of histoid leprosy. Int J Dermatol 2013;52:580-6.  Back to cited text no. 2
    
3.
Kaur I, Dogra S, De D, Saikia UN. Histoid leprosy: A retrospective study of 40 cases from India. Br J Dermatol 2009;160:305-10.  Back to cited text no. 3
    
4.
Annigeri SR, Metgu SC, Patel JR. Lepromatous leprosy of histoid type: A case report. Indian J Med Microbiol 2007;25:70-1  Back to cited text no. 4
    
5.
Bhutani LK, Bedi TR, Malhotra YK, Kandhari KC, Deo MG. Histoid leprosy in north India. Int J Lepr Other Mycobact Dis 1974;42:174-81.  Back to cited text no. 5
    
6.
Palit A, Inamdar AC. Histoid leposy as a reservoir of the disease: A challenge to leprosy elimination. Lepr Rev 2007;78:47-9.  Back to cited text no. 6
    
7.
Sehgal VN, Srivastava G, Singh N, Prasad PV. Histoid leprosy: The impact of the entity on the post global leprosy elimination era. Int J Dermatol 2009;8:603-10.  Back to cited text no. 7
    
8.
Kalla G, Purohit S, Vyas MC. Histoid, a clinical variant of multibacillary leprosy: Report from so called non-endemic areas. Int J Lepr Other Mycobact Dis 2000;68:267-71.  Back to cited text no. 8
    
9.
Sehgal VN, Srivastava G. Histoid leprosy: A prospective diagnostic study in 38 patients. Dermatologica 1988;177:212-7.  Back to cited text no. 9
    
10.
Murthy SV, Rao SM, Thejasvini, Mannan K. Denovo Histoid leprosy. J Lab Physicians 2011;3:110-2.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.
Manoharan R, Madhu R, Srinivasan MS. Histoid Hansen's: A case report. EJ Indian Soc Teledermatol 2008;2:12-6.  Back to cited text no. 11
    
12.
Singal A, Sonthalia S. Leprosy in post-elimination era in India: Difficult journey ahead. Indian J Dermatol 2013;58:443-6.  Back to cited text no. 12
[PUBMED]  Medknow Journal  

What is new?
Our report is the case of new onset histoid leprosy without any previous treatment or underlying immunosuppression from a post-elimination area.


    Figures

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



 

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