Indian Journal of Dermatology
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CORRESPONDENCE
Year : 2016  |  Volume : 61  |  Issue : 6  |  Page : 694-696
Localized glistening nodules of the right ear: A rare de novo occurrence of histoid leprosy


Department of Dermatology, Sri Ramachandra University, Chennai, Tamil Nadu, India

Date of Web Publication9-Nov-2016

Correspondence Address:
Aditya Kumar Bubna
Department of Dermatology, Sri Ramachandra University, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.193703

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How to cite this article:
Bubna AK. Localized glistening nodules of the right ear: A rare de novo occurrence of histoid leprosy. Indian J Dermatol 2016;61:694-6

How to cite this URL:
Bubna AK. Localized glistening nodules of the right ear: A rare de novo occurrence of histoid leprosy. Indian J Dermatol [serial online] 2016 [cited 2019 Jun 19];61:694-6. Available from: http://www.e-ijd.org/text.asp?2016/61/6/694/193703


Sir,

Histoid leprosy (HL) is a rare variant of lepromatous leprosy (LL) having a total incidence of 1-2%. This form of leprosy has been associated with dapsone resistance and clinically manifests as glistening nodules having a generalized distribution over the body. Localized presentation of HL is extremely rare and could be easily missed even by astute clinicians. It would, therefore, be worthwhile to be familiar with this entity along with the likely differentials encountered, to enable arrival at a conclusive diagnosis.

A 21-year-old boy presented to the department of Dermatology with chief complaints of elevated lesions over the right ear for the past 2 years. He stated that initially it began as one lesion and now had gradually increased to 3, within a period of 2 years. The lesions were absolutely asymptomatic. Cutaneous examination revealed 3 smooth surfaced, flesh colored firm nodules over the lobule and helix of the right ear [Figure 1]. These nodules were firm and non-tender. None of the peripheral nerves were enlarged or tender. Systemic examination also, did not reveal any underlying abnormality. Differentials considered included, dermatofibroma, keloid, atypical fibroxanthoma and HL. A slit skin smear using the Ziehl-Neelsen technique from the nodule on the lobule of the right ear revealed numerous acid fast bacilli [Figure 2]. A skin biopsy from the same nodule demonstrated an atrophic epidermis with an underlying grenz zone separating the dermal pathology from the epidermis. Dermis revealed numerous interlacing vacuolated spindle-shaped histiocytes laden with acid-fast bacilli [Figure 3]. A Wade-Fite's stain further helped in substantiating the diagnosis [Figure 4]. With these findings, a diagnosis of HL was made. The patient was started on multibacillary multi-drug therapy and asked to be on regular follow-up.
Figure 1: Glistening, firm nodules involving the lobule and helix of the right ear

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Figure 2: Numerous solid staining acid fast bacilli demonstrated on Ziehl-Neelsen staining (Ziehl-Neelsen ×1000 [oil immersion])

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Figure 3: Section of diseased skin demonstrating thinned out epidermis with a grenz zone and underlying dermis demonstrating vacuolated interlacing spindle shaped histiocytes (H and E, ×10)

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Figure 4: Section of diseased skin stained with Wade-Fite's stain revealing numerous acid fast bacilli within the spindle shaped histiocytes. (Wade-Fite ×20)

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HL is a rare variant of LL. This spectrum of LL is associated with irregular and incomplete dapsone monotherapy. However, rarely HL may even arise de novo. There have been very recent reports in the postleprosy elimination era of the spontaneous occurrence of HL, without any underlying factor by Bhat et al. [1] and Pandey et al. [2]

As HL is a variant of LL, it would be obvious that like LL it too should have a generalized and symmetric distribution pattern. Previous reports of HL also have not demonstrated this localized occurrence of histoid lesions. [1],[2]

Histopathology in HL consists of a thinned out epidermis, an underlying clear grenz zone and below this a dermal infiltrate composed of spindle-shaped histiocytes arranged in whorls, bands, and occasional tight curlicue patterns. [3] Embedded within these histiocytes are long acid-fast rods with tapering ends representing mutant lepra bacilli. These bacilli are arranged in parallel bundles with their long axis parallel to the diseased histiocyte. This alignment is referred to as histoid habitus and is the hallmark finding of HL. [4] Although globus formation is not the classical feature in HL, its occurrence does not negate the presence of HL. Two unique features visualized here were localized lesional distribution and the de novo occurrence of HL. Leprosy certainly is a great mimicker of other diseases. In this case too, although there was a suspicion of HL, it was not the primary diagnosis considered because of the unusual presentation. Finally, although today we stand in the era of leprosy elimination, it is not unusual to find leprosy still existent and many times the presentation is characterized by unconventional phenotypes that could further confuse the diagnosing clinician. It would, therefore, be prudent to have a complete workup done for Hansen's disease whenever there exists, even the remotest suspicion, so that treatment could be promptly instituted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
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.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Pandey P, Suresh MS, Dey VK. De novo histoid leprosy. Indian J Dermatol 2015;60:525.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Sehgal VN, Srivastava G. Histoid leprosy: A prospective diagnostic study in 38 patients. Dermatologica 1988;177:212-7.  Back to cited text no. 3
    
4.
Wade HW. The histoid variety of lepromatous leprosy. Int J Lepr 1963;31:129-42.  Back to cited text no. 4
    


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