A young man with livid facial nodules and a loss of eyebrows

Abstract

A 25 year old man from Laos, who had been living in Germany for 4 years, presented at our dermatology outpatient clinic with symptomless symmetrical lividbrown nodules on the cheeks, nose, and earlobes accompanied by a loss of the eyebrows (fi gure, A). This presentation was not disturbing the patient and he reported that these lesions had been present for years. His overall health status was good. Skin biopsies confi rmed the clinical suspicion of granulomatous infi ltrates. Chest radiographs, PCR for Mycobacterium tuberculosis complex, and a quantiferon test were negative for tuberculosis. Ziehl-Neelsen stains of the tissue showed multiple acid-stable rods. These rods formed cigar-like clusters, which are typical for an infection with Mycobacterium leprae (fi gure, B). The bacterial index was high with about 50 mycobacteria per high power fi eld. A PCR targeting the internal transcribed spacer (ITS) region of Mycobacterium spp and subsequent DNA sequencing confi rmed the diagnosis of leprosy. The patient was treated with a 12 month schedule for multibacillary leprosy according to WHO guidelines with rifampicin 600 mg once a month, dapsone 100 mg a day, and clofazimine 50 mg a day and 300 mg once a month. After 2 months of treatment the patient’s eyebrows started to regrow and the nodules reduced in size (fi gure, C). The clinical picture presented here resembles a leonine facies. In developed countries a leonine facies suggests mainly lymphoma or sarcoidosis (also called lupus pernio). In developing countries leprosy is more often the cause despite the worldwide successes of WHO leprosy elimination strategy over the past years. WHO classifi cation distinguishes paucibacillary leprosy with low bacterial index and hypopigmented anaesthetic macules from multibacillary leprosy with a medium-tohigh bacterial index and more likely nodules and infi ltrated plaques.