Histoid Leprosy Research Articles

De Novo Histoid Leprosy with unique feature of Transmigration: A case report.

De Novo Histoid Leprosy with unique feature of Transmigration: A case report.

Diagnosing leprosy: revisiting the role of the slit‐skin smear with critical analysis of the applicability of polymerase chain reaction in diagnosis

Diagnosing leprosy is challenging, especially in early-stage cases, and the need for a sensitive diagnostic tool is urgent. Polymerase chain reaction (PCR) holds promise as a simple and sensitive diagnostic tool, but its usefulness in the Indian context requires further evaluation. Slit-skin smear (SSS) remains the conventional method of leprosy detection. Hence, this study was undertaken to evaluate and compare the diagnostic efficacy of PCR versus that of SSS. Punch biopsy of skin and SSS were obtained from the active margins of lesions. Cases were clinically grouped according to whether they were multibacillary (MB) or paucibacillary (PB) and classified into tuberculoid (TT), borderline tuberculoid (BT), borderline lepromatous (BL), lepromatous (LL), histoid, and indeterminate groups after clinicopathological correlation. DNA was extracted from biopsy specimens, and multiplex PCR was carried out incorporating primers intended for the amplification of a specific 372-bp fragment of a repetitive sequence of Mycobacterium leprae DNA. Among 164 patients, PCR was positive in 82.3%. The sensitivity of PCR was significantly greater (P < 0.0001) than that of SSS in both the MB (85.9% vs. 59.8%) and PB (75.4% vs. 1.8%) subgroups; the difference in sensitivity in the PB subgroup is remarkable. Positivity by PCR and SSS was found in 100% of LL and histoid leprosy, but PCR had significantly greater (P < 0.0001) positivity in BT leprosy and was of definite increased value in indeterminate and TT leprosy. Polymerase chain reaction had higher sensitivity compared with SSS, especially in diagnostically challenging and PB cases. Thus, the use of this costly but sensitive tool should be restricted to this subgroup, because SSS is sufficiently sensitive in the diagnosis of LL and histoid leprosy.

De-novo Histoid Leprosy

Histoid leprosy is a rare form of multibacillary leprosy with distinct clinical and histopathological features. It is a variant of lepromatous leprosy. It occurs in lepromatous patients, who relapse after dapsone monotherapy, in the presence of dapsone resistance or at times ‘de-novo’. We describe here a case of histoid leprosy, clinically mimicking neurofibromatosis.

Transepidermal elimination of Mycobacterium leprae in histoid leprosy: A case report suggesting possible participation of skin in leprosy transmission

An Indian patient of histoid leprosy presenting de novo, having numerous solid staining bacilli inside the intact epidermis and eliminating bacilli from the intact and the eroded epidermis, is reported. The diagnosis, suggested by the clinical features, was confirmed histopathologically. This unusual report indicates possible participation of skin in leprosy transmission.

Lèpre histoïde familiale

Histoid leprosy is a very particular and rare anatomoclinical form of lepromatous leprosy. Familial cases are extremely rare. We report two new cases of histoid leprosy in a sister and brother born of a non-consanguineous marriage. We report the case of a sister and brother, aged 21 and 25 years respectively, who were admitted to the National Leprology Centre for multibacillary leprosy. Questioning revealed the existence of family contact with an uncle and two maternal cousins, all of whom had histoid leprosy. On clinical examination, multiple erythematous papules and nodules were noted, some of which were umbilicated while others were ulcerated. Palpation also revealed subcutaneous nodules on the thighs and forearms. No neurological disorders were found in the two patients. Histopathological analysis of cutaneous biopsy samples of nodular lesions for the two patients showed dermal-hypodermic nodular infiltrates comprising spindle cells with a few macrophages. Ziehl-Neelsen staining showed numerous alcohol-acid resistant bacilli (BAAR) without globi. Both patients were placed on the multi-drug regimen recommended by the WHO for multibacillary leprosy. An extremely favourable therapeutic response was obtained after 3months of treatment. The patients had presented no relapse of erythema nodosum leprosum after two years of follow-up. Histoid leprosy is a clinical entity that must be clearly differentiated through its clinical and histopathological features, which distinguish it from polar lepromatous leprosy. There may be a genetic predisposition to this clinical leprosy form, but this requires confirmation by genetic studies.

Histoid leprosy in an HIV positive patient taking cART

Histoid leprosy in an HIV positive patient taking cART

Histoid Leprosy

Histoid Leprosy is a variant of lepromatous leprosy with characteristic clinical and histopathological features. Usually it is occured in lepromatous patients who relaps after dapsone monotherapy, in those with dapsone resistance , sometimes even after multidrug treatment, or at times, de novo with characteristic clinical and histopathological features. A 36 years old male, originated from Papua, visited to the skin outpatient clinic with translucent shiny nodules on the left elbow and thumb for the last 18 months. The nodules were multiple, painless and firm. There were nasal congestion, tickening of ear lobes and loss of eye brows. Patient did not have any history of previous antileprotic treatment. Routine blood examination was normal. Bacteriological examination of slit skin smear revealed acid-fast bacilli of Bacterial Index 4+ and Morfologic Index 10%. Histopathology of skin suggested lepromatous leprosy of histoid type with characteristic interlacing bundles of spindle shaped cells. Anti-PGL1 antibody (ELISA) revealed high titer of IgM (&gt;5.300 u/ml) and also IgG anti PGL-1 (&gt;5.300 u/ml). Polymerase chain reaction examination test to detect M.leprae was positive and direct sequencing of M.leprae isolate shows no mutation, which means no resistancy to MDT treatment. Treatment with MDTWHO regiment give clinical improvements and the histoid lesions disappered after 3 months treatment.The histoid form of leprosy in this case developed without any prior treatment of anti leprotic drugs ( de novo ). Some theoretical aspects of the patho-mechanism of histoid leprosy are discussed.

Borderline lepromatous leprosy with neurofibromatosis

The coexistence of leprosy with neurofibromatosis is rare both the diseases present with nerve thickening and skin lesions (patches and nodules). The coexistence of neurofibroma with borderline tuberculoid, lepromatous, histoid, and neuritic leprosy has been reported in the past. We report here a case of borderline lepromatous leprosy coexisting with neurofibromatosis in a 60 year-old male, who presented with neurofibromata and nerve thickening. Histopathology of skin biopsy from the leprosy and neurofibroma nodules confirmed the diagnosis of leprosy and neurofibroma.

Histoid leprosy: the impact of the entity on the postglobal leprosy elimination era

A fresh focus on histoid leprosy is the primary objective of this article, especially in the context of the postglobal leprosy elimination era. The emergence of the entity following dapsone monotherapy is well recognized, in addition to de novo cases. Irregular and inadequate therapies, coupled with resistance to dapsone and/or mutant organisms, are responsible. It was considered to be worthwhile to take stock of the condition through its history, nomenclature, epidemiology, clinical characteristics, diagnosis, and differential diagnosis. The bacteriologic and histopathologic features and immunologic profile are also described.

Histoid Leprosy: Histopathological Connotations' Relevance in Contemporary Context

A reappraisal of histoid leprosy in the contemporary postglobal leprosy elimination era, a fallout of the World Health Organization leprosy elimination program, is succinctly outlined. The cardinal clinical expression, differential clinical diagnosis, the cytodiagnosis, and diagnostic salient histopathological features are highlighted.

Molluscoid skin lesions in histoid leprosy with pseudo‐isomorphic Koebner phenomenon

A 30‐year‐old Indian man presented with multiple asymptomatic skin lesions on the arms, buttocks, trunk, and knees of 4 months’ duration. These lesions had started over the right arm and gradually increased in number and spread to involve the other sites. There was no history of any skin lesions in the past. Family members were normal. Cutaneous examination showed multiple, skin‐colored, shiny papules abruptly arising over the surrounding normal skin of the arms, buttocks, legs, trunk, and pinnae, varying from 2 to 3 mm in size. Some of the papules over the trunk and arms showed central umbilication resembling molluscum contagiosum, and a few showed superficial erosions and/or crusting (Fig. 1a,b). A few similar, erythematous papules over the left buttock showed a linear distribution, suggestive of pseudo‐isomorphic Koebner phenomenon (Fig. 2a,b). There was hypoesthesia in the distal part of the arms and legs for thermal, touch, and pain sensation, and the bilateral lateral popliteal and ulnar nerves were thick and mildly tender. The clinical features were suggestive of histoid leprosy. Systemic and eye examination were normal. Routine hematology and liver and kidney function tests were normal, and blood venereal disease research laboratory (VDRL) test and enzyme‐linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) 1 and 2 were negative. Histopathology from a papular lesion showed a thinned out epidermis, flattened rete ridges, a subepidermal Grenz zone, and granulomas of closely packed, spindle‐shaped histiocytes arranged in whorls, with foamy macrophages. In addition to the above histologic findings, the molluscoid lesion also showed an epidermal erosion with acid‐fast bacilli demonstrated by Ziehl–Neelsen stain (Fig. 3a,b). Slit skin smear examination from both the ear lobes and umbilicated lesions was highly positive, with a bacillary index (BI) of 6+ (&gt; 1000 bacilli per oil immersion field) and a morphologic index (MI) of 80% (Fig. 3c). A diagnosis of histoid leprosy was made. The patient was treated with daily rifampicin and ofloxacin for 2 months, followed by standard multibacillary (MB) multidrug therapy (MDT) with daily dapsone and clofazimine with monthly rifampicin for 2 years. An excellent response to treatment was obtained with regression of all the skin lesions.(a) Umbilicated and shiny papular skin lesions arising abruptly over normal skin. (b) Umbilicated, crusted, and eroded pigmented lesions over the armimage(a) Multiple shiny papular lesions over both buttocks, showing linearly arranged skin lesions on the outer aspect of the upper lateral quadrant of the left buttock. (b) Close‐up view of the linearly arranged papular skin lesions on the buttockimage(a) Histopathology from a ruptured umbilicated papule showing a thinned out epidermis with flattened rete ridges, an epidermal erosion in the center, a subepidermal Grenz zone, and granuloma of closely packed spindle‐shaped histiocytes arranged in whorls, with foamy macrophages (Ziehl–Neelsen stain; original magnification, ×40). (b) Close‐up view of the marked portion of (a) showing acid‐fast bacilli at the mouth of the ruptured area arranged in a globus and discretely, shown by red arrows (Ziehl–Neelsen stain; original magnification, oil immersion, ×1000). (c) Slit smear examination from a skin lesion showing long, thick, acid‐fast bacilli, arranged in clumps and discretely (Ziehl–Neelsen stain; original magnification, oil immersion, ×1000)image

Histoid leprosy: a retrospective study of 40 cases from India

Rare variants of leprosy pose a diagnostic challenge even to astute clinicians and histoid leprosy is one such form of disease with unique clinical and histopathological features. There are very few large series on this entity, mainly reported from India. To study the epidemiological and clinical characteristics of patients with histoid leprosy. We undertook this retrospective study including patients registered with the leprosy clinic of our tertiary care referral centre from January 1991 to December 2006. Data regarding demographic details, clinical features, treatment, complications and course following treatment were extracted from the records of the leprosy clinic. The incidence of histoid leprosy among the registered patients of our clinic was 1.8% (40 of 2150). There was a significant male preponderance with a male/female ratio of 5.7 : 1. The anatomical areas of involvement were thighs/buttocks (67.5%), arms (62.5%), back (52.5%), face (47.5%), forearms (47.5%) and legs (35%) in descending order of frequency. This variety of leprosy was found most commonly in patients with a primary diagnosis of lepromatous leprosy (40%). De novo histoid lesions, i.e. lesions of histoid leprosy developing without evidence of lesions of other types of leprosy in the Ridley-Jopling classification, appeared in 12.5% of patients only. Only three patients had received antileprosy treatment before presentation. Episodes of erythema nodosum leprosum (ENL) had occurred in 40% of patients, although only one patient manifested ENL after the diagnosis of histoid leprosy. The disease responded satisfactorily to the respective World Health Organization multidrug therapy regimens in all except in one patient who relapsed with borderline lepromatous leprosy. As the bacillary load is very high in these patients, they can form a potential reservoir of the infection in the community especially in the postleprosy elimination era. Contrary to the earlier belief in the dapsone era, most of our patients manifested disease without any history of inadequate or incomplete antileprosy therapy.

Wade Histoid Leprosy masquerading as eruptive xanthomas

Wade Histoid Leprosy masquerading as eruptive xanthomas

Fine needle aspiration cytology in leprosy

Laboratory diagnosis of leprosy by slit skin smear and skin biopsy is simple but both techniques have their own limitations. Slit skin smear is negative in paucibacillary cases whereas skin biopsy is an invasive technique. Fine needle aspiration cytology (FNAC) from skin lesions in leprosy with subsequent staining with May-Grunwald-Giemsa (MGG) stain has been found useful. To evaluate the possible role of cytology in classifying leprosy patients. Seventy-five untreated cases of leprosy attending the outpatient department were evaluated. Smears were taken from their skin lesions and stained using the MGG technique. Skin biopsy was also done from the lesions, which was compared with cytology smears. A correlation of clinical features with FNAC was noticed in 87.5% of TT, 92.1% of BT, 81% of BL, and 66% of LL cases. Correlation of clinical with histopathological diagnoses revealed 12.5% specificity in TT leprosy, 55.3% in BT, 52.4% in BL and 50% in LL, and 100% in neuritic and histoid leprosy cases. Both correlations were found to be statistically significant by paired t test analysis. Thus, it was possible to distinguish the tuberculoid types by the presence of epithelioid cells and the lepromatous types by the presence of lymphocytes and foamy macrophages. FNAC may be used to categorize the patients into paucibacillary and multibacillary types, but is not a very sensitive tool to classify the patients across the Ridley-Jopling spectrum.

Wade's histoid leprosy: three clinical presentations

Wade's histoid leprosy is a rare form of multibacillary leprosy with distinctive characteristics which were first described in patients treated with a short course of sulfones. Wade's histoid leprosy may occur as a relapse, in the setting of sulfone resistance, or may present de novo. We report the clinical, histologic, immunologic, and bacteriologic features of three adult male patients with this rare variant of lepromatous leprosy as the initial presentation of the disease, observed in the Dermatology Department of Hospital Córdoba, Córdoba, Argentina between 1999 and 2003. Two of the three patients were from an endemic leprosy area. All patients presented with a number of erythematous to brownish gray, firm but elastic nodules involving mainly the extremities, which responded to treatment for multibacillary leprosy without reactional episodes.

Histoid leprosy as reservoir of the disease; a challenge to leprosy elimination

In the month of January, 2006, India was declared to have eliminated leprosy. In an article by the Director General of Health Services, Government of India, the graphical representation of the progressively decreasing prevalence rate and new case detection rate for leprosy was quite encouraging and the goal of elimination by December, 2005 was supposed to be in sight. However, as dermatologists, from our day to day experience in dealing with the patients with leprosy, it was rather difficult to accept this contention. Histoid leprosy is an uncommon form of multibacillary disease, characterized by distinct clinical, histopathological, bacteriological and immunological features. It is quite rare and mostly occurs among patients with leprosy who had received dapsone monotherapy in the past. However, it was reported in previously untreated patients, as a manifestation of relapse several years after effective completion of an adequate course of MDT and in HIV infected patients with severe immunosuppression. As the bacillary load is very high in these patients, they can form a potential reservoir of the disease. While reporting a patient of histoid leprosy presenting as relapse following complete and effective MDT, it was appropriately stated by Ebenezer et al.: ‘occurrence of such cases reminds us that the road to elimination is not an easy one.’ Continued occurrence of histoid leprosy in areas of low endemicity and in areas from where leprosy has been declared as eliminated as in the state of Karnataka is a matter of concern. Moreover, the authors have been diagnosing histoid leprosy regularly (13 cases in 9 years) in their leprosy clinic in a smaller town of Karnataka, Bijapur, even though the total case load is not very heavy (Table 1). New cases of histoid leprosy turning up even in areas of low endemicity leave us in doubt, and raise few pertinent questions:

Lepromatous leprosy of histoid type

Histoid leprosy is a variant of lepromatous leprosy, which develops as a result of resistance to dapsone monotherapy. Here we report two cases of lepromatous leprosy of histoid type, one with typical and another with atypical presentations.

Spontaneous Appearances of Papules, Nodules, and/or Plaques: A Prelude to Abacillary, Paucibacillary, or Multibacillary Histoid Leprosy

Spontaneous Appearances of Papules, Nodules, and/or Plaques: A Prelude to Abacillary, Paucibacillary, or Multibacillary Histoid Leprosy

Histoid leprosy – unusual presentation

A 39-year-old man presented with a chronic nonhealing toe ulcer and multiple skin-colored papules on the back, arms, and knees. From an initial small erosion, the toe lesion ulcerated over a 1.5-year period, while the papules progressed over a 6-month period, first appearing on the back and then spreading to the arms and knees. The past medical and family history were non-contributory. Pertinent findings included the aforementioned well-defined, asymmetric, shiny papules (Fig. 1). There were multiple, discrete, erythematous, pedunculated, tumor-like masses of various sizes over the right thigh (Fig. 2) and a well-defined 4 cm x 3 cm ulcer on the second toe of the left foot, the floor of which was covered by necrotic slough. There was distal loss of sensation to temperature, touch, and pain. The greater auricular, ulnar, radial cutaneous and common peroneal nerves were thickened bilaterally, but non-tender. A clinical diagnosis of histoid leprosy was made. The differential diagnosis for the tumor-like thigh masses included dermatofibroma, neurofibroma, and Kaposi's sarcoma. The hemogram, liver/renal function tests, chest X-ray, and abdominal ultrasound were normal. Human immunodeficiency virus enzyme-linked immunosorbent assay (HIV ELISA) was negative. The ear lobe smear (ELS) for acid-fast bacilli showed a bacterial index (BI) of 6+[> 1000 organisms/oil immersion field (oif)] and a morphological index (MI) of 50%. The skin-colored papules on the back and the pedunculated masses showed a BI of 5+ (100-1,000 organisms/oif) and an MI of 50%. The normal skin showed a BI of 4+ (10-100 organisms/oif) and an MI of 5%. Biopsy of the papules and pedunculated tumors showed a well-circumscribed area of the dermis packed with many acid-fast organisms and foamy macrophages, consistent with histoid leprosy (Fig. 3). Fite-Faraco stain demonstrated cells packed with lepra bacilli. A final diagnosis of lepromatous leprosy, histoid variant, was made. Dapsone, clofazimine, rifampicin, and, later, ofloxacin were started.

Cutaneous Mycobacterium Avium Intracellulare Infection in an HIV+ Patient Mimicking Histoid Leprosy

Cutaneous infections with Mycobacterium avium intracellulare (MAI) are uncommon in healthy patients but may arise in those with underlying immunocompromise, including patients with HIV. Their clinical manifestations are protean. We report an AIDS patient with a cutaneous MAI infection that clinically and histopathologically mimicked histoid leprosy, a presentation not previously described in this population.