“Is that contagious?” - Pediatric Infectious Diseases ... and popliteal nerves. Neurologic ......
Transcript of “Is that contagious?” - Pediatric Infectious Diseases ... and popliteal nerves. Neurologic ......
HPI: Previously healthy 16 y/o male on return from a 4 year stay in
Nigeria presented with a rash on his face, back and upper and lower extremities that had become more prominent over the past four months
The rash was first noted on his lower extremities 12 months earlier and was initially pruritic but the involvement of his upper extremities and face was non-pruritic and painless
Seen by physicians in Nigeria 6 months earlier and was given a powder to apply to the rash on his lower extremities which did not improve his symptoms
Applying olive oil to the rash on his face with no relief
Denied fevers, weight loss, visual or neurologic deficits
Denied sick contacts including anyone with tuberculosis
PMH: None Medications: None Immunizations: Up to date Social History: Born in Nigeria and immigrated to the U.S. at age 2 Attending boarding school in Nigeria for the past 4
years. He reported no classmates or teachers with similar dermatologic symptoms. While in Nigeria had had visited a rural village where
there was no running water Exposure to goats, cows, and chickens. Denies sexual
activity, alcohol, or drug use
PE: T: 36.8 °C, BP: 116/67, HR: 67, RR: 18 GEN: Comfortable, pleasant male with obvious
lesions on face EXT: 2 + pitting edema was noted up to his knees
bilaterally. SKIN: Lichenified skin was noted on both shins.
Papules, nodules, and plaques were noted on his face, ears, upper and lower extremities with sparing of the trunk. Some hypopigmented patches were noted on his back.
NEURO: There was prominence of the temporal, ulnar and popliteal nerves. Neurologic exam was grossly intact. All sensation was normal including fine touch and proprioception.
Remainder of exam was normal
Studies: CBC: WBC 6.84 Thou/uL (S-68%, L-22%, M-4%, E-6%) Hgb 12.6 g/dL Hct-37.3% Plt-279 Thou/uL
Chemistries and LFTs: Normal UA: Normal Chest x-ray: Normal HIV ELISA: Negative
Diagnostic testing Patient underwent a skin biopsy from one of the lesions on his left arm. Stains
from the tissue revealed:
Skin, H&E Stain, 200X (Courtesy of Douglas Parker, MD)
Differential Diagnosis
1) Cutaneous leishmaniasis 2) Cutaneous onchocerciasis
(Onchocerca volvulus) 3) Lepromatous leprosy
(Hansen’s Disease) 4) Mycobacterium marinum 5) Human Immunodeficiency
Virus (HIV) type 2 infection 6) Fungal dermatitis 7) Allergic reaction to
homeopathic therapy
Diagnosis and Follow-up Ziehl-Neelsen staining did not
identify acid fast organisms but a modified Fite-Faraco stain demonstrated numerous bacilli within histiocytes consistent with Mycobacterium leprae
He was started on dapsone,
rifampin and clofazimine
Noticeable reduction in size and distribution of lesions after 6 months of therapy
Will undergo a skin biopsy after 12 months of therapy to guide duration of therapy. Plans are for a minimum of 24 months of treatment
Leprosy (Hansen’s Disease) Disease caused by bacillus Mycobacterium leprae
Spectrum of disease manifestations related to cell
mediated immune response
Highly infectious but low virulence - Believed to be spread by direct contact or nasal droplet - Skin and peripheral nerves most affected organs
Incubation period 2-5 Years
Leprosy: Keys to Diagnosis
Diagnosis is Clinical: Hypopigmented or erythematous anesthetic plaque
“Leonine Facies” and madarosis
Peripheral Nerve Thickening
Decrease in peripheral sensation to fine touch and
vibration
Diagnostic Confirmation
Skin Biopsy or Scraping: Modified Fite-Faraco Stain
Histopathologic appearance varies with type of leprosy Number of organisms Number of histiocytes, plasma cells, and lymphocytes Extent of organism invasion into subepidermal layers
Invasion of organism into superficial nerves
Treatment and Prognosis Multi-drug Therapy: Dapsone Rifampin Need to check for G6PD and TB Clofazimine prior to initiating therapy
Recommended length of therapy is minimum of 2 years
Goal of therapy is prevention of permanent nerve damage
Leprosy is curable