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CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 210-212

Single plaque lepromatous leprosy presenting as granuloma annulare: A rare presentation


Department of DVL, Government Medical College, Nizamabad, Telangana, India

Date of Submission02-Mar-2020
Date of Decision18-Jul-2020
Date of Acceptance22-Sep-2020
Date of Web Publication26-Aug-2021

Correspondence Address:
Sudha Rani Chintagunta
Plot No. #5, Jupiter Colony, Kakaguda, Kharkhana, Secunderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_56_20

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  Abstract 


Leprosy is a chronic infectious disease caused by Mycobacterium leprae, primarily affecting the peripheral nerves and skin. The clinical presentation of leprosy is highly variable, depending on the immune status of the individual. Based on the Ridley–Jopling classification, the clinical spectrum ranges from tuberculoid to lepromatous leprosy (LL). In all its stages, it can mimic various other conditions. Early and accurate diagnosis of leprosy is crucial because late recognition may give rise to permanent deformity resulting from the disease. Here, we report a case of LL clinically presenting as granuloma annulare in a 75-year-old man, which was diagnosed and confirmed by histopathology.

Keywords: Granuloma annulare, lepromatous leprosy, single plaque


How to cite this article:
Chintagunta SR, Jaju P. Single plaque lepromatous leprosy presenting as granuloma annulare: A rare presentation. Clin Dermatol Rev 2021;5:210-2

How to cite this URL:
Chintagunta SR, Jaju P. Single plaque lepromatous leprosy presenting as granuloma annulare: A rare presentation. Clin Dermatol Rev [serial online] 2021 [cited 2021 Dec 1];5:210-2. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/2/210/324566




  Introduction Top


Leprosy is a chronic infectious disease caused by Mycobacterium leprae, primarily affecting peripheral nerves and skin. The clinical presentation of leprosy is highly variable, depending on the immune status, ranging from tuberculoid to lepromatous spectrum.

Tuberculoid leprosy is a benign form, relatively stable, infrequently positive on bacteriological examination, and presents as erythematous, elevated, well-defined lesions.

In lepromatous leprosy (LL), the lesions are bilaterally symmetrical, shiny, and characterized by numerous macules, papules, nodules, or plaques.

Usually, tuberculoid and borderline leprosy can mimic granulomatous conditions such as sarcoidosis, lupus vulgaris, and granuloma annulare, which is rarely reported in LL.

Here, we report a unique presentation of LL clinically mimicking granuloma annulare.


  Case Report Top


A 75-year-old male presented with asymptomatic elevated skin lesion (5 cm × 5 cm) on the right elbow region for 2 months. There was no history of trauma or insect bite. There was no history of fever, cough, weight loss, or joint pains. There was no personal or family history of previous skin disorders.

Cutaneous examination revealed a single, well-defined, annular plaque with beaded papules at the margin. The overlying skin was shiny, erythematous to normal in color [Figure 1]. Touch and temperature sensations over the plaque were normal. There was no thickening of the peripheral nerves. General and systemic examination was unremarkable. A differential diagnosis of granuloma annulare, lupus vulgaris, and tuberculoid Hansen's disease was considered. Routine investigations were normal. X-ray chest was normal and Mantoux test was negative.
Figure 1: Solitary, annular, erythematous plaque on the right elbow

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A punch biopsy taken from the margin of the lesion showed epidermis with mild hyperkeratosis with loss of rete ridges and a clear subepidermal grenz zone. Dermis showed foamy histiocytes and lymphocytes arranged in diffuse sheets and along the periadnexal and perivascular areas. Adnexal destruction is noted in the deeper dermis. There is absence of granuloma, giant cells, and epithelioid cells [Figure 2] and [Figure 3]. Fite Faraco stain revealed numerous lepra bacilli within the foamy histiocytes and lying free in the dermis diagnostic of LL [Figure 4].
Figure 2: Thinned out epidermis, clear grenz zone, diffuse lymphoplasmacytic cells, and adnexal destruction with inflammatory infiltrate in deep dermis (H and E, ×10)

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Figure 3: Atrophy of epidermis, clear grenz zone and diffuse lymphoplasmacytic infiltrate, and few foamy macrophages (H and E, ×40)

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Figure 4: Fite Faraco stain showing multiple globi of acid-fast bacilli suggestive of lepromatous leprosy ([a] ×10, [b] ×40)

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Slit skin smear was done from the plaque and right ear lobule. Both the smears were positive for solid staining bacilli.

Based on histopathology findings and skin smears, a diagnosis of LL was made. The patient was treated with multibacillary multidrug therapy for 12 months and the lesion healed with pigmentary changes [Figure 5].
Figure 5: Pigmentary changes after treatment

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  Discussion Top


The cardinal features of leprosy include (1) the presence of skin lesions with definite sensory loss, (2) thickened peripheral nerves, and (3) the presence of acid-fast bacilli on skin smears or tissue biopsy. At least two of the three cardinal signs or demonstration of acid-fast bacilli is essential for the diagnosis of leprosy.[1]

LL is a multisystem disease with massive multiplication of M. leprae that infiltrate the skin, nerves, and internal organs.

The common clinical presentations include diffuse, infiltrative, and nodular LL.[2]

The uncommon presentations reported were localized lepromatous disease presenting with a single nodule or localized area of papules and nodules, verrucous plaques, cutis laxa, annular bullous lesions, cutaneous lymphoma,[3] nonhealing ulcer, infiltrated linear lesions, nerve abscess, lupus vulgaris, erythema multiforme-like lesion,[4] and Granuloma annulare-like lesion.

As in leprosy, the lesions of lupus vulgaris are reddish brown, infiltrated, well defined, and persist without symptoms but have a tendency to heal with scarring. They characteristically heal at one edge and spread at another, in contrast to the central healing observed in leprosy. This type of cutaneous tuberculosis can at an early-stage mimic tuberculoid leprosy.

On histopathological examination, epidermal proliferation is seen in lupus vulgaris,[5] in contrast to an atrophic epidermis in tuberculoid leprosy. The granuloma in leprosy is perineural and peri-appendageal.

Granuloma annulare frequently affects children and young adults and clinically resembles tuberculoid or borderline leprosy. It is characterized by asymptomatic skin-colored papules or nodules arranged in an annular pattern. The histology is characteristic, with histiocytes arranged in palisades around central necrobiosis.[6]

Granuloma annulare-like presentation is very rare in leprosy. Literature search showed only two cases of this uncommon presentation.[7],[8] Das et al. and Rupla et al. have reported granuloma annulare-like presentation in borderline tuberculoid and borderline LL, respectively.[7],[8]

So far, no cases of granuloma annulare-like presentation have been reported in LL. Here, we report a rare case of LL presenting as a solitary plaque of granuloma annulare.

This patient presented with granuloma annulare-like lesion as the first manifestation of LL which developed within a short duration of 2 months. Unlike GA, this lesion is shiny with moderate erythema. There was no evidence of sensory loss over the plaque and enlargement of peripheral nerves. On examination, there were no other systemic or cutaneous features suggestive of LL elsewhere on the body.

Skin biopsy and skin smears helped in establishing the diagnosis.

The absence of typical dermatological features greatly decreases clinical diagnostic accuracy and necessitates histological confirmation.

Histopathology is an important tool in arriving at correct diagnosis and thus should be done in all suspected cases.

Awareness about common and uncommon presentations and appropriate timely investigations helps in avoiding delay in diagnosis and treatment, especially in postelimination era of leprosy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kar HK, Sharma P. Leprosy research. In: Kar HK, Kumar B, editors. IAL Textbook of Leprosy. 1st ed. New Delhi: Jitendar P Vij-Jaypee Brothers Medical Publishers (P) Ltd; 2010. p. 274.  Back to cited text no. 1
    
2.
Prasad P.V.S, Kaviarasan P.K. Leprosy: Classification, clinical features and differential diagnosis. In: Oberai C, Inamdar A.C, editors. IADVL Textbook of dermatology, 4th ed. Mumbai: Bhalani Publishing House 2015:3089-119.  Back to cited text no. 2
    
3.
Raval RC. Various faces of Hansen's disease. Indian J Lepr 2012;84:155-60.  Back to cited text no. 3
    
4.
Sgambatti S, Andrade G, Sousa AL, Stefani M, Costa MB and Andrade SS. An unusual presentation of leprosy at diagnosis: Erythema multiforme like Type 2 reaction. Rev Pathol Trop 2010; 39:221-7.  Back to cited text no. 4
    
5.
Min KW, Ko JY, Park CK. Histopathological spectrum of cutaneous tuberculosis and non-tuberculous mycobacterial infections. J Cutan Pathol 2012;39:582-95.  Back to cited text no. 5
    
6.
Piette EW, Rosenbach M. Granuloma annulare: Clinical and histologic variants, epidemiology, and genetics. J Am Acad Dermatol 2016;75:457-65.  Back to cited text no. 6
    
7.
Das S, Roy AK, Kar C, Giri PP. Atypical presentation of leprosy: A report of two cases. Indian J Dermatol 2007;52:198.  Back to cited text no. 7
  [Full text]  
8.
Rupla R, Dey VK, Gupta R: PJSR. 2017:10(2):82-84.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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