A 52-year-old Malay man presented with an acute one week history of multiple erythematous papules and nodules on the limbs, trunk, and face. On physical examination, he had multiple erythematous nontender, nonpruritic nodules and plaques on the trunk, limbs, and forehead ( Fig. 1). A few nodules showed pustulation and ulceration ( Fig. 2). He was febrile at 38°C. Systemic review and general examination were normal. There were no thickened nerves, neurological deficits, or deformities of the hands or feet. Eyes and oral mucosa were normal.The initial clinical impression was that of Sweet's syndrome in view of the acute onset of typical lesions and fever. Complete blood count revealed marked leukocytosis (24.1 · 10 3 /ll) with predominant neutrophilia (87.5%). Erythrocyte sedimentation rate (ESR) was markedly raised. Differential diagnoses included cutaneous lymphoma and infective causes, such as cutaneous tuberculosis, multibacillary leprosy, and nontuberculous mycobacterial or subcutaneous fungal infection.Skin biopsy confirmed the diagnosis of lepromatous leprosy with erythema nodosum leprosum reaction. The histology showed a Grenz zone with granulomas throughout the dermis, consisting of foamy macrophages with globi of bacilli within. Focal areas showed thrombosed vessels with necrosis of vessel walls and numerous neutrophils. Fite stain was positive for leprae bacilli (Fig. 3). Direct immunofluorescence showed granular deposits of IgA and C3 in the upper and lower dermal blood vessel walls, consistent with vasculitis.Slit skin smear confirmed the presence of Mycobacterium leprae with a Bacteriological Index of 5+ and a Morphological Index of <1%. DiscussionLeprosy has been controlled in Singapore for many years. This has been achieved by a good program for control of Figure 1 Erythematous plaques and nodules on the trunk Figure 2 Erythematous plaque with pustule and healing ulcer

We report a case of a 20-year-old Chinese man with an alopecic congenital combined compound and blue melanocytic nevus of the scalp, associated with alopecia areata. The diagnosis of a combined melanocytic nevus was confirmed by histopathological examination and immunohistochemical stains, with exclusion of neurocristic hamartoma, which can have a similar clinical and histopathological appearance but different prognosis. In addition, we explore the association of this large melanocytic lesion with alopecia areata.

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