Diffuse Lepromatous Leprosy Due to Mycobacterium lepromatosis in Quintana Roo, Mexico

Abstract

A 43-year-old woman of Mayan origin from Quintana Roo, Mexico, was diagnosed with diffuse lepromatous leprosy. The etiologic bacillus was determined to be Mycobacterium lepromatosis instead of Mycobacterium leprae. This case likely represents the first report of this leprosy form and its agent in the southeastern tip of Mexico. CASE REPORTA 43-year-old woman of Mayan ancestry sought dermatologic care in the town of Chetumal, Quintana Roo, Mexico. The patient complained of a 2-year history of burning skin sensation, loss of eyelashes and eyebrows, lower leg edema, and generalized weakness. She was a widowed housewife and had been previously healthy.Physical examination revealed generalized skin infiltration, including areas of prominent "peau d=orange" (erythematous and turgid appearance) and shining skin on the central face, cheeks, and chin. There was extensive loss of hair on arms, legs, and the pubic area. There were no eye lashes or eyebrows. The cornea reflex was diminished. The earlobes were enlarged and indurated. The body skin was dry and did not sweat. There was a generalized loss of sensation to needle pricks over the body. Laboratory examinations showed a normal hemoglobin level (140g/liter), normal counts of blood leukocytes (6.0 ϫ 10 9 / liter) and platelets, a negative VDRL test, a negative human immunodeficiency virus test, and a normal urine test. No thickened nerves were noted. Smears of the nasal mucosa and an earlobe showed acid-fast bacilli with intensities of ϩ and ϩϩ, respectively. These findings led to a working diagnosis of diffuse lepromatous leprosy (DLL) in view of the absence of skin nodules.A skin biopsy of the chin was performed. Histopathology showed extensive infiltration of histiocytes that involved skin appendages and a small nerve (Fig. 1). A Fite stain revealed moderate number of acid-fast bacilli in the skin tissue, with additional locations in the endothelia and a nerve (Fig. 2). These results rendered the diagnosis of DLL.The patient was treated with a multidrug regimen consisting of dapsone, rifampin, and clofazimine. In the third month of treatment, she developed weakness and red nodules on the face and arms, which was consistent with erythema nodosum leprosum. This mild reaction was controlled with 30 mg prednisone daily for 1 week with taper. Upon treatment for 12 months, nasal and earlobe smears remained positive for intact acid-fast bacilli, which led to continued treatment. The patient completed 18 months of treatment, resulting in negative smears and resolution of the skin infiltration and partial recovery of pain sensation, sweating, and hair (in the legs especially). At a 3-year follow-up, she showed nearly complete recovery of sensation and regrowth of hair on her eyelids and eyebrows. Thus, she was considered cured.The diagnosis of DLL prompted a quest to determine the identity of the acid-fast bacillus. Thus, differential PCRs were used to test the DNA extracted from the formalin-fixed paraffin-embedded biopsy tissue. The PCRs targeted the 16S rRNA genes of the...

MycobacteriumlepromatosisLepromatous Leprosy in US Citizen Who Traveled to Disease-Endemic Areas

“…Our patient’s earliest symptoms of arthritis and neuropathy were in December 2014, suggesting acquisition in Puerto Vallarta (2005) or Acapulco (2007), consistent with the leprosy incubation period of 7–8 years ( 6 ). His signs and symptoms were similar to those of patients from Mexico ( 1 , 6 , 12 , 13 ) and a patient from Canada in whom peripheral neuropathy developed 1–2 years before onset of skin lesions. Nasal mucosal involvement was prominent in both.…”

“…Future reports may help determine if this feature is specific for M. lepromatosis . In the case reported by Han et al, ( 13 ), cure was associated with nearly complete regrowth of eyebrows and eyelashes.…”

“…Nasal mucosal involvement was prominent in both. Loss of eyebrows, eyelashes, or both is common in M. lepromatosis infection ( 6 , 8 , 13 ) and might be an early sign of infection. Future reports may help determine if this feature is specific for M. lepromatosis .…”

Two Cases of Leprosy in Siblings Caused by Mycobacterium lepromatosis and Review of the Literature

“…Nasal mucosal presence of acid-fast bacilli, the purported route of leprosy transmission, has also been described in three reports of M. lepromatosis infection. 7,9,13 The likely incubation span for the sister's disease was about 8 years (2004-2012), well within the average prodromal period known for leprosy.…”

“…13 Elsewhere in the world, reports have shown five cases caused or contributed by M. lepromatosis, including two cases of Singaporean Chinese, 5 one case of a native Canadian, 7 and two cases in native Costa Ricans who now live in the United States (B. M. Stryjewska, unpublished data). To date, there have been eight cases in the United States, the above mentioned two Costa Ricans, as well as six patients of Mexican origin.…”