Leukomelanodermic leprosy

Abstract

A 39‐year‐old woman presented with a 6‐year history of asymptomatic macules on her back. The patient had no other complaints, and she did not report any case of infectious disease in her family. Examination revealed hyperpigmented macules, presenting irregular edges but with a sharp demarcation, on the midline of the back from the cervical to the lumbar region. Within these hyperpigmented areas, islands of normal appearing skin were observed. There were also some hypopigmented macules on the lateral and posterior aspects of the trunk (Fig. 1). The patient presented thickening of the left ulnar nerve and sensory loss to temperature on the lateral aspect of the left arm. 1 Hyperpigmented macules, presenting irregular but sharply demarcated edges, on the midline of the back. Islands of normal appearing skin are observed in these hyperpigmented areas. Hypopigmented macules on the lateral and posterior aspects of the trunk Biopsy specimens were obtained from the hyper‐ and hypopigmented areas. In the hyperpigmented macule, the biopsy revealed focal areas of hypomelanosis in the epidermis and the presence of melanophages in the superficial dermis, but no acid‐fast bacilli were found (Fig. 2a). The Masson–Fontana stain showed an evident pigmentary incontinence (Fig. 2b). The biopsy obtained from the hypopigmented lesion also revealed focal areas of hypomelanosis, but in the superficial dermis an infiltrate of foamy macrophages was observed, as typically found in lepromatous leprosy (Fig. 3a); acid‐fast bacilli were found by Fite–Faraco stain. The focal hypomelanosis was confirmed by Masson–Fontana stain (Fig. 3b). Mitsuda's reaction in this patient was negative and slit‐skin smears (cutaneous lesion, earlobes, elbows, and knees) were negative for acid‐fast bacilli. 2 Biopsy of hyperpigmented macule. (a) Focal areas of hypomelanosis and presence of melanophages in the superficial dermis (hematoxylin and eosin stain, ×100). (b) Evident pigmentary incontinence in the superficial dermis (Masson–Fontana stain, ×100) 3 Biopsy of hypopigmented macule. (a) Focal areas of hypomelanosis in the epidermis and dermal infiltrate of foamy macrophages (hematoxylin and eosin stain, ×100). (b) Focal areas of hypomelanosis (Masson–Fontana stain, ×100) The patient was treated with multidrug therapy for multibacillary leprosy: rifampin, 600 mg once monthly (supervised), clofazimine, 300 mg once monthly (supervised), dapsone, 100 mg daily, and clofazimine, 50 mg daily, all given for 2 years. After 7 months of treatment, the hypopigmented lesions diminished and the hyperpigmented lesions improved after 2 years of treatment and the sensory loss to temperature was restored.