Winning Abstracts from the 2007 Medical Student Abstract Competition: An Old World Disease Finding its Place in the Modern World.
Anna Karina Celaya, MPH, Charles R. Drew University of Medicine and Science
Hansenis disease is an uncommon condition encountered in the United States. In patients of Mexican ancestry there is an ulcerative vasculitis form called Luciois leprosy that may be confused with diseases caused by bioterrorist infectious agents.
A 51-year-old Mexican male presented to the emergency room with an 8 day history of painful facial lesions. The first lesion began at the left mandibular angle as a small, red papule which over a few days enlarged and centrally ulcerated. Similar lesions developed over the face but sparing the eyes, nose, and ears. Patient denied a past medical history, is originally from southern Mexico, and has lived in the U.S. for 30 years where he works as a factory assembly person. On admission, patient was febrile (102°F) and vital signs stable. He was noted to have multiple ulcerative lesions throughout the face, the largest being 8cm in diameter, with a central eschar, a rim of surrounding erythema, and a lack of pustular discharge (images available). The rest of the exam was found to be normal. The lack of a medical history and the aggressive, unusual lesions caused concern for bioterrorist agents. Given the potential for bioterrorism we have seen in recent years, the concern for anthrax, tularemia, and bubonic plague were entertained. Wound scrapings obtained at admissions were sent promptly to the public health department laboratory. PCR of the wound specimens were negative for the above. Wound swabs eventually revealed AFB + organisms which subsequently were identified as Mycobacterium leprae. A biopsy of the deltoid was then performed which also revealed the M. leprae bacilli (histopathology images available). The patient was treated with thalidomide and at a 9-month follow up visit the patientis lesions had resolved.
Luciois leprosy was first described by Lucio and Alvarado in 1852 in Mexico. Luciois phenomenon is common only in the diffuse lepromatous leprosy of Mexicans. It is clinically manifested by painful, violaceous, and hemorrhagic plaques followed by ulcerated, necrotic, irregular-shaped skin lesions. It has an aggressive and rapid clinical course that can be fatal. Histopathologic characteristics include colonization of the endothelial cells by acid fast bacilli, ischemic epidermal necrosis, necrotizing vasculitis of small vessels in the upper dermis, or a leukocytoclastic vasculitis along with lymphocytes and foamy macrophages throughout the dermis. The treatment of Luciois phenomenon is the same as that used for other type 2 reactions in leprosy: high dose clofazimine (200-300 mg/day) and prednisone (40-60 mg/day) or low-dose thalidomide (50-100 mg/day).
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