De-Novo Keloid-Like Presentation in Lepromatous Leprosy
Year: 2024
Type: article
Study design: Case Report
Abstract: A 23-year-old male patient hailing from Bihar presented with asymptomatic skin-coloured raised lesions over the body for 3 months, which initially started as keloid-like plaque over the right forearm and progressed to other areas [Figure 1]. On examination: multiple skin coloured to erythematous papules coalesced to form plaques present over the upper Back [Figures 2 and 3]. Nodules with ulceration present over the posterior aspect of both elbows resembling keloid and few discrete papules present over the back. Bilateral ulnar and radial cutaneous nerves were thickened with cord-like consistency that was non-tender and non-nodular.Figure 1: Keloid like plaque over backFigure 2: Hypopigmented nodules with ulcerationFigure 3: Keloid like plaques over the forearmSensations were intact, with no loss of power, no deformities and no trophic ulcer. General physical examination- normal, slit skin smear was performed from the lesion showed, bacillary index 6+, and the morphological index 70%. Biopsy features showed atrophic epidermis with clear grenz zone, lymphohistiocytic infiltrate in the dermis [Figures 4 and 5], and a few showing vacuolated histiocytes and bacilli (long, slender, with rounded edges) showed positive Fite-Faraco staining.Figure 4: Diffuse Granuloma on 10 X powerFigure 5: Postive Fite-Faraco (long, slender, with rounded edges) stainingAnswer: Keloid Like Presentation in Lepromatous Leprosy The patient was started on MB-MDT with regular follow-up. Review The term histoid is derived from the microscopic appearance of the nodule showing spindle-shaped cells resembling dermatofibroma. Histoid leprosy is an uncommon variant of lepromatous leprosy, first described by Wade in 1960 as a histological component of bacillary-rich leproma composed of spindle-shaped cells.[1] The higher load of lepra bacilli in these cases makes it a concern as a reservoir for leprosy, and it is commonly seen in patients relapsing after dapsone monotherapy, in the presence of dapsone resistance, relapse in the inactive case of lepromatous leprosy or de novo or mutant organism (histoid bacillus).[2] Histoid leprosy is a rare and highly transmissible variant of lepromatous leprosy. In India, prevalence of histoid leprosy is estimated between 1.8% to 3.2% Maximum number of patients belonged to 21-40 years age group as observed with M:F ratio being 2.9:1. Clinically, histoid lesions are characterised by painless, firm, discrete, smooth and rounded, skin-coloured cutaneous and subcutaneous nodules and plaques appearing on otherwise normal-looking skin, affecting the back, buttocks, face and extremities. Various sizes range from 1.5 to 3.5 cm and are usually 3-50 in number.[3] The cell-mediated immunity is better in histoid leprosy than in active lepromatous patients, as substantiated by increased CD36 expression by the keratinocytes, predominance of CD4 lymphocytes over CD8 lymphocytes and increased number of activated lymphocytes and macrophages in the lesion. This may well be explained by the attempted localisation of the lesions to limited regions of the body in histoid leprosy.[4] On histopathology, the cardinal feature of histoid leproma is its circumscribed nature. They grow in an expansile rather than an infiltrative fashion. The classical feature is the presence of numerous, thin, spindle-shaped histiocytes forming interlacing bands, whorls and, at times, tight curlicues. A large number of acid-fast bacilli are seen in active lesions. The epidermis is usually stretched and atrophic. A free subepidermal grenz zone (band of Unna) is present. Histoid lesions can also have lymphocytes and, occasionally, polymorphonuclear leukocytes, especially at the lesion’s periphery. Pseudo capsule is often seen.[4] Keloid-like presentations in histoid leprosy are rare, and they can be present de novo. Although few cases reported have been reported over the period.[5] Learning points Keloid-like lesions are rare and unusual and have to be considered as one of the differentials. Skin ulceration due to localised CMI. They have a high bacillary load and hence they can be a source of transmission. Type II reaction is not prevalent in cases of histoid leprosy. The histoid lesions contain a high number of bacilli and are therefore reservoirs for resistant strains of infection. 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 initials 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.
Source: Indian Journal of Dermatology
Authors: M Bhagyashree, B Sreeja, Ashok Rao Matety
Language: English
Subfield: Infectious Diseases
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4402515256