1. “Is that contagious?”

2.  HPI:  Previously healthy 16 y/o male on return from a 4 year stay in Nigeria presented with a rash on his face, back and upper and lower extremities that had become more prominent over the past four months  The rash was first noted on his lower extremities 12 months earlier and was initially pruritic but the involvement of his upper extremities and face was non-pruritic and painless  Seen by physicians in Nigeria 6 months earlier and was given a powder to apply to the rash on his lower extremities which did not improve his symptoms  Applying olive oil to the rash on his face with no relief  Denied fevers, weight loss, visual or neurologic deficits  Denied sick contacts including anyone with tuberculosis

3.  PMH: None  Medications: None  Immunizations: Up to date  Social History:  Born in Nigeria and immigrated to the U.S. at age 2  Attending boarding school in Nigeria for the past 4 years. He reported no classmates or teachers with similar dermatologic symptoms.  While in Nigeria had had visited a rural village where there was no running water  Exposure to goats, cows, and chickens. Denies sexual activity, alcohol, or drug use

4.  PE : T: 36.8 °C, BP: 116/67, HR: 67, RR: 18  GEN: Comfortable, pleasant male with obvious lesions on face  EXT: 2 + pitting edema was noted up to his knees bilaterally.  SKIN: Lichenified skin was noted on both shins. Papules, nodules, and plaques were noted on his face, ears, upper and lower extremities with sparing of the trunk. Some hypopigmented patches were noted on his back.  NEURO: There was prominence of the temporal, ulnar and popliteal nerves. Neurologic exam was grossly intact. All sensation was normal including fine touch and proprioception.  Remainder of exam was normal

7. Studies:  CBC:  WBC 6.84 Thou/uL (S-68%, L-22%, M-4%, E-6%)  Hgb 12.6 g/dL Hct-37.3% Plt-279 Thou/uL  Chemistries and LFTs: Normal  UA: Normal  Chest x-ray: Normal  HIV ELISA: Negative

8. Differential Diagnosis 1) Cutaneous leishmaniasis 2) Cutaneous onchocerciasis (Onchocerca volvulus) 3) Lepromatous leprosy (Hansen’s Disease) 4) Mycobacterium marinum 5) Human Immunodeficiency Virus (HIV) type 2 infection 6) Fungal dermatitis 7) Allergic reaction to homeopathic therapy

9. Diagnosis and Follow-up  Ziehl-Neelsen staining did not identify acid fast organisms but a modified Fite-Faraco stain demonstrated numerous bacilli within histiocytes consistent with Mycobacterium leprae  He was started on dapsone, rifampin and clofazimine  Noticeable reduction in size and distribution of lesions after 6 months of therapy  Will undergo a skin biopsy after 12 months of therapy to guide duration of therapy. Plans are for a minimum of 24 months of treatment

10. Leprosy (Hansen’s Disease)  Disease caused by bacillus Mycobacterium leprae  Spectrum of disease manifestations related to cell mediated immune response  Highly infectious but low virulence  - Believed to be spread by direct contact or nasal droplet  - Skin and peripheral nerves most affected organs  Incubation period 2-5 Years

11. Leprosy: Keys to Diagnosis  Diagnosis is Clinical:  Hypopigmented or erythematous anesthetic plaque  “Leonine Facies” and madarosis  Peripheral Nerve Thickening  Decrease in peripheral sensation to fine touch and vibration

12. Treatment and Prognosis  Multi-drug Therapy:  Dapsone  Rifampin Need to check for G6PD and TB  Clofazimine prior to initiating therapy  Recommended length of therapy is minimum of 2 years  Goal of therapy is prevention of permanent nerve damage  Leprosy is curable

13. Final Diagnosis Lepromatous Leprosy (Hansen’s Disease) caused by Mycobacterium leprae