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CLINICAL VIGNETTE

Leprosy: Challenges in diagnosis


Carolina Diaz Pallares MD1, Samuel Bourassa-Blanchette MDCM1, Kevin Fonseca PhD1,
Stephen Vaughan MD1

Leprosy (Hansen’s disease) is caused by Mycobacterium leprae. It affects the skin and peripheral nerves. Incidence and prevalence are
underestimated due to challenges in diagnosis and unfamiliarity with the disease in Canada. Untreated disease can lead to perma-
Official Journal of the Association of Medical Microbiology and Infectious Disease Canada 2019.4:187-189.

nent nerve damage with subsequent loss of function. We present a case of Hansen’s disease with delay in diagnosis and treatment.
A 31-year-old female recent immigrant from the Philippines presented with a 2-year history of a palpable erythematous rash on
her face and arms. She had a diagnosis of cryoglobulinemic vasculitis associated with her chronic hepatitis B. A course of topical
corticosteroids did not alleviate symptoms. The rash had a waxing and waning pattern that was felt to mirror her antiviral therapy.
Although hepatitis B cryoglobulinemia has been reported in the remote literature, further studies have failed to illustrate that it is
a significant cause of cryoglobulinemia. Retrospective analysis of the case identified that anchoring to the initial diagnosis was the
reason for delay in diagnosis and treatment.

KEY WORDS: Canada, Hansen’s Disease, leprosy, Mycobacterium leprae

La lèpre est causée par le Mycobacterium leprae. Elle touche la peau et les nerfs périphériques. Son incidence et sa prévalence sont
sous-estimées en raison du diagnostic difficile à poser et de la méconnaissance de cette maladie au Canada. Non traitée, cette
maladie peut provoquer des lésions nerveuses permanentes, suivies d’une perte de fonction. Les chercheurs présentent un cas
de maladie de Hansen qui a tardé à être diagnostiqué et traité. Une néo-immigrante de 31 ans des Philippines a consulté à cause
d’une éruption érythémateuse palpable qu’elle avait depuis deux ans sur le visage et les bras. Elle avait reçu un diagnostic de
vascularite cryoglobulinémique associé à une hépatite B chronique. Une corticothérapie topique n’a pas soulagé les symptômes.
L’éruption avait un aspect de creux et de bosses qui semblait refléter l’antivirothérapie. Même si la cryoglobulinémie causée
par l’hépatite B est signalée dans des publications isolées, d’autres études n’ont pu démontrer de lien important entre ces deux
affections. L’analyse rétrospective du cas a établi que l’association des symptômes avec le diagnostic initial explique le retard de
diagnostic et de traitement.

MOTS-CLÉS : Canada, maladie de Hansen, lèpre, Mycobacterium leprae


1
Division of Infectious Diseases, Department of Medicine, University of Calgary, Calgary, Alberta

Correspondence: Carolina Diaz Pallares, Division of Infectious Diseases, Department of Medicine, University of Calgary,
2500 University Dr NW, Calgary, Alberta T2N 1N4. E-mail: Carolina.diazpallares@albertahealthservices.ca

with her son. She denied recreational drug use, smoking


CASE PRESENTATION tobacco, and drinking alcohol.
A 31-year-old female from the Philippines who immigrated She had a diagnosis of cryoglobulinemic vasculitis ­associated
to Canada in 2015 presented with a 2-year history of a pal- with her chronic hepatitis. The rash had a waxing and waning
pable erythematous rash on her face and arms. Past medical pattern following initiation of antiviral therapy (Tenofovir).
history was relevant for e-antigen–positive chronic hepatitis A course of topical corticosteroids had not a­ lleviated her
B. The patient was employed as a health care aide and lived symptoms.

Official Journal of the Association of Medical Microbiology and Infectious Disease Canada  4.3, 2019  doi:10.3138/jammi.2019.05.24.01
C Diaz Pallares, S Bourassa-Blanchette, K Fonseca, S Vaughan

The rash was initially located on her face and arms but
had later progressed to her legs, 1 year prior to this visit.
The skin changes were not pruritic or painful, but she had
complained of numbness. This led to a presumed diagnosis
of carpal tunnel syndrome, as the numbness was exacerbated
by repeated movements at work. Carpal tunnel syndrome was
confirmed by demonstration of median nerve neuropathy on
nerve conduction studies (NCS)/electromyography (EMG). At
that point, she had also noticed an ulcer on her right thumb
that she felt was associated with repetitive movements from
her occupation.
Review of systems was negative. She had no sick contacts, Figure 1: Clinical manifestations of leprosy (Hansen's Disease)
no animal exposures, and no travel outside of Canada fol-
Official Journal of the Association of Medical Microbiology and Infectious Disease Canada 2019.4:187-189.

in the patient. Figure courtesy of Samuel Bourassa-Blanchette


lowing her immigration.
On physical exam, she appeared well. There were several
well demarcated lesions with varying degree of erythema Although hepatitis B cryoglobulinemia has been reported
and hypoesthesia spread over her extremities and her back. in the remote literature, further studies have failed to illus-
(Figure 1) The largest lesion was on her right proximal arm trate that it is a significant cause of cryoglobulinemia (5) We
measuring approximately 10 cm × 8 cm, with other lesions present a case of Hansen’s Disease in which there was delay
on the hands, soles, calves, thighs, and back. No induration in diagnosis and treatment. Retrospective analysis of the case
of nerves could be palpated. identified that anchoring to the initial diagnosis was one of
Other relevant investigations revealed a normal hemoglobin the reasons for delay (6) Leprosy should be high on the dif-
A1c, negative serology for hepatitis C, HIV, and syphilis, a ferential diagnosis in patients presenting with longstanding
normal immune panel except for mildly elevated erythrocyte skin lesions and peripheral neuropathy, particularly if they
sedimentation rate (ESR), and weak positive cryoglobulins. have resided in an endemic area, such as South America and
A percutaneous skin biopsy was performed. the Philippines. Hansen’s Disease presents as a spectrum that
can range from tuberculoid leprosy to lepromatous leprosy,
DIAGNOSIS which can make diagnosis challenging.
In clinic, there was a strong suspicion that her symptoms
were related to Hansen’s Disease. Skin biopsy showed dermal CONTRIBUTORS: Conceptualization, CDP, SBB; Resources,
granulomas with scant acid-fast bacilli, and polymerase chain KF; Writing – Original Draft, CDP; Writing – Review &
reaction (PCR) testing for Mycobacterium leprae was posi- ­Editing, SBB, SDV, KF; Visualization, CDP; Supervision,
tive. Bacillary loading was not available from skin biopsies; SBB, SDV; Project Administration, CDP.
however, the patient was given a diagnosis of multibacillary
borderline lepromatous. FUNDING: Publication of this article was funded by the
Association of Medical Microbiology and Infectious Disease
DISCUSSION (AMMI) Canada.
Leprosy is caused by M. leprae. It involves the skin and pe-
ripheral nerves. Incidence and prevalence are underestimated DISCLOSURES: The authors have nothing to disclose.
due to challenges in diagnosis (1) and unfamiliarity with the
disease in Canada (2,3).
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188 Official Journal of the Association of Medical Microbiology and Infectious Disease Canada   4.3, 2019
Leprosy: Challenges in diagnosis

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Official Journal of the Association of Medical Microbiology and Infectious Disease Canada 2019.4:187-189.

4.3, 2019   Journal officiel de l’Association pour la microbiologie médicale et l’infectiologie Canada 189