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Lepromatous Leprosy in a 26-Year-Old Man With Concurrent Disseminated Tuberculosis

Lepromatous Leprosy in a 26-Year-Old Man With Concurrent Disseminated Tuberculosis Report of a Case A 26-year-old man from the Marshall Islands presented with complaints of chest pain and cough for 2 days and abdominal pain for several months. His chest radiograph showed right lower lobe consolidation and pleural effusion while computed tomography and magnetic resonance imaging revealed thoracic vertebral osteomyelitis and paraspinal abscess. The result of a tuberculin skin test was positive, but this was attributed to his history of BCG vaccination. His sputum sample tested negative for acid-fast bacilli. Pulmonary and cutaneous coccidioidomycosis was suspected because he had lived in Arizona and had skin nodules. The patient had had ear nodules (Figure 1) for 3 years. He also had a half dozen scars of similar size on his extremities that had begun as nodules. Hematoxylin-eosin staining of a skin biopsy specimen from a nodule showed a dense histiocytic dermal infiltrate. Fite staining revealed acid-fast bacilli (Figure 2). Results of polymerase chain reaction (PCR) DNA analysis from skin samples were negative for Mycobacterium tuberculosis but positive for Mycobacterium leprae. Pleural fluid from the right lung and a liver biopsy specimen tested PCR positive for M tuberculosis. Findings of a human immunodeficiency virus (HIV) assay were negative. View LargeDownload Figure 1. Clinical photograph of patient's ear showing multiple skin-colored nodules. View LargeDownload Figure 2. Skin biopsy specimen from the ear highlighting numerous bacilli (magenta) in the dermis (Fite stain, original magnification ×600). The patient was diagnosed as having lepromatous leprosy (Hansen disease) and disseminated tuberculosis, and his case was reported to the public health authorities. The US Centers for Disease Control and Prevention (CDC) recommend treatment of lepromatous leprosy with dapsone, rifampin, and clofazimine and of tuberculosis with isoniazid, rifampin, ethambutol, and pyrazinamide. Owing to concerns for toxic effects, our patient was treated with clofazimine, rifampin, ethambutol, and levofloxacin, and his condition improved. Comment The incidence of concurrent leprosy and tuberculosis in the United States is unknown. To our knowledge, this is the first reported case in the United States of concurrent lepromatous leprosy and disseminated tuberculosis. Two cases of tuberculoid and borderline lepromatous leprosy in the setting of pulmonary tuberculosis in the United States have constituted the only previous reports.1 Internationally, a study of an Indian area where both diseases are endemic showed that approximately 2.5% of patients with leprosy there have pulmonary tuberculosis2 and suggests that approximately 7.5% of these coinfected patients show signs of extrapulmonary tuberculosis. Susceptibility to coinfection with tuberculosis and leprosy likely depends on multiple variables. Environmental factors such as poor nutrition, low socioeconomic status, regional prevalence of organisms, and host factors such as HIV and chemo-immunosuppression may play a role.1,3 The Marshall Islands have a high prevalence of leprosy, and the CDC has found that most cases in the United States originate from endemic areas.4 Both tuberculosis and leprosy present clinically along a spectrum where dissemination and multibacillary disease correlate with T-helper cell type 2 immunity, which is predominantly humoral rather than macrophagocytic.5 This case offers clinical lessons. First, the incidence of dual mycobacteria infections in the United States deserves increased attention. From 2006 through 2009, the annual reported cases of leprosy ranged from 73 to 109.4 The presentation of this patient with skin nodules and lung opacities was initially attributed to Coccidioides, erroneously designating him as noncontagious for tuberculosis. Second, even after diagnosis of 1 mycobacterium, attention should be paid to any suspicion of coinfection; treating leprosy with monotherapy in a patient with tuberculosis facilitates the emergence of multidrug resistance.3 Back to top Article Information Correspondence: Dr Loh, Department of Dermatology, University of California, Davis, 3301 C St, Ste 1400, Sacramento, CA 95816 (ernloh6@gmail.com). Financial Disclosure: None reported. Funding/Support: This study was supported in part by grants from Howard Hughes Medical Institute and the Burroughs Wellcome Fund (Dr Maverakis). Additional Contributions: We are indebted to Dalila Ramirez-Maverakis for administrative support. References 1. Negrete V, Ida J, Dillig G, Zohrabian N, Feldman J. Concurrent Hansen disease and pulmonary tuberculosis. J Am Acad Dermatol. 2011;64(5):1001-100321496714PubMedGoogle ScholarCrossref 2. Nigam P, Dubey AL, Dayal SG, Goyal BM, Saxena HN, Samuel KC. The association of leprosy and pulmonary tuberculosis. Lepr India. 1979;51(1):65-73449287PubMedGoogle Scholar 3. Grace M, Shameemurahman . Coinfection of two age old diseases. Indian J Community Med. 2011;36(3):228-23022090679PubMedGoogle ScholarCrossref 4. Hall-Baker PA, Groseclose SL, Jajosky RA, Goyal BM, Saxena HN, et al. Summary of Notifiable Diseases—United States, 2009. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5853a1.htm. Accessed July 10, 2012 5. Bhatt K, Salgame P. Host innate immune response to Mycobacterium tuberculosis. J Clin Immunol. 2007;27(4):347-36217364232PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Lepromatous Leprosy in a 26-Year-Old Man With Concurrent Disseminated Tuberculosis

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References (5)

Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archdermatol.2012.970
Publisher site
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Abstract

Report of a Case A 26-year-old man from the Marshall Islands presented with complaints of chest pain and cough for 2 days and abdominal pain for several months. His chest radiograph showed right lower lobe consolidation and pleural effusion while computed tomography and magnetic resonance imaging revealed thoracic vertebral osteomyelitis and paraspinal abscess. The result of a tuberculin skin test was positive, but this was attributed to his history of BCG vaccination. His sputum sample tested negative for acid-fast bacilli. Pulmonary and cutaneous coccidioidomycosis was suspected because he had lived in Arizona and had skin nodules. The patient had had ear nodules (Figure 1) for 3 years. He also had a half dozen scars of similar size on his extremities that had begun as nodules. Hematoxylin-eosin staining of a skin biopsy specimen from a nodule showed a dense histiocytic dermal infiltrate. Fite staining revealed acid-fast bacilli (Figure 2). Results of polymerase chain reaction (PCR) DNA analysis from skin samples were negative for Mycobacterium tuberculosis but positive for Mycobacterium leprae. Pleural fluid from the right lung and a liver biopsy specimen tested PCR positive for M tuberculosis. Findings of a human immunodeficiency virus (HIV) assay were negative. View LargeDownload Figure 1. Clinical photograph of patient's ear showing multiple skin-colored nodules. View LargeDownload Figure 2. Skin biopsy specimen from the ear highlighting numerous bacilli (magenta) in the dermis (Fite stain, original magnification ×600). The patient was diagnosed as having lepromatous leprosy (Hansen disease) and disseminated tuberculosis, and his case was reported to the public health authorities. The US Centers for Disease Control and Prevention (CDC) recommend treatment of lepromatous leprosy with dapsone, rifampin, and clofazimine and of tuberculosis with isoniazid, rifampin, ethambutol, and pyrazinamide. Owing to concerns for toxic effects, our patient was treated with clofazimine, rifampin, ethambutol, and levofloxacin, and his condition improved. Comment The incidence of concurrent leprosy and tuberculosis in the United States is unknown. To our knowledge, this is the first reported case in the United States of concurrent lepromatous leprosy and disseminated tuberculosis. Two cases of tuberculoid and borderline lepromatous leprosy in the setting of pulmonary tuberculosis in the United States have constituted the only previous reports.1 Internationally, a study of an Indian area where both diseases are endemic showed that approximately 2.5% of patients with leprosy there have pulmonary tuberculosis2 and suggests that approximately 7.5% of these coinfected patients show signs of extrapulmonary tuberculosis. Susceptibility to coinfection with tuberculosis and leprosy likely depends on multiple variables. Environmental factors such as poor nutrition, low socioeconomic status, regional prevalence of organisms, and host factors such as HIV and chemo-immunosuppression may play a role.1,3 The Marshall Islands have a high prevalence of leprosy, and the CDC has found that most cases in the United States originate from endemic areas.4 Both tuberculosis and leprosy present clinically along a spectrum where dissemination and multibacillary disease correlate with T-helper cell type 2 immunity, which is predominantly humoral rather than macrophagocytic.5 This case offers clinical lessons. First, the incidence of dual mycobacteria infections in the United States deserves increased attention. From 2006 through 2009, the annual reported cases of leprosy ranged from 73 to 109.4 The presentation of this patient with skin nodules and lung opacities was initially attributed to Coccidioides, erroneously designating him as noncontagious for tuberculosis. Second, even after diagnosis of 1 mycobacterium, attention should be paid to any suspicion of coinfection; treating leprosy with monotherapy in a patient with tuberculosis facilitates the emergence of multidrug resistance.3 Back to top Article Information Correspondence: Dr Loh, Department of Dermatology, University of California, Davis, 3301 C St, Ste 1400, Sacramento, CA 95816 (ernloh6@gmail.com). Financial Disclosure: None reported. Funding/Support: This study was supported in part by grants from Howard Hughes Medical Institute and the Burroughs Wellcome Fund (Dr Maverakis). Additional Contributions: We are indebted to Dalila Ramirez-Maverakis for administrative support. References 1. Negrete V, Ida J, Dillig G, Zohrabian N, Feldman J. Concurrent Hansen disease and pulmonary tuberculosis. J Am Acad Dermatol. 2011;64(5):1001-100321496714PubMedGoogle ScholarCrossref 2. Nigam P, Dubey AL, Dayal SG, Goyal BM, Saxena HN, Samuel KC. The association of leprosy and pulmonary tuberculosis. Lepr India. 1979;51(1):65-73449287PubMedGoogle Scholar 3. Grace M, Shameemurahman . Coinfection of two age old diseases. Indian J Community Med. 2011;36(3):228-23022090679PubMedGoogle ScholarCrossref 4. Hall-Baker PA, Groseclose SL, Jajosky RA, Goyal BM, Saxena HN, et al. Summary of Notifiable Diseases—United States, 2009. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5853a1.htm. Accessed July 10, 2012 5. Bhatt K, Salgame P. Host innate immune response to Mycobacterium tuberculosis. J Clin Immunol. 2007;27(4):347-36217364232PubMedGoogle ScholarCrossref

Journal

Archives of Dermatology – American Medical Association

Published: Sep 1, 2012

Keywords: leprosy, lepromatous,miliary tuberculosis

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