Leprosy-Like Illness in a Patient With Mycobacterium lepromatosis From Ontario, Canada

February 2012 | Volume 11 | Issue 2 | Case Reports | 229 | Copyright © February 2012


Peter G. Jessamine MD,a Marc Desjardins PhD,a Tom Gillis PhD,b David Scollard MD PhD,bFrances Jamieson MD,c George Broukhanski PhD,c Pam Chedore MLT,c Anne McCarthy MDa

aThe Ottawa Hospital and The Ottawa Hospital Research Institute, Ottawa, Canada bNational Hansen’s Disease Programs, Baton Rouge, LA cPublic Health Laboratory, Public Health Ontario, Toronto, Canada

Abstract

Here we present the first case of a patient from Ottawa Canada, presenting with leprosy-like illness associated with Mycobacterium lepromatosis. The patient had no history of travel to leprosy-endemic areas or any obvious risk factors. Clinically, the patient presented with an anesthetic maculopapular rash on the trunk, back, and extremities. A skin biopsy of a lesion revealed a dermal lymphohistiocytic infiltration involving the vessels with an inflammatory process extending to the nerves. A neurological exam also identified a severe sensorimotor polyneuropathy. Concurrently, the patient was diagnosed with non-resectable, non small cell carcinoma of the lung, further complicating his clinical presentation. A Kinyoun stain of nasal blows and a Fite stain of the skin biopsy revealed few to moderate acid fast bacilli respectively. Cultures of the skin biopsy and multiple nasal blows were negative. Molecular studies of a skin biopsy sample including sequence analysis of a 765 bp region of the 16s rRNA gene eventually identified the organism with 100% homology to M. lepromatosis. The patient was treated for leprosy and appeared to improve slightly on therapy but died as a result of his malignancy approximately five months after the initiation of therapy. This represents the first case of a patient with M. lepromatosis like illness outside of Mexico and Singapore.

J Drugs Dermatol. 2012;11(2):229-233.

INTRODUCTION

A 72-year-old Canadian, retired French language professor, who was born and raised in central Canada developed distal paraesthesias in both feet while wintering in Florida in 2002. Over the subsequent months the paraesthesia ascended, and also appeared in both hands. The use of a cane became necessary and whether this was due to impaired balance or weakness was not clear; the patient preferred to wear gloves and it became difficult to type. A lack of sensation in his feet was noted when trimming his toe nails. The loss of approximately 40 pounds occurred over the subsequent year and was ascribed mostly to loss of appetite. The development of foot drop caused the patient to trip and fall, and he became more withdrawn.
The emergence of a maculopapular rash involving the trunk was noted in 2004 (Figure 1). Travel history included wintering in Florida in the few years preceding his presentation and one Caribbean cruise out of Cape Canaveral where he remained on the boat.
The patient was seen by a neurologist who noted bilateral atrophy of the thenar eminences, and the small hand muscles. Symmetrical, mild to moderate weakness was present in the distal muscles of his upper and lower extremities. There was symmetrical impairment in sensation for pain, light touch, vibration, and proprioception in his upper and lower extremities. Pain and light touch sensation were altered from his hands to mid forearms bilaterally, with a similar pattern in his lower extremities. Ankle reflexes were absent, while knee and upper limb reflexes were normal. The neurological opinion was that of a severe sensorimotor polyneuropathy.
With normal blood glucose and vitamin B12 levels a paraneoplastic process was considered. A dermatologist described the rash as reddish brown papules and plaques on the trunk and legs that were hypoaesthesic, and noted the loss of lateral portions of both eyebrows. Nerve thickening was not evident. A punch biopsy of the rash from his back was performed and revealed the presence of a moderate lymphohistiocytic infiltration within the dermis that involved vessels and adnexal structures. The inflammatory process was described as involving the nerves, and consisted of lymphocytes, plasma cells, and histiocytes. A Fite stain revealed the presence of numerous bacilli within the dermis. The histological appearance was felt to be
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