Download 17 y/o male with diziness and lethargy

“Is that contagious?”
 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
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
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
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
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
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
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
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
Treatment and Prognosis
 Multi-drug Therapy:
 Dapsone
 Rifampin
 Clofazimine
Need to check for G6PD and TB
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
Final Diagnosis
Lepromatous Leprosy (Hansen’s Disease) caused by
Mycobacterium leprae