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Updated: Dec 23 2021


  • Snapshot
    • A 50-year-old woman presents to her primary care physician for a rash. She describes her past year of backpacking throughout the world including multiple areas of Southeast Asia. She states that her face feels thicker than normal and that she has developed a rash throughout her body. On physical exam, she has leonines facies with thickened earlobes, cheeks, and eyebrows. There are also diffuse nodular and plaque-like lesions with hypopigmentation and non-defined borders. She is counselled on the need for long-term antibiotics.
  • Introduction
    • Classification
      • Mycobacterium leprae
        • a non-motile acid-fast bacillus
        • prefers cool temperatures
      • transmission
        • respiratory via nasal mucosa
        • via armadillo reservoirs
    • Associated conditions
      • lepromatous Hansen disease
      • tuberculoid Hansen disease
      • erythema nodosum
  • Epidemiology
    • Incidence
      • more common in Southeast Asia and South America
    • Location
      • affects skin and peripheral nerves
    • Risk factors
      • travel to endemic countries
      • contact with others with leprosy
      • contact with or consumption of reservoirs such as armadillos
    • Pathogenesis
      • the bacteria grows in cool regions, such as the skin and peripheral nerves
      • infects macrophages, Schwann cells, and keratinocytes
      • lepromatous Hansen disease
        • weak cell-mediated immunity
        • humoral Th2-type immune response
        • high burden of bacteria in lesions
      • tuberculoid Hansen disease
        • strong cell-mediated immunity
        • Th1-type immune response
        • low burden of bacteria in lesions
  • Presentation
    • Symptoms
      • lepromatous Hansen disease
        • diffuse rash
      • tuberculoid Hansen disease
        • multiple discrete lesions
    • Physical exam
      • patients often present with overlapping findings
      • peripheral neuropathy
        • foot drop
        • facial nerve palsy
        • contractures or hand or feet
        • loss of sensation
      • lepromatous Hansen disease
        • leonine facies (lion-like)
          • thickened foreheard, ears, eyebrows, and cheeks
        • diffuse plaques and nodular skin lesions symmetrically distributed
          • may be erythematous or hypopigmented without sharp borders
      • tuberculoid Hansen disease
        • multiple discrete erythematous plaques with central hypopigmentation and raised discrete borders
          • plaques often have loss of sensation
          • hairless
          • dry with some scale
  • Studies
    • Labs
      • tissue polymerase chain reaction (PCR)
      • may test as falsely positive on VDRL testing
    • Biopsy or slit-skin smear
      • acid-fast bacilli
      • granulomas
    • Making the diagnosis
      • based on clinical presentation and tissue diagnosis
  • Differential
    • Morphea
      • distinguishing factor
        • also presents with thickened skin but usually does not involve peripheral nerve damage
    • Vitiligo
      • distinguishing factor
        • also presents with hypopigmentation but without peripheral nerve damage or raised borders
  • Treatment
    • Medical
      • dapsone and rifampin
        • indication
          • tuberculoid and lepromatous types
      • clofazimine
        • indication
          • added therapy for lepromatous types
  • Complications
    • Permanent nerve impairment
    • Deformities
  • Prognosis
    • Slow progression that may develop over months or years
    • May have intermittent acute leprosy reactions
    • Lepromatous type is more severe
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