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Post-Traumatic Inoculation Tuberculoid Leprosy After Injury with a Glass Bangle

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Post-Traumatic Inoculation Tuberculoid Leprosy After Injury with a Glass Bangle Lepr Rev (2009) 80, 215–218 CASE REPORT Post-traumatic inoculation tuberculoid leprosy after injury with a glass bangle ASHOK GHORPADE Department of Dermatology, Venereology & Leprosy, JLN Hospital & Research Centre, Bhilai Steel Plant, Bhilai, Chhattisgarh state, India Accepted for publication 27 March 2009 Summary A lesion of tuberculoid leprosy in an Indian lady presenting at the site of injury from a broken glass bangle is reported. The diagnosis was by classical clinical features and histopathology. The importance of the skin in leprosy transmission is emphasised. Case Report A 44 year-old Indian woman presented with a 2 month history of a skin lesion on her right hand. She was a coordinator in a school for slum children in this highly endemic region for 22 years. The lesion had started exactly over a site of an injury with her glass bangle, sustained about 2 years earlier. There was no family history of skin problems, or of any local or oral medication. Cutaneous examination showed a single, circular, raised, uniformly infiltrated, erythematous plaque around 3 cms in diameter, anaesthetic to temperature, touch and pain on the medial aspect of her right hand, near the wrist joint (Figure 1a). There was no other skin lesion and systemic examination was normal. Histopathological examination revealed multiple compact non-caseating granulomas of lymphocytes, epitheloid cells and Langhans’ giant cells in the upper dermis almost touching the normal epidermis from below, with a similar infiltrate invading a nerve in deeper dermis (Figure 2). Ziehl-Neelsen stain from the section and the slit smear examination from the lesion did not reveal any acid-fast bacilli. The mycotect multiplex polymerase chain reaction for M. tuberculosis DNA from the skin biopsy tissue was negative. She was treated with paucibacillary multidrug treatment, dapsone 100 mg daily and rifampicin 600 mg once a month. The lesion regressed over 6 months (Figure 1b). Correspondence to: Ashok Ghorpade, 1B, Street 13, Hospital Sector, Bhilai, Chhattisgarh- 490006, India (Tel: þ91 788 2322309; Fax: þ91 788 2241926; e-mail: [email protected]) 0305-7518/09/064053+04 $1.00 q Lepra 215 216 A. Chorpade Figure 1. (a) Uniformly infiltrated, raised, erythematous circular plaque on medial aspect of right hand. (b) Same lesion six months after PB MDT, showing marked regression. Discussion Though the exact mode of leprosy transmission is unclear, most leprologists suggest that an airborne spread through the upper respiratory tract is likely in the majority of cases. If so, M. leprae probably enters the body through the nose and then spreads via the circulation to the skin and nerves.1 Reports of inoculation leprosy over the sites of tattooing and vaccination and the first description of the pseudo-koebner phenomenon in leprosy,2–7 have contributed support to the alternative hypothesis that leprosy can be transmitted through inoculation, as have reports of leprosy lesions developing in a surgeon after operating upon a lepromatous leprosy patient,8 on a gynaecologist’s finger,9 and after traumatic injury.10,11 The appearance of the first leprosy lesion at the site of a dog-bite or inoculation in armadillos,12,13 and over the trauma-prone exposed sites of the body,14,15 are similar pointers. Single leprosy lesions were seen commonly on the trauma-prone posterior aspect of the arm as compared to the anterior aspect.16 Like other mycobacterial infections, including tuberculosis, leprosy can also be transmitted through abraded or traumatised skin.17 – 19 In the case reported here, the clinical features and the histopathological findings favour a diagnosis of leprosy and are against the diagnosis of cutaneous tuberculosis, foreign body Post-traumatic inoculation TB leprosy 217 Figure 2. (a) Histopatholgy showing upper dermal compact non-caseating granulomas of lymphocytes, epitheloid cells and Langhans’ giant cells almost touching the epidermis from below (Haematoxylin and eosin; original magnification £ 400), and (b) Similar granulomatous infiltrate as above, in linear fashion in mid dermis invading the nerve fibres (Haematoxylin and eosin; original magnification £ 400). granuloma or sarcoidosis. The absence of M. tuberculosis DNA in mycotect multiplex DNA polymerase chain reaction from the skin biopsy tissue is also against tuberculosis. That the lesion developed 2 years after a traumatic injury, and its exclusive localisation to the site of the injury favour transmission through the skin, although it is difficult to ascertain the exact time of infection with M. leprae. It might have been at the time her bangle broke and cut her, or it might have been at an earlier time during her work in the slums, remaining latent until it localised in recently traumatised skin. The pseudo-isomorphic phenomenon of Koebner seen in warts and molluscum contagiosum,20 due to inoculation of the causative agent through traumatised skin, has now been demonstrated in leprosy.6 and is evidence for the skin as the site of entry of M. leprae. The previous reports of inoculation leprosy support the concept that the appearance of an initial leprosy lesion on an exposed, trauma-prone site on the skin, or at a site where the skin has been abraded, may be the result of direct inoculation of M. leprae,2 –7, 11,17. Many infectious multibacillary patients, discharging bacilli from the nose and skin, are diagnosed late. These bacilli can survive for several weeks outside the body, offering a potential transmission by inoculation.21 This might be happening more often than is realised, since the large surface-area of the skin provides an increased opportunity, for minor abrasions and trauma. References 1 Walker SL, Lockwood DNJ. The clinical and immunological features of leprosy. Br Med Bull, 2006; 77–78: 103–121. 2 Ghorpade A. Inoculation (tattoo) leprosy: a report of 31 cases. J Eur Acad Derm Venereol, 2002; 16: 494–499. 3 Ghorpade A. Reactional borderline tuberculoid leprosy over a tattoo mark. Lepr Rev, 2004; 75: 91–94. 218 A. Chorpade 4 Ghorpade A. Ornamental tattoos and skin lesions. Int J Dermatol, 2009; 48: 11–13. 5 Ghorpade A. Inoculation indeterminate leprosy localised to a smallpox vaccination scar. Lepr Rev, 2007; 78: 398–400. 6 Ghorpade A. Molluscoid skin lesions in histoid leprosy with pseudo-isomorphic koebner phenomenon. Int J Dermatol, 2008; 47: 1278–1280. 7 Ghorpade A. Inoculable leprosy. Int J Dermatol (accepted for publication). 8 Achilles EG, Hagel M, Vierbuchen M, Dietrich M. Leprosy accidentally transmitted from a patient to a surgeon in a non endemic area. Ann Int Med, 2004; 141: 51. 9 Naafs B. Some observations from the past year. Hansenol Int, 2004; 29: 51–54. 10 Brandsma JW, Yoder L, Macdonald M. Leprosy acquired by inoculation from a knee injury. Lepr Rev, 2005; 76: 175–179. 11 Mittal RR, Handa F, Sharma SC. Inoculation leprosy subsequent to roadside injury. Indian J Dermatol Venereol Leprol, 1976; 42: 175–177. 12 Gupta CM, Tutakne MA, Tiwari VD. Inoculation leprosy subsequent to dog bite. Ind J Lepr, 1984; 56: 919–921. 13 Job CK, Sanchez RM, Mc Cormick GT, Hastings RC. First lesion in experimental armadillo leprosy. Ind J Lepr, 1985; 57: 71–77. 14 Bedi BMS, Narayanan E, Doss AG et al. Distribution of single lesion of tuberculoid leprosy. Lepr Rev, 1975; 47: 15–18. 15 Po¨nnighaus JM, Fine PEM, Gruer PJK, Maine N. The anatomical distribution of single leprosy lesions in an African population, and its implications for the pathogenesis of leprosy. Lepr Rev, 1990; 61: 242–250. 16 Naafs B, Silva E, Vilani- Moreno F et al. Factors influencing the development of leprosy: an overview. Int J Lepr Other Mycobact Dis, 2001; 69: 26–33. 17 Brandsma JW, Bizuneh E, Temam F, Naafs B. Mycobacterial infections causing cutaneous disease; or how is leprosy transmitted? Lepr Rev, 2008; 79: 196–198. 18 Ghorpade A. Lupus vulgaris over tattoo mark-inoculation tuberculosis. J Eur Acad Dermatol Venereol, 2003; 17: 569–571. 19 Ghorpade A. Tattoo inoculation lupus vulgaris in two Indian ladies. J Eur Acad Dermatol Venereol, 2006; 20: 476–477. 20 Boyd AS, Neldner KH. The isomorphic response of Koebner. Int J Dermatol, 1990; 29: 401–410. 21 Desikan KV, Sreevatsa SA. Extended studies on the viability of Mycobacterium leprae outside the human body. Lepr Rev, 1995; 66: 287–295..
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