Fine needle aspiration cytologic diagnosis of erythema nodosum leprosum: a case report

BACKGROUND

Erythema nodosum leprosum (ENL), the type 2 lepra reaction occurring in lepromatous or borderline lepromatous leprosy, presents clinically with acute manifestations that compel the patient to seek medical attention. Recognition and timely management of these patients is critical in order to avoid permanent disability. Fine needle aspiration cytology (FNAC) is a simple, effective tool that aids in correct diagnosis and management of ENL.

CASE

A 30-year-old woman presented with history of fever, reddening of the face, and multiple raised, reddish, painful swellings of the bilateral forearms and legs for 7 days. One year previously, she was diagnosed and treated for lepromatous leprosy with type 2 reaction. After a thorough clinical examination a diagnosis of ENL was made. FNA smears from the forearm swellings showed pus-like material with intact and degenerated polymorphonuclear leukocytes and many foamy macrophages with strong granular acid-fast bacillus (AFB) positivity. A cytologic diagnosis of ENL was given, which was confirmed on histopathologic examination of skin biopsy.

CONCLUSION

Cytologic features such as a large number of intact and degenerated neutrophils with foamy macrophages and strong granular AFB positivity, in an appropriate clinical background, allows a confident diagnosis of ENL.

Diffuse leprosy of Lucio and Latapí: a histologic study

BACKGROUND AND PURPOSE

Ladislao de la Pascua described the spotted or lazarine leprosy for first time in 1844. Later on, Lucio and Alvarado studied and published it with the same names in 1852. Latapí re-discovered it in 1938 and reported it as 'Spotted' leprosy of Lucio in 1948. Frenken named it diffuse leprosy of Lucio and Latapí in 1963. Latapí and Chévez-Zamora explained that the fundamental condition of this variety of leprosy was a diffuse generalised cutaneous infiltration, naming it pure and primitive diffuse lepromatosis, upon which necrotising lesions develop, calling these lesions Fenómeno de Lucio or erythema necrotisans. A great number of histopathological reports have addressed the study of Lucio's phenomenon, and few about the histologic changes that take place in the course of diffuse lepromatous leprosy. The purpose of this work is to report the histologic findings observed in the study of 170 cutaneous biopsies of diffuse leprosy of Lucio and Latapí and 30 of Lucio's phenomenon.

METHODS

This is a retrospective study, which included the examination of 200 biopsy skin specimens from 199 patients with diffuse leprosy at different course of the disease. These cases were diagnosed in Mexico from 1970 to 2004.

RESULTS

The histologic examination revealed a vascular pattern affecting all cutaneous vessels, characterised by five outstanding features: a) colonisation of endothelial cells by acid-fast bacilli, b) endothelial proliferation and marked thickening of vessel walls to the point of obliteration, c) angiogenesis, d) vascular ectasia, and e) thrombosis. Necrotising lesions seen in diffuse lepromatous leprosy displayed two histopathological patterns: one of them, non-inflammatory occlusive vasculopathy and, the other one, occlusive vasculopathy, leukocytoclastic vasculitis, large neutrophilic infiltrate and lobular panniculitis. The first appeared as a result of the course of the occlusive vasculopathy produced by the colonisation of endothelial cells by Mycobacterium leprae. The second, as a result of a previous occlusive vasculopathy plus a leprosy reaction which is considered here as variant of ENL.

CONCLUSIONS

Endothelial cell injury appears to be the main event in the pathogenesis of diffuse leprosy of Lucio and Latapí. Once M. leprae has entered the endothelial cell, the micro-organism damages the blood vessels, leading to the specific changes seen in this variety of lepromatous leprosy.

Expression of B7-1 costimulatory molecules in patients with multibacillary leprosy and reactional states

BACKGROUND

The expression of B7 as a costimulatory molecule on the surface of antigen-presenting cells such as macrophages and on dendritic cells characterizes the efficiency of the cell-mediated immune response.

AIMS

Our purpose was to evaluate B7-1 expression in peripheral blood mononuclear cells (PBMCs) immediately after cell isolation ('spontaneous' B7 expression), and in inflammatory cells from cutaneous lesions of patients with multibacillary leprosy (MB-L) without and during the reactional states of erythema nodosum leprosum (ENL) or reversal reaction (RR).

METHODS

Peripheral blood samples and skin biopsies of eight patients without (MB-L) and with reactional episodes (ENL and RR) were studied using antibodies against B7-1, CD1b, DR and CD14 in flow-cytometry and immunohistochemistry experiments.

RESULTS

The flow-cytometry studies (mean +/- SD% of fluorescent cells) revealed significant B7-1 expression on PBMCs isolated from patients with ENL (8.0 +/- 0.6%) and RR (15.0 +/- 1.4%) compared with that observed for patients with MB-L (0.4 +/- 0.2%). Similar results were observed for cutaneous lesions of these patients by immunohistochemical assays. One patient studied before and during ENL revealed weak B7 expression before the reactional episode (0.3% of cells) compared with the marked level of B7-expressing cells detected during ENL (8.5% fluorescent cells). Interestingly, an even higher B7 expression (15% of cells) was observed in patients with RR.

CONCLUSIONS

Our results strongly suggest that B7 expression precedes reactional episodes in MB-L, which could be related to the acquisition of effective immunity to Mycobacterium leprae during reactional episodes in leprosy. We propose B7 expression as a marker of CMI response in reactional episodes in leprosy.

Vasculonecrotic reactions in leprosy

Multibacillary, lepromatous or borderline leprosy patients may present two types of vasculonecrotic reactions: Lucio phenomenon and that associated with erythema nodosum leprosum. Despite they can be distinguished through clinical and histological characteristics; both are often used as synonyms. It is said that leprosy reaction should be properly classified for therapeutic reasons, since it is well known that in Lucio phenomenon there is not a good response to thalidomide. The authors reported two cases of vasculonecrotic phenomena in lepromatous leprosy sharing clinical and histopathological characteristics of both reaction subtypes. The findings may indicate the spectral nature of the reaction phenomena in leprosy and emphasize the importance of the clinic-pathological correlation for proper classification. Our findings may contribute to the understanding of leprosy reactions pathogenesis, broaden the knowledge about their outcome with standard treatment, and provide the scientific background to design better therapeutic strategies for these complications.

Erythema Nodosum Leprosum: Reactional Leprosy

The different clinical forms of leprosy are mainly related to the variety of immunological responses to the infection. Thus, lepromatous leprosy occurs in patients with a poor cell-mediated immunity to Mycobacterium leprae, whereas tuberculoid leprosy is associated with a high resistance to leprosy bacillus. Intermediate forms, including borderline tuberculoid leprosy, borderline lepromatous leprosy, and borderline leprosy, are a continuous and unstable spectrum of the disease. Leprosy reactions are rare and not well-known states that interrupt the usual chronic course and clinical stability of patients with leprosy. They are expressions of immunological perturbations. Attending to the clinical and histopathological manifestations, leprosy reactions may be separated in 2 or 3 different variants: reverse reaction (type I), erythema nodosum leprosum (type II), erythema polymorphous (type II) and Lucio's phenomenon, mainly considered a type II reaction, but sometimes designated type III. Type I leprosy reaction, also named "upgrading reaction," occurs in borderline leprosy states and is associated with a shift toward the tuberculoid pole. Type II reaction usually occurs in lepromatous leprosy, and there are 3 different clinical variants, including erythema nudosum leprosum, erythema polymorphous-like reaction, and Lucio's phenomenon.

[Nasal leprosy: impact of multitherapy in the morphology and physiology of the nose]

INTRODUCTION

The multi-drug therapy protocol has allowed leprosy patients following this strategy to achieve complete recovery without developing neurotrophic sequelae or deformities.

OBJECTIVES

To assess the impact of multi-drug therapy on the development of nasal deformities and nasal airway patency.

PATIENTS AND METHOD

In an overall group of 84 patients studied, 38 were treated with a therapy based on a single drug and 22 were treated with multi-drug while 24 subjects formed a control group. Nose morphology was determined by anterior rhinoscopy. Nasal patency and flow resistances were measured by anterior rhinomanometry. The results were compared by using the Anova test for a single variable.

RESULTS

The nasal structures in the group with therapy based on a single drug underwent resorption of bone and cartilage in the structures of the nose and increased flow resistance. In the group receiving the multi-drug protocol, there were no significant morphological alterations and nasal patency and flow resistance remained within normal levels.

CONCLUSIONS

The multi-drug therapy is effective in preventing the development of nasal deformities and maintains normal nasal airflow.

Use of fine needle aspiration cytology in leprotic lesions: a report of 4 cases

BACKGROUND

Although a few studies have shown fine needle aspiration cytology (FNAC) to be a sensitive diagnostic tool in the detection of nerve involvement, its role as an initial diagnostic procedure in pure neuritic leprosy (PNL) and in the detection of skeletal lesions with unusual findings has not been documented before.

CASES

Three patients who presented with thickened nerves and a fourth with biopsy-proven lepromatous leprosy with lesions in hand bones underwent FNAC. Of the 3 patients with nerve thickening, 2 had a clinical suspicion or diagnosis of neuritic leprosy, whereas in the third patient a clinical differential diagnosis of a soft tissue tumor or parasitic cyst was considered. FNAC in all 3 cases revealed epithelioid cell granulomas, Langhans giant cells and caseous necrosis. Fites and Ziehl-Neelsen stains were negative for acid-fast bacilli. Cytologic diagnosis of pure neuritic leprosy was made in all 3 cases and confirmed by histopathologic examination. FNAC of skeletal lesions from the fourth patient confirmed involvement of bone with unusual cytologic findings of epithelioid cell granulomas and giant cells along with a significant proportion of foamy macrophages and strong Fites stain positivity.

CONCLUSION

FNAC is a simple, useful, minimally traumatic and routinely applicable procedure in the diagnosis of pure neuritic leprosy and leprous osteitis.

Lepromatous leprosy

A 51-year-old woman presented with a 2-month history of pruritic, erythematous papules and plaques on her arms that were treated as chronic urticaria. Histopathologic examination demonstrated acid-fast bacilli, and a diagnosis of lepromatous leprosy was made. Presentation and treatment of leprosy are reviewed.

Lepromatous leprosy of histoid type

Histoid leprosy is a variant of lepromatous leprosy, which develops as a result of resistance to dapsone monotherapy. Here we report two cases of lepromatous leprosy of histoid type, one with typical and another with atypical presentations.

Fine needle aspiration cytology in reactional and non-reactional leprosy

BACKGROUND

Histopathological evaluation of skin lesions is not feasible in many leprosy endemic areas. Fine needle aspiration cytology (FNAC) is a simpler tool compared to histopathology for the evaluation of the cytomorphology of skin lesions.

AIMS

To study the cytomorphology of leprosy lesions in fine needle aspirates and correlate it with the histopathology.

METHODS

Seventy leprosy patients diagnosed and classified according to Ridley Jopling scale were included. Fine needle aspirates were taken from the lesion followed by a skin biopsy from the same site for histopathological examination after H/E staining.

RESULTS

Borderline leprosy patients with Type I reaction showed significantly large numbers of giant cells, collagen and elastin in their smears as compared to those without reaction. The smears were more heavily cellular with fragmented collagen and elastin along with significant increase in neutrophils in patients with Type II reaction while foamy macrophages with fatty background were common in non-reactional lepromatous leprosy patients. A complete correlation between histopathological and cytomorphological findings was observed in 77.3% of cases.

CONCLUSION

FNAC may be used as an alternative tool to assess leprosy lesions in areas where histopathological services are not readily available.

Comparative cytomorphology of skin, lymph node, liver and bone marrow in patients with lepromatous leprosy1

OBJECTIVE

The aim of this study was to compare the cytological changes in skin, lymph nodes, liver and bone marrow in patients with lepromatous leprosy.

METHODS

Skin lesion, lymph node, liver and bone marrow aspirates were analysed. May-Grunwald-Giemsa (MGG) and Ziehl-Neelsen (Z-N) stains were employed. Comparative cytomorphology was studied.

RESULTS

Twenty patients with lepromatous leprosy were studied. Lepra cells (LC) predominated in the skin aspirates of 12 patients with lepromatous leprosy (LL), lymphocytes accompanied LC in eight patients with borderline-lepromatous (BL) leprosy. Three patients of LL leprosy and two of BL leprosy in type 2 reaction additionally had numerous neutrophils. Two patterns of lymph node aspirates were seen: partial replacement with few LC in a reactive lymphoid background (10), complete replacement with either only LC or LC in a background of degenerating neutrophils (10), the latter a feature of type 2 reaction. Liver aspiration was performed in seven patients and of bone marrow in eight patients. Occasional LC were present in five liver-aspirated patients, steatosis and Kupffer cell hyperplasia in four patients, and myelopoiesis in two patients. Bone marrow smears invariably had occasional LC and a relative increase in mature plasma cells; sea-blue histiocytes were seen in six patients.

CONCLUSION

Lepra cells predominated in skin and lymph node aspirates with complete replacement. In comparison, liver, bone marrow and lymph node aspirates with partial replacement were dominated by a preponderance of cells native to these organs with only few or occasional LC.

Role of azathioprine in preventing recurrences in a patient of recurrent erythema nodosum leprosum

The pathogenesis of erythema nodosum leprosum (ENL) involves both immune complex deposition and dysfunction of cell mediated immunity. Tumour necrosis factor-alpha (TNF-alpha) plays an important role in its pathogenesis. Thalidomide and corticosteroids are the mainstay of treatment for ENL. However, there are often severe limitations to their use. We report a case of recurrent ENL treated successfully with azathioprine. A 15-year-old unmarried girl with lepromatous leprosy had recurrent ENL for 2 years. She was treated with WHO-MB MDT and prednisolone in doses of 40-90 mg a day for 2-12 weeks. Her condition was inadequately controlled. The patient was therefore treated with thalidomide 300 mg and prednisolone 40 mg. The symptoms subsided after 5 days and ENL lesions healed in 2 weeks. Prednisolone was reduced by 10 mg per week and stopped, while thalidomide was reduced to 100 twice daily after 4 weeks. Azathioprine 100 mg (2 mg/kg per day) daily orally was added to prevent recurrences. Thalidomide was further reduced and stopped after another 4 weeks while she continued with azathioprine in the same doses for 8 months. There was no recurrence of ENL lesions and no side effects of the therapy. MB-MDT was stopped 1 year ago, and she is on follow-up without any relapse. Azathioprine, therefore, appears to be an effective and safe drug to prevent recurrences of ENL.

An Uncommon Presentation of an Uncommon Disease: Leprosy in a Heart Transplant Recipient

The effect of solid-organ transplantation on the acquisition, presentation and course of leprosy is unknown. We present a case of leprosy in a heart transplant recipient with multiple unique features possibly attributed to altered immune function.

Histological and genotypical characterization of feline cutaneous mycobacteriosis: a retrospective study of formalin-fixed paraffin-embedded tissues

Twenty-nine cases presumptively diagnosed as feline cutaneous mycobacteriosis were evaluated microscopically with haematoxylin and eosin and modified Fite's stained sections using archived formalin-fixed paraffin-embedded tissue specimens. Lesions were characterized histologically as feline leprosy (7 cases lepromatous and 16 cases tuberculoid) or atypical mycobacteriosis (3 cases); three cases did not fit these criteria and were classified as 'miscellaneous'. Actinomycetales-specific polymerase chain reaction (PCR) of variable regions 1, 2 and 3 of the 16S ribosomal RNA (rRNA) gene and subsequent sequence analysis of the amplicons were performed to identify the species of mycobacteria associated with each case. Together, this study identified 10 different Actinomycetales organisms with greater than 98% nucleotide sequence identity to named species, nine were of the genus Mycobacterium and eight were associated with feline leprosy (both lepromatous and tuberculoid). Based on this study, we conclude that feline cutaneous mycobacteriosis should be considered as a syndrome with varied clinical and histological presentations associated with a variety of different Mycobacterium species, organisms other than Mycobacterium sp. may be associated with feline cutaneous mycobacteriosis lesions, and molecular diagnostic techniques can be an important tool for identifying agents associated with lesions of feline cutaneous mycobacteriosis.

Clinical course of erythema nodosum leprosum: an 11-year cohort study in Hyderabad, India

Erythema nodosum leprosum (ENL) or type 2 lepra reactions complicate lepromatous leprosy and borderline lepromatous leprosy. We report an 11-year retrospective case record analysis of 481 outpatients with borderline lepromatous and lepromatous leprosy at the Dhoolpet Leprosy Research Center in Hyderabad, India.. The overall prevalence of ENL was 24%, 49.4% among cases of lepromatous leprosy (LL) and 9% among cases of borderline lepromatous (BL) leprosy. Logistic regression analysis identified LL (odds ratio [OR] = 8.4, 95% confidence interval [CI] = 4.6-15.4, P < 0.001) and BL with a bacterial index > or = 4+ (OR = 5.2, 95% CI = 2.1-12.9, P = 0.001) as major risk factors. The average patient with ENL was male, 34.7 years of age, and had multiple episodes of ENL (mean = 3.1) over an 18.5-month period. Three types of ENL were identified: single acute ENL, multiple acute ENL (repeated discrete episodes), and chronic ENL (continuous episodes). Acute single ENL is rare, accounting for only 8% of cases. Chronic ENL accounted for 62.5% of the cohort. Chronic ENL was of longer duration and more severe. An age > or = 35 years was a risk factor for developing chronic ENL. Patients with chronic ENL were more compliant with multi-drug therapy, especially during the first six doses of multi-drug therapy. Distinguishing these different types of ENL would be useful for patient management and developing improved treatment of these debilitating reactions. Improved strategies for treatment and management of these reactions need to be developed.