Tropical/Infectoparasitary Dermatology
Histoid leprosy - A rare clinical presentation
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class="elsevierStyleTextfn">Tropical/Infectoparasitary Dermatology</span>" "titulo" => "Histoid leprosy - A rare clinical presentation" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "598" "paginaFinal" => "601" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Angélica Bauer, Letícia Maria Eidt, Renan Rangel Bonamigo, Renata Heck" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Angélica" "apellidos" => "Bauer" "email" => array:1 [ 0 => "dermatoangelicabauer@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Letícia Maria" "apellidos" => "Eidt" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Renan Rangel" "apellidos" => "Bonamigo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Renata" "apellidos" => "Heck" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Sanitary Dermatology Outpatient Clinic, Health Department of Rio Grande do Sul State, Porto Alegre, RS, Brazil." "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil." "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1660 "Ancho" => 905 "Tamanyo" => 182840 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple papules and nodular lesions diffusely distributed on the trunk.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Histoid leprosy is a rare and highly transmissible variant of lepromatous leprosy.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–7</span></a> It presents with erythematous-brownish papules and nodules, with smooth or rarely umbilicated surface.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–7</span></a> Due to its unusual clinical features, it is a challenging diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This is the report of a 60-year-old male patient, with skin lesions for one year, presenting to a reference service for leprosy management. He denied contact with leprosy. He had keloidiform erythematous-brownish lesions, with a smooth surface, some with umbilication, distributed mainly on the trunk and face (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). He had a preserved corneal reflex, absence of lagophthalmos, trichiasis, and ectropion. There were no thickened nerves and no muscle strength or sensory alterations in the upper limbs. At the examination of the lower limbs, decreased protective sensitivity in both feet was detected. He had a Grade 1 physical disability. Bacilloscopy showed a mean bacillary index (MBI) of 4.75; with 2% of whole bacilli and clusters. Histopathological analysis showed macrophages with clear, vacuolated cytoplasm, some with phagocytized bacilli and an evident Grenz zone. In the periphery of the lesion, histiocytes in a storiform pattern enclosed collagen fibers and extended into the deep dermis. The Ziehl Neelsen stain showed the presence of multiple bacilli (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>). With the diagnosis of histoid leprosy, multibacillary (MB) multidrug therapy (MDT) was started.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">At the end of the supervised MB MDT, the patient was reevaluated at the referral center and a new intradermal smear bacilloscopy was performed to control and identify possible recurrence or leprosy reactions.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8,9</span></a> Bacilloscopy showed an MBI = 4.25; intact and grouped bacilli.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5,8</span></a> When the MDT was stopped, the patient presented a type II leprosy reaction (erythema nodosum leprosum). It was decided, by the reference medical team, to prescribe an additional 12 months of MB MDT.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The histoid leprosy subtype has been associated with dapsone resistance and mutations of <span class="elsevierStyleItalic">Mycobacterium leprae</span> strains due to inadequate treatment.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,4,7</span></a> Currently, there is an increase in cases of the histoid form again.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a> There is an association with increased cellular and also humoral immunity, absent in lepromatous patients, increasing the number of T lymphocytes locally. However, bacillary hyperactivity and the attempt to contain the infection, end up weakening the local immune system.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,4,6</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The lesions represent a reservoir of <span class="elsevierStyleItalic">Mycobacterium leprae</span> and are extremely infectious.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">According to previous studies, type II leprosy reactions were not prevalent in histoid patients; however, Brazilian reports show a high incidence of erythema nodosum leprosum.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> It occurred in the present case, which developed into a type II reaction.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Differential diagnoses include keloids, dermatofibromas, disseminated reticulohistiocytosis, xanthomas, lobomycosis, skin metastases, neurofibromas, lymphomas, angiosarcoma.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4,10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The histopathology of histoid leprosy encompasses three patterns: pure fusocellular, fusocellular with an epithelioid component and fusocellular with vacuolated cells.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Bacilli phagocytized by macrophages, isolated bacilli and grouped bacilli were observed.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,6</span></a> The histoid variant may presente an inflammatory cell infiltrate, containing mainly lymphocytes. The spindle-shaped histiocytes are organized in a storiform pattern and enclose collagen fibers and fibroblasts in the periphery of the lesion.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3,6</span></a> Bacilli stained with Ziehl-Neelsen or Fite-Faraco staining methods can appear in parallel arrangements close to the histiocytes.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Despite being a rare form of leprosy, these patients are considered major disease transmitters, thus being of special importance regarding early diagnosis and treatment.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors’ contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Angélica Bauer: Contributed intellectually to the design and creation of the article; participated in the writing of the manuscript draft; critical and scientific review of the content; approval of the final version of the manuscript.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Letícia Maria Eidt: Contributed intellectually to the design and creation of the article; participated in the writing of the manuscript draft; critical and scientific review of the content; approval of the final version of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Renan Rangel Bonamigo: Contributed intellectually to the design and creation of the article; participated in the writing of the manuscript draft; critical and scientific review of the content; approval of the final version of the manuscript.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Renata Heck: Contributed intellectually to the design and creation of the article; participated in the writing of the manuscript draft; critical and scientific review of the content; approval of the final version of the manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:3 [ "identificador" => "xres1581938" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1423931" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-12-10" "fechaAceptado" => "2021-02-07" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1423931" "palabras" => array:4 [ 0 => "Communicable diseases" 1 => "Leprosy" 2 => "Leprosy, multibacillary" 3 => "<span class="elsevierStyleItalic">Mycobacterium leprae</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Histoid leprosy is considered a rare form of lepromatous leprosy. Its peculiar clinical picture makes its diagnosis a challenging one, which can delay starting treatment and perpetuate the disease as endemic. In addition to representing a reservoir of bacilli, and being an important means of contamination, these patients have greater resistance to standard treatment. This is a report of a typical case of this rare presentation, aiming to share the knowledge and favor earlier diagnosis of the disease.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Bauer A, Eidt LM, Bonamigo RR, Heck R. Histoid leprosy - A rare clinical presentation. An Bras Dermatol. 2021;96:598–601.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at Sanitary Dermatogy Outpatient Clinic, Health Department of Rio Grande do Sul State - SES/RS, Porto Alegre, Brazil.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1660 "Ancho" => 905 "Tamanyo" => 182840 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple papules and nodular lesions diffusely distributed on the trunk.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1248 "Ancho" => 905 "Tamanyo" => 192158 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A), Keloidiform nodular lesions, with smooth surface and an erythematous-brownish color, with evident vessels. (B), Papulonodular lesion with umbilications and satellite umbilicated papules.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1845 "Ancho" => 1605 "Tamanyo" => 724440 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Light microscopy - (A), at low power one sees a Grenz zone; and a lymphohistiocytic infiltrate throughout the dermis, interspersed with collagen fibers (Hematoxylin & eosin, ×40). (B), Vacuolized clear-cytoplasm histiocytes, along with lymphocytic infiltrate (Hematoxylin & eosin, ×200). (C), Detail of the Grenz zone; multiple histiocytes, some of them spindle-shaped in a storiform pattern (multidirectional) (Hematoxylin & eosin, ×100).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 623 "Ancho" => 905 "Tamanyo" => 168128 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Several bacilli stained with fuchsin, acquiring a pinkish-red color. They are isolated and grouped. (Ziehl-Neelsen, ×40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Histoid leprosy presenting with figurate lesions: A unique and rare presentation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Rao" 1 => "A. Kolli" 2 => "S. Farheen" 3 => "U. Reddy" 4 => "A. Karanam" 5 => "K. 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