This was a 49-year-old man from Venezuela who presented with erythematous papular lesions on the trunk for the past four years, with loss of eyebrows and facial and ear infiltration. He had just arrived, having barely been in Spain for 24 h (Fig. 1).
For the last two weeks he had been suffering from fever up to 41 °C, joint pain, oedema of the hands and feet, as well as an increase in the number of skin lesions. Physical examination revealed erythematous and painful nodular lesions on his arms, legs and abdomen, and erythematous plaques with a whitish centre on his trunk, in the cervical spine area. Some lesions had no tactile sensitivity, the patient had significant oedema of his hands and feet, with distal ulcers, as well as palpable bilateral axillary and inguinal lymphadenopathy. Pain on palpation of the popliteal and posterior tibial nerve pathways. Testicular examination revealed a thickened epididymis and pain on palpation. He reported daily epistaxis coinciding with this outbreak. He had no respiratory or urinary signs or symptoms. He reported no family history.
The patient had been investigated in his own country and provided a report with a diagnosis of "vasculitis" under treatment until a week previously with prednisone 5 mg, which he had not taken in the previous 72 h due to lack of medication. He reported having been treated with methotrexate for one week approximately two months previously.
While in hospital, he was assessed by neurology, cardiology and ophthalmology, with no abnormalities of interest detected. Assessment by Ear, Nose and Throat discovered a complete perforation of the nasal septum with loss of substance. Abdominal ultrasound showed hepatosplenomegaly.
Clinical course and diagnosisSkin biopsies were taken of the lesions on the patient's trunk and pinna and sent to microbiology for Ziehl-Neelsen staining, which showed abundant acid-fast bacteria. As a confirmatory technique, identification by reverse hybridisation (GenoType LepraeDR, Bruker®) was performed, confirming the clinical suspicion of leprosy, as it cannot be cultured on artificial media (Fig. 2).
To complete the study, a complete blood test was carried out which showed iron deficiency anaemia, as well as elevated liver enzymes, and HCV, HBV, HIV, VZV and HSV serologies were also requested, which were negative.
The patient was diagnosed with lepromatous leprosy (LL), characterised by confluent papules and nodules leading to a marked diffuse infiltration of the skin. His symptoms suggested that he also had a type II leprosy reaction or erythema nodosum leprosum, which is associated with immune complex deposition and occurs in about 60% of cases. Erythema nodosum is accompanied by systemic manifestations such as fever, joint pain and oedema, as reported by the patient.
Treatment is started with dapsone 100 mg/day + rifampicin 600 mg/month + clofamizine 50 mg/day plus a monthly supplement of 300 mg. For type II leprosy, patients are started on treatment with prednisone 60 mg for seven days.
Here in Spain, 10 new cases were reported in 2022.1 The predominant clinical form (7 cases) was multibacillary. As far as country of acquisition was concerned, there were two in Spain, with the others coming from Brazil (2), Colombia (1), Indonesia (1), Equatorial Guinea (1), Morocco (1), Venezuela (1) and Senegal (1). With these data, the number of new leprosy diagnoses in Spain was five more than in 2021, reflecting a slight increase, mainly due to imported cases.2 The patient reported here was from Venezuela, with prevalence rates below one per 10,000 population, but with sporadic cases in some areas.3 Lastly, as a reflection on the case, it should be noted that although it is a rare disease here in Europe, it should be considered by dermatologists even in non-endemic countries.
FundingThe authors declare that they received no funding.
