|Year : 2020 | Volume
| Issue : 4 | Page : 445-447
Verrucous lesions in leprosy
Raihan Ashraf, Tarun Narang, Sunil Dogra
Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||08-Sep-2020|
|Date of Acceptance||22-Sep-2020|
|Date of Web Publication||15-Dec-2020|
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Leprosy is a chronic infectious disease with varied presentation. Hypopigmented or erythematous patches and plaques, skin-colored nodules, and diffuse cutaneous infiltration are the different types of cutaneous lesions seen among patients of leprosy. Verrucous lesions are an uncommon finding of the disease and may be misdiagnosed in the present times due to its rarity. We have herein described two such patients, one of whom had verrucous lesions as the only evident manifestation of leprosy, while the other developed verrucous plaque as the part of leprosy relapse.
Keywords: Lepromatous leprosy, verrucous leproma, verrucous lesions
|How to cite this article:|
Ashraf R, Narang T, Dogra S. Verrucous lesions in leprosy. Int J Mycobacteriol 2020;9:445-7
| Introduction|| |
Leprosy is a chronic infectious disease with a polymorphous presentation, and it may mimic other dermatoses. Hypopigmented or erythematous patches and plaques, skin-colored nodules, and diffuse cutaneous infiltration are the different types of cutaneous lesions seen among leprosy patients. Verrucous lesions are an uncommon finding of the disease and may be misdiagnosed in the present times due to its rarity and declining disease expertise. We have herein described two such patients in whom verrucous lesions were the presenting complaints.
| Case Report|| |
A manual laborer in his forties presented to us with warty lesions on his ankles of 5-year duration. He had been previously prescribed keratolytic topical agents such as salicylic acid and urea, with a provisional diagnosis of hyperkeratosis due to friction caused by ill-fitting footwear. The lesions improved but recurred on stopping therapy.
Cutaneous examination showed well-defined verrucous plaques with filiform keratotic projections and accentuation of skin creases on the anterior aspect of both ankles. Surrounding skin was dyspigmented and dry [Figure 1]. There was no inguinal lymphadenopathy or pedal edema. A skin biopsy was performed with the possibility of eccrine syringofibroadenoma, however demonstrated only hyperkeratosis and papillomatosis, and a repeat biopsy was suggested by the pathologist.
|Figure 1: Well-defined verrucous plaques with filiform keratotic projections and accentuation of skin creases on the anterior aspect of both ankles of Case 1|
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A re-evaluation revealed a loss of touch and temperature sensations symmetrically on the dorsum of feet and the distal third of legs. Although the patients did not have any hypopigmented or erythematous plaques, subtle infiltration of skin on the ears, face, and upper trunk could also be appreciated. He also had thickening of bilateral lateral popliteal and posterior tibial nerves. Slit-skin smear (SSS) from the ear lobes and feet revealed bacteriological (BI) and morphological indices (MI) of 6+ and 30%, respectively [Figure 2]. With the final diagnosis of lepromatous leprosy, he was started on WHO-multidrug therapy-multibacillary regimen (MDT-MBR; rifampicin, dapsone, and clofazimine) along with keratolytics and instructed on appropriate foot care and provided with micro-cellular rubber footwear.
|Figure 2: Slit skin smear of verrucous lesion in Case 1 showing numerous acid-fast bacilli, with bacteriological index 6+ and morphological index 30% (Ziehl-Neelson stain; ×400)|
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A 40-year-old farmer, formerly treated for lepromatous leprosy with 12 months of MDT-MBR 5 years ago, presented to us with asymptomatic verrucous lesion on his left elbow of 6 months' duration. Apart from this, he had had no other symptoms since release from treatment previously. Examination revealed a keratotic plaque on the left elbow, with heaped up white scales [Figure 3]. The skin on his face and trunk appeared shiny and wrinkled. He also had hypoaesthesia over his left forearm and left foot, but there was no motor weakness and the sensory loss had been stable since the time he was diagnosed and started on MDT. SSS from the verrucous lesion showed BI 5+, MI 0 [Figure 4], while from other sites it was BI 2+ and MI 0. His previous records had documented a BI of 2+ at the time of initiation of MDT. He was diagnosed as relapse based on the appearance of new lesions and a 3 log increase in BI and started on MDT-MBR, along with emollients and keratolytics awaiting his drug resistance studies report. The drug resistance studies did not identify any mutation in the rpoB, fol P, and gyr A regions, and he was advised to continue MDT-MBR.
|Figure 3: Verrucous plaque with heaped up scales and filiform projections on the left elbow of Case 2|
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|Figure 4: Slit skin smear of verrucous lesion in Case 2 showing numerous fragmented acid fast bacilli, with bacteriological index 5+ and morphological index 0 (Ziehl-Neelson stain; ×400)|
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| Discussion|| |
Verrucous lesions in leprosy, previously called “leprous verrucous dermatitis” and “verrucous leproma,” are less commonly seen manifestations of the disease in present times. Patki and Mehta in 1994 reported 15 cases leprosy with verrucous lesions and described three morphological types-lesions with filiform projections, thick horn-like projections and those with hyperkeratosis, and deep transverse fissures. Among our patients, Case 1 had lesions that showed all three morphologies, whereas Case 2 showed only filiform projections. Medeiros et al., more recently, described two cases with florid verrucous lesions on the lower limbs who had lepromatous leprosy.
Most reports of similar presentation showed involvement of friction-prone sites, especially on lower limbs. Face, wrists, heels, and soles are less commonly involved sites.,, Loss of sensation and an altered local autonomic response (resulting in dryness) likely contributes to its pathogenesis. Similar lesions have also been described in diabetics with peripheral neuropathy and peripheral vascular disease, where faulty inflammatory responses and disturbed angiogenesis have been proposed to be contributory factors. A role of cytokines such as epidermal growth factor, transforming growth factor alpha, and insulin-like growth factor in the proliferation of epidermal keratinocytes in such lesions has been hypothesised. Poor quality footwear in patients with poorer socioeconomic status adds fuel to the fire, making anterior ankle region the most common site for these lesions. These lesions are more commonly seen in the lepromatous spectrum of Hansen's probably due to the more widespread sensory loss and persistence of bacilli in them.
Verrucous lesions in similar locations may also be seen in tuberculosis verrucosa cutis, florid viral warts, sporotrichosis, chromoblastomycosis, leishmaniasis, elephantiasis nostras verrucosa, eccrine syringofibroadenoma, and verrucous carcinoma. A thorough cutaneous and peripheral nervous examination is warranted, as patients with lepromatous leprosy with diffuse infiltration may sometimes be asymptomatic and do not volunteer any history of sensory loss.
Patients of leprosy often hail from a poor socioeconomic background and often neglect self-care or care of hands and feet. It is important that these patients are counseled regarding care of extremities with sensory loss and provided with appropriate footwear in addition to anti-leprosy medications which would help prevent these manifestations.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]