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 Table of Contents  
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 454-456

Painless subcutaneous nodules in an adolescent male: A diagnostic challenge

1 MBBS Graduate, Indira Gandhi Medical College and Research Institute, Puducherry, India
2 Department of Pediatrics, All India Institute of Medical Sciences, (AIIMS) Mangalagiri, Andhra Pradesh, India

Date of Submission18-Oct-2020
Date of Acceptance18-Oct-2020
Date of Web Publication14-Dec-2020

Correspondence Address:
Thirunavukkarasu Arun Babu
Department of Pediatrics, All India Institute of Medical Sciences, (AIIMS) Mangalagiri, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmy.ijmy_187_20

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Cutaneous nodules in children arise from variety of pathologic conditions. Thorough history taking and clinical examination helps in narrowing down the differential diagnosis and reducing the need for an extensive panel of investigatons. Here, we report a case of cutaneous nodules in an adolescent male which posed diagnosed challenge and finally diagnosed with cytology.

Keywords: Adolescent, cutaneous nodules, cytopathology, leprosy

How to cite this article:
Balakrishnan P, Babu TA. Painless subcutaneous nodules in an adolescent male: A diagnostic challenge. Int J Mycobacteriol 2020;9:454-6

How to cite this URL:
Balakrishnan P, Babu TA. Painless subcutaneous nodules in an adolescent male: A diagnostic challenge. Int J Mycobacteriol [serial online] 2020 [cited 2022 May 20];9:454-6. Available from: https://www.ijmyco.org/text.asp?2020/9/4/454/303459

  Introduction Top

Cutaneous nodules in children arise from a variety of pathologies such as infections, inflammatory conditions, hypersensitivity reactions, and neoplasms. Clinical suspicion and diagnosis depends on the age group of the patient, site involved, duration of illness, and associated findings. A good history taking and appropriate focused clinical examination helps in decreasing the need for extensive investigations. Fine-needle aspiration cytology (FNAC) is cheap, cost-effective, and fairly rapid investigation which gives accurate diagnosis in infectious and neoplastic causes of cutaneous swelling.[1] The special stains such as Ziehl–Neelsen stain, Warthin–starry silver stain, Giemsa stain, and fite faraco stain help in identifying various infectious conditions and should be utilized wherever needed for early diagnosis.[1] We report a case of cutaneous nodules in an adolescent male which was diagnosed with cytology.

  Case Report Top

A 14-year-old boy presented with multiple swellings in upper extremities over 6-month duration which were painless, progressive in number and size, and were not associated with itching. There was no history of fever, cardiac symptoms, joint pain or swelling, involuntary movements, weight loss, fatigue, alopecia, sore throat, trauma, insect bite, or drug intake. There was no history of similar complaints in family members or contact with tuberculosis. On clinical examination, he was well built and nourished with normal higher mental function. There were multiple cutaneous nodules of varying sizes (1–4 cm in diameter) and few papules present predominantly over flexor and extensor aspects of the upper limbs [Figure 1]a and [Figure 1]b. These nodules were nontender, firm, and immobile with normal overlying skin. There were no pallor, lymphadenopathy, hepatosplenomegaly, hypo- or hyperpigmented macules with sensory loss, freckling, Irish nodules, arthritis, and rashes. Bacillus Calmette–Guérin scar was present. There were no cutaneous markers of tuberculosis. Oral, genital, and systemic examinations were normal.
Figure 1: Multiple cutaneous nodules in extensor (a) and flexor (b) aspects of bilateral upper limbs in an adolescent male

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Based on the clinical presentation of the index case, the differential diagnoses considered were lipomatosis, neurofibromas, subcutaneous nodules of rheumatic fever, nodular syphilis, sarcoidosis, cutaneous manifestation of acute lymphoblastic leukemia, and lymphoma. His complete hemogram was within the normal limits. Workup for acute rheumatic fever including acute phase reactants, Anti-streptolysin O (ASLO), throat swab culture, and echo heart came back negative. HIV and Venereal Disease Research Laboratory test (VDRL) serology were nonreactive. FNAC of nodules and subsequent cytopathological examination of aspirate stained with hematoxylin and eosin revealed foamy macrophages, plenty of unstained slightly curve-shaped refractile structures present inside macrophages and in the background [Figure 2]. The special staining done was Ziehl–Neelsen stain which revealed plenty of acid-fast lepra bacilli within macrophages and extracellularly [Figure 3]. Diagnosis of multibacillary lepromatous leprosy was considered since slit-skin smear of more than six skin nodules revealed acid-fast bacilli. Subsequent re-examination did not reveal any classic findings such as ear lobe, facial, or neuromotor involvement. The patient responded well to anti-lepromatous multidrug therapy for multibacillary leprosy.
Figure 2: Fine-needle aspiration cytology smear showed unstained refractile structures inside macrophages and extracellularly (H and E, ×100)

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Figure 3: Plenty of acid-fast lepra bacilli inside macrophages and extracellularly (Ziehl–Neelsen stain, ×100)

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  Discussion Top

Leprosy (also known as Hansen's disease) is a chronic granulomatous disorder mainly affecting skin and nervous system with a long incubation period of 2–6 years.[2] It is caused by mycobacterium leprae, an obligate intracellular acid-fast bacterium which is mainly transmitted through respiratory droplets of a leprosy patient.[3] The bacteria can survive outside human body even for months. Most of the patients, especially children and adolescents, do not have contact with a known case of leprosy and have a huge variation in presentation.[2]

Leprosy is classified into five major types based on bacillary load and clinical presentation by Ridley and Jopling as tuberculoid, borderline tuberculoid, mid-borderline, borderline lepromatous, and lepromatous. Lepromatous leprosy has three clinical types of presentations such as macular, nodular, diffuse skin, and nerve infiltration.[4] Leprosy manifesting as isolated cutaneous nodules can be confused with other conditions such as cutaneous tuberculosis, syphilis, sarcoidosis, cutaneous neoplasm, neurofibromatosis, cutaneous leishmaniasis and adult-onset Still's disease.[5]

Although diagnosis of leprosy is mainly clinical, investigations like skin smear bacilloscopy, FNAC, and histopathology can help in making a specific microbiological diagnosis.

Contact tracing and screening of secondary contacts of leprosy patients are crucial for early diagnosis, interrupting the chain of transmission, and preventing deformities.

  Conclusion Top

We report a rare presentation of lepromatous leprosy as isolated cutaneous nodules in an adolescent boy. As leprosy is a great mimicker of many conditions with varied presentations, clinicians should have a high index of suspicion for early diagnosis and treatment. Diagnosing leprosy earlier is crucial in preventing disability and deformity in patients and to prevent chronic exposure to family members.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Patel S, Mahadevappa A, Manjunath GV. Fine needle aspiration cytology of papulonodular lesions of skin: A study of 50 Cases. J Clin Diagn Res 2016;10:EC09-13.  Back to cited text no. 1
Narang T, Kumar B. Leprosy in children. Indian J Paediatr Dermatol 2019;20:12-24.  Back to cited text no. 2
  [Full text]  
Walker SL, Lockwood DN. The clinical and immunological features of leprosy. Br Med Bull 2006;77:103-21.  Back to cited text no. 3
Rea TH, Ridley DS. Lucio's phenomenon: A comparative histological study. Int J Lepr Other Mycobact Dis 1979;47:161-6.  Back to cited text no. 4
Shrestha B, Li YQ, Fu P. Leprosy mimics adult onset Still's disease in a Chinese patient. Egypt Rheumtol 2018;40:217-20.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3]


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