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Indian Journal of Dermatology, Venereology and Leprology
Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL)
ISSN: 0378-6323 EISSN: 0973-3922
Vol. 71, Num. 2, 2005, pp. 125-127
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Indian Journal of Dermatology, Venereology, Leprology, Vol. 71, No. 2, March-April, 2005, pp. 125-127
Case Report
Penile tuberculoid leprosy in a five year old boy
Kar BikashRanjan, Ebenezer Gigi, Job C.K.
Departments of Dermatology, Schieffelin Leprosy Research and Training Centre, Karigiri, Vellore
Correspondence Address: Department of Dermatology, SLR & TC, Karigiri
karbikash@hotmail.com
Code Number: dv05031
ABSTRACT
A 5-year-old contact of a lepromatous leprosy patient with a tuberculoid
lesion on the anterior aspect of the shaft of the penis is reported.
The child was clinically suspected to have borderline tuberculoid leprosy
during a survey of contacts of leprosy patients, which on histopathology
revealed features of subpolar tuberculoid leprosy. The father of the
child was recently detected as a case of lepromatous leprosy and was
started on multibacillary regime of WHO multidrug therapy. The reason
for the localization of the lesion to the shaft of the penis is also
suggested. Skin as a route of transmission of tuberculoid leprosy is
also emphasized.
INTRODUCTION
Though the stage is all set for the "final push" of leprosy from the
world, our knowledge and concepts of some aspects of this stigmatizing
disease still need refinement. A lot is known about the entry of the
organism into the host and establishment of the infection, and a lot
still remains to be explored. Till date there is no scientific study
on a large scale to demonstrate the exact route of entry of the bacillus
though it is widely believed to be airborne by most of the leprologists.
However, skin-to-skin transmission of the disease definitely takes place
in a subgroup of leprosy patients. Here we report a case of tuberculoid
leprosy in a contact of a lepromatous patient and discuss the most likely
mode of entry of the organism and the localization of the lesion to the
shaft of the penis.
CASE REPORT
A 5-year-old boy was brought by his father to the hospital with complaints
of a small papular lesion on the shaft of the penis since two years.
The lesion started as a pinhead sized, hypopigmented macule and slowly
enlarged over 2 years to arrive at the present dimensions. The lesion
was completely asymptomatic throughout the evolution. There were no complaints
of numbness over the plaque. On examination, there was a single plaque,
located over the dorsal aspect of the shaft of the penis, measuring 1.5
cm x 1 cm.
The margin of the lesion was well defined [Figure
- 1]. The surface was dry and rough. There was some central healing
in the plaque causing mild depression. Sensation over the lesion could
not be ascertained, as the child was too young to cooperate. No feeding
cutaneous nerve could be palpated. Trunk nerves were not enlarged. There
were no other cutaneous patches. Peripheral motor and sensory assessments
were within normal limits.
Hemogram revealed eosinophilia. Urine analysis, chest X-ray and other
systemic examinations were within normal limits. Slit skin smear done
from the plaque could not demonstrate any organism. A clinical diagnosis
of borderline tuberculoid (BT) leprosy was made. Skin biopsy done from
the lesion showed granulomas composed of epithelioid cells, Langhan′s
giant cells, foreign body type giant cells and lymphocytes around the
blood vessels and skin adnexa occupying a major portion of the dermis [Figure
- 2].
There was partial destruction of the skin adnexal structures. Granuloma
fraction was 90%. Acid-fast stain showed occasional scattered
bacilli with in the granuloma. A diagnosis of subpolar tuberculoid leprosy
was offered.
The child was suspected to have BT leprosy during a survey of contacts
of leprosy patients. The father of the child was recently detected as
a case of lepromatous leprosy. He presented with multiple, hypopigmented
and coppery macules over the trunk with a diminished sensation over the
lower limbs along with dryness and fissuring of both feet of 3 years
duration.
On examination, he had multiple, ill defined, coppery colored, shiny
macules present on the trunk distributed almost symmetrically, which
included numerous ill defined but infiltrated lesions over the waist [Figure
- 3].
There was no lesional anesthesia or madarosis. The lower limbs were xerotic,
with several fissures in the soles. Ulnar and lateral popliteal nerves
were enlarged bilaterally, so were the radial cutaneous and superficial
peroneal nerves. Slit skin smear done from routine sites revealed a bacillary
index (BI) of 4+ and from the waist region had a BI of 5+.
Skin biopsy done from one of the infiltrated macules on the back showed
focal and confluent granulomas in the dermis composed of histiocytes
and a few lymphocytes around the blood vessels and skin adnexa. A number
of dermal nerves were seen within the granulomas. Granuloma fraction
was 40%. BI of granuloma was 5+.
Histopathology was consistent with subpolar type of lepromatous leprosy.
Other members in the family screened had no evidence of leprosy.
DISCUSSION
The mode of infection in leprosy is still an ongoing debate. Skin as
a possible route of entry or exit of leprosy bacilli is not given priority
by most of the leprologists.[1] However,
it was recently reported that a significant number of M. leprae is present
in all layers of the epidermis, including the stratum corneum especially
in lepromatous leprosy patients.[2] This "route" has
been sidelined since the reports by Pedley on the non-emergence of M.
leprae from intact lepromatous skin[3] and
later by Rees and Meade on the possibility of airborne infections.[4] From
two separate studies Rees and Meade noted that the attack rate of leprosy
and tuberculosis were similar and therefore they concluded that the route
of transmission of the two must be the same. Pneumonic plague and pulmonary
tuberculosis have the same route of transmission. Does that mean their
attack rate should be the same? Recently, leprologists and pathologists
have come to consider the nasal route as the common and accepted portal
of entry[5] without adequate
and undisputed scientific evidence. Skin as a route of transmission is
mentioned in many reports such as infection occurring after tattooing,[6] dog
bites and accidental inoculation[7] or
after skinning of infected armadillos.[8] There
are also numerous observations of a first patch on the forehead or cheek
of a baby carried on the back of its lepromatous mother, and the first
lesions[9] seen on the bare
buttocks of toddlers sitting on contaminated soil. Abraham et al[10] concluded
that the first lesions often occur at sites most vulnerable to trauma.
It has also been shown that contaminated thorns may infect susceptible
mice.[11] All these suggest
that the mode of entry of the bacilli into the body of the host is often
through the skin.
Reports of isolated involvement of the penile shaft,[12] which
is a relatively warmer zone, in paucibacillary leprosy patients, are
rare in the literature and the possible mode of transmission in those
cases is still more intriguing. Our index case further strengthens the
hypothesis of inoculation leprosy in a close contact. In our case, the
father is a case of subpolar lepromatous leprosy with a few coppery patches
in the lower trunk and in such a case, carrying the kid, usually naked,
which is practiced widely in rural India could be the possible way of
contact that culminated in manifestation of a lesion of tuberculoid leprosy
on the genitalia of the child. The incubation period in the index child
also tallies with that described for leprosy averaging 2-5 years. This
case also emphasizes the need for a detailed examination of all the contacts
including the genitalia.
REFERENCES
1. | Job CK, Baskaran B, Jayakumar J, Aschoff M. Histopathologic evidence to show that indeterminate leprosy may be a primary lesion of the disease. Int J Lepr 1997;65:443-9. Back to cited text no. 1 |
2. | Job CK, Jayakumar J, Aschoff M. "Large numbers" of Mycobacterium leprae are discharged from the intact skin of lepromatous patients; A preliminary report. Int J Lepr 1999:67;164-7. Back to cited text no. 2 |
3. | Pedley JC. Composite skin contact smears: A method of demonstrating the non-emergence of Mycobacterium leprae from intact lepromatous skin. Lepr Rev 1970;41:31-43. Back to cited text no. 3 |
4. | Rees RJ, Meade TW. Comparison of the modes of spread and the incidence of tuberculosis and leprosy. Lancet 1974;1:47-8. Back to cited text no. 4 |
5. | Leiker DL. On the mode of transmission of Mycobacterium leprae. Lepr Rev 1977;48:9-16. Back to cited text no. 5 |
6. | Ghorpade A. Inoculation (Tattoo) Leprosy: A report of 31 cases. J Eur Acad Dermatol Venereol 2002;16:494-9. Back to cited text no. 6 |
7. | Pallen MJ, McDermott RD. How might Mycobacterium leprae enter the body. Lepr Rev 1986;57:289-97. Back to cited text no. 7 |
8. | Meyers WM. Leprosy. Dermatol Clin 1992;10:73-96. Back to cited text no. 8 |
9. | Horton RJ, Povey S. The distribution of the first lesion in leprosy. Lepr Rev 1966:37;113-4. Back to cited text no. 9 |
10. | Abraham S, Mozhi NM, Joseph GA, Kurian N, Sundar Rao PS, Job CK. Epidemiological significance of first skin lesion in leprosy. Int J Lepr Other Mycobact Dis 1998;66:131-9. Back to cited text no. 10 |
11. | Job CK, Chehl SK, Hastings RC. Transmission of leprosy in nude mice through thorn pricks. Int J Lepr Other Mycobact Dis 1994:62;395-8. Back to cited text no. 11 |
12. | Ghorpade A, Ramanan C. Primary penile tuberculoid leprosy. Indian J Lepr 2000:72:499-500. Back to cited text no. 12 |
Copyright 2005 - Indian Journal of Dermatology, Venereology, Leprology
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