Challenging diagnosis of leprosy in a psychotic homeless patient with atypical clinical manifestations: an interesting case report

Gunawan H., Johan R., Achdiat P.A., Suwarsa O.

Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Jl. Pasteur No. 38, Bandung, 40161, Indonesia


Background: A decision to diagnose certain skin diseases in patient undergoing psychotic break is challenging; this includes establishing the diagnosis of leprosy. Diagnosis of leprosy is established if there is at least one of the three cardinal signs of leprosy. Histopathological examination is not a gold standard, but remains useful in atypical or clinically suspicious cases. Case presentation: We report for the first time, an interesting case of leprosy with atypical clinical manifestations in a psychotic homeless male with unknown history of present illness. Upon examination, hypopigmented macules, hyperpigmented macules, and plaques were observed, with unclear sensation impairment. Peripheral nerve thickening and acid-fast bacilli from slit-skin smear were not found. Histopathological examination from hypopigmented macule on the upper right limb showed no granulomatous reaction and other histopathological features of leprosy. Although the condition did not fulfill the cardinal signs of leprosy, we found lagophthalmos, claw hands, pseudomutilation of fingers and toes. Therefore, the diagnosis of suspected leprosy was established. The patient was hospitalized and attempts to administer oral rifampicin and clofazimine were made. Several days after treatment, annular erythematous macules appeared on the patient’s face, abdomen, and back. Histopathological examination results on sample taken from erythematous macule and right sural nerve were consistent with the diagnosis of leprosy with reversal reaction. Conclusion: In certain conditions, histopathological examination of the skin and nerves are a highly rewarding test in establishing a diagnosis of leprosy. © 2021, The Author(s).

Atypical manifestation; Case report; Histopathological examination; Psychotic homeless leprosy


BMC Infectious Diseases

Publisher: BioMed Central Ltd

Volume 21, Issue 1, Art No 540, Page – , Page Count

Journal Link:

doi: 10.1186/s12879-021-06242-0

Issn: 14712334

Type: All Open Access, Gold, Green


Lee, D.J., Rea, T.H., Modlin, R.L., Leprosy (2012) Fitzpatrick’s dermatology in general medicine, pp. 2253-2262. , Goldsmith LA, Katz SI, (eds), 8, McGraw Hill, New York; Lockwood, D.N., Leprosy (2016) Rook’s textbook of dermatology, pp. 28.1-2818. , Burns T, Breathnach S, Cox N, Griffiths C, (eds), 9, Wiley-Blackwell, Oxford; Ploemacher, T., Faber, W.R., Menke, H., Rutten, C., Pieters, T., Reservoirs and transmission routes of leprosy; a systematic review (2020) PLoS Negl Trop Dis, 14 (4); Barreto, J.G., Frade, M.A.C., Bernardes Filho, F., da Silva, M.B., Spencer, J.S., Salgado, C.G., Leprosy in children (2017) Curr Infect Dis Rep, 19 (6), p. 23; Antunes, S.L., Chimelli, L., Jardim, M.R., Vital, R.T., Histopathological examination of nerve samples from pure neural leprosy patients: obtaining maximum information to improve diagnostic efficiency (2012) Mem Inst Oswaldo Cruz, 107 (2), pp. 246-253; Vallat, J.M., Vital, A., Magy, L., Negrier, M.L.M., Vital, C., An update on nerve biopsy (2009) J Neuropathol Exp Neurol, 68 (8), pp. 833-844; Moschella, S.L., An update on the diagnosis and treatment of leprosy (2004) J Am Acad Dermatol, 51 (3), pp. 417-426; Eichelmann, K., González González, S.E., Salas-Alanis, J.C., Ocampo-Candiani, J., Leprosy. An update: definition, pathogenesis, classification, diagnosis, and treatment (2013) Actas Dermosifiliogr, 104, p. 554; Shrestha, A., Chauhan, S., Mathur, M., Clinicohistopathological correlation of leprosy (2017) J Pathol Nepal, 7 (1), pp. 1095-1102; Massone, C., Belachew, W.A., Schettini, A., Histopathology of the lepromatous skin biopsy (2015) Clin Dermatol, 33 (1), pp. 38-45; Weedon, D., Bacterial and rickettsial infection (2010) Weedon’s skin pathology, pp. 562-566. , Weedo(ed), 3, Elsevier, Australia; Goto, M., Pathology and classification (2011) Leprosy science working towards dignity, pp. 118-130. , Makino M, Matsuoka M, Goto M, Hatano K, (eds), 1, Tokai University Press, Japan; Kar, H.K., Chauhan, A., Leprosy reactions: Pathogenesis and clinical features (2010) IAL textbook of leprosy, pp. 416-437. , Kar HK, Kumar B, (eds), 2, Jaypee Brothers Medical Publishers Ltd, New Delhi; Kaur, S., Sharma, V.K., Basak, P., Kaur, I., Radotra, B.D., Concurrent skin and nerve histology in leprosy and its role in the classification of leprosy (1993) Lepr Rev, 64, p. 110; Pedley, J.C., Harman, D.J., Waudby, H., McDougall, C., Leprosy in peripheral nerves: Histopathological findings in 119 untreated patients in Nepal (1980) J Neurol Neurosurg Psychiatry, 43 (3), pp. 198-204; Kumar, S.K.A., Reddy, B.S.N., Ratnakar, C., Correlation of skin and nerve histopathology in leprosy (1996) Lepr Rev, 67, p. 119; Nilsen, R., Mengistu, G., Reddy, B.B., The role of nerve biopsies in the diagnosis and management of leprosy (1989) Lepr Rev, 60, p. 28; Jacob, M., Mathai, R., Diagnostic efficacy of cutaneous nerve biopsy in primary neuritic leprosy (1988) Int J Lepr Other Mycobact Dis, 56 (91), pp. 56-60. , COI: 1:STN:280:DyaL1c3ivFChug%3D%3D, PID: 3373086; Srinivasan, H., Disability, deformity and rehabilitation (1994) Leprosy, pp. 411-448. , Hasting RC, Opromolla DVA, (eds), 2, Churchill Livingstone, Edinburgh; Amirudin, M.D., Hakim, Z., Darwis, E., Diagnosis penyakit kusta (2003) Kusta, pp. 12-32. , Daili ES, Menaldi SL, Ismiarto SP, Nilasari H, (eds), 2, Fakultas Kedokteran Universitas Indonesia, Jakarta; Yawalkar, S.J., (2009) Clinical feature. Leprosy for medical practitioners and paramedical workers, pp. 29-43. , 8, Novartis foundation, Switzerland; (1961) Scientific meeting on rehabilitation in leprosy, pp. 3-36. , Wld Hlth Org. techn. Rep. Ser, Geneva; Withington, S.G., Leprosy and disability in Bangladesh (2012) Dis Inf Res, 1, pp. 1-9; Hatano, K., Prevention and management of impairments and disabilities (2011) Leprosy science working toward dignity, pp. 174-185. , Makino M, Matsuoka M, Goto M, Hatano K, (eds), Tokai University, Kanagawa; Saunderson, P.R., Chemotherapy of leprosy (2010) IAL textbook of leprosy, pp. 441-447. , Kar HK, Kumar B, (eds), 2, Jaypee Brothers Medical Publishers Ltd, New Delhi; Reaksi kusta (2012) Buku Pedoman Nasional Program Pengendalian Penyakit Kusta, pp. 111-122. , Bakti Husada, Jakarta

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