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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 332-336

Dermoscopy and clinicopathology features in diagnosing paucibacillary leprosy: Case series


Department of Dermatology and Venereology, Medical Faculty, Sriwijaya University/Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia

Date of Submission16-Jun-2022
Date of Decision16-Jul-2022
Date of Acceptance09-Aug-2022
Date of Web Publication12-Sep-2022

Correspondence Address:
R Rusmawardiana
Department of Dermatology and Venereology, Medical Faculty of Sriwijaya University/Dr. Mohammad Hoesin General Hospital, Jendral Sudirman Street KM 3, 5 Palembang
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_113_22

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  Abstract 


A wide variety of leprosy clinical manifestations poses an early diagnostic challenge. Currently, various diagnostic modalities have been developed to optimize the definite diagnostic of leprae. Leprosy diagnosis was established based on the presence of either hypopigmented or reddish skin lesions accompanied with loss of sensation, peripheral nerve involvement, and a positive skin-slit smear (SSS) test result for acid-fast bacilli. Resemblance of leprosy skin lesions to excessively many other differential diagnoses, unclear nerve involvement, and negative results of SSS in paucibacillary (PB) leprosy become a diagnostic veil to clinicians. Furthermore, an additional modality for PB leprosy is needed as an important way to prevent misdiagnoses and complications of leprosy. Commonly, a biopsy or polymerase chain reaction examination is performed to exclude other similarly presenting diseases. Dermoscopy examination, the noninvasive technique that allows a better examination to visualize skin lesions, along with clinicopathology features of skin lesions can help to establish the diagnosis of PB leprosy.

Keywords: Clinicopathology features, dermoscopy, paucibacillary leprosy


How to cite this article:
Rusmawardiana R, Nursyarifah N, Argentina F, Pamudji R. Dermoscopy and clinicopathology features in diagnosing paucibacillary leprosy: Case series. Int J Mycobacteriol 2022;11:332-6

How to cite this URL:
Rusmawardiana R, Nursyarifah N, Argentina F, Pamudji R. Dermoscopy and clinicopathology features in diagnosing paucibacillary leprosy: Case series. Int J Mycobacteriol [serial online] 2022 [cited 2022 Sep 29];11:332-6. Available from: https://www.ijmyco.org/text.asp?2022/11/3/332/355918




  Introduction Top


Early diagnosis of leprosy in the early stages of the disease is an important part of the leprosy control program. A report by Henry et al. states that the majority of leprosy patients experience a delay in the diagnosis of up to 2 years.[1] The diagnosis of leprosy itself is based on the clinical and additional examination. In some cases with a doubtful clinical feature, the additional examination can help to confirm the suspected cases of leprosy. Work-up examinations in establishing the diagnosis of leprosy include skin-slit smear (SSS) of acid-fast bacilli, histopathology of skin lesion biopsy, serology, polymerase chain reaction, and dermoscopy.[2]

Dermoscopy examination is one of the options for leprosy work up with a fast, mobile, simple, and noninvasive procedure. The report of Mohta et al. mentioned that dermoscopy is a noninvasive modality that can help in diagnosing leprosy quickly and should be used to complement other modalities in leprosy workup.[3] Leprosy based on the World Health Organization was classified into two types, namely paucibacillary (PB) and multibacillary (MB).[4] Upholding the diagnosis of leprosy, especially PB,[5] is currently still a great challenge for clinicians because of the negative results of SSS, the resemblance of clinical features to other skin diseases, and unclear peripheral nerve involvement.

The diagnosis of PB leprosy has been established based on the clinical features and supported by the results of histopathological biopsy.[6] Dermoscopy examination in leprosy patients, especially the PB type, is expected to help establish an early diagnosis of leprosy and reduce the delay in the diagnosis of leprosy patients, especially the PB type. In the following, we report a case series of two patients with PB-type leprosy diagnosed based on clinical, histopathological examination, and dermoscopy. The purpose of writing this case report is to understand the dermoscopic description of PB leprosy with clinical symptoms and histopathological biopsy so that it can assist in the diagnosis of PB type of leprosy.


  Case Reports Top


Case 1

A 41-years-old female patient presented with a red, numb lesion on the right cheek that had been getting wider over 6 months and was not accompanied by pain or itching. There were no stiffness in both hands and feet, and numbness in the palms and feet was denied. The history of family members or co-workers who complained of numbness spots or was diagnosed with leprosy was denied. The patient has a lower middle socioeconomic history.

The clinical appearance of the lesion in the right buccal region showed solitary erythematous plaques with multiple irregular erosions and dry white fine scales [Figure 1]. The dermoscopy examination from the lesion showed yellowish orange structureless areas (yellow circles) surrounded by branching vessels (blue arrows), grayish scaling (yellow arrows), follicular plugs (red circles), and less pigmentary network [Figure 2]. SSS examination of acid-fast bacilli from six locations was negative. Histopathological examination of the lesion biopsy revealed periadnexal granuloma in the superficial dermal and subcutaneous layer consisting of epithelioid cells and multinucleated giant cell Langhans [Figure 3].
Figure 1: Skin lesion: (a) Solitary erythematous plaque at buccal region, (b) irregular multiple erosion and white fine scales (yellow sign)

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Figure 2: Dermoscopy: (a) Yellowish orange structureless areas (yellow circles) surrounded by branching vessels (blue arrows), grayish scaling (yellow arrows), and follicular plugs (red circles) (b) outer part of the lesion showed more pigmentary network

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Figure 3: Hystopathology: Periadnexal granuloma () with epitheloid cell (×400)

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Case 2

A 34-year-old male patient complained of numbness in his left calf, back, and waist. About 1 year ago, the patient complained of a brown, numb coin spot on the left calf which was not accompanied by itching or pain. About 3 months ago, numb red patches appeared on the back of the neck and two backs. Low-middle socioeconomic history means the patient has low income and low social status from poor family. Around 1 week before, new numb coin spots appeared on the waist and numb patches size on the back and calf were getting wider.

Clinical lesions in the posterior trunk region showed multiple rings from erythematous patches with multiple confluent erythematous papules at the margins [Figure 4]. There were solitary erythematous patches with harsh margins in the left cruris region [Figure 5]. Dermoscopy examination in the posterior trunk region showed yellowish orange structureless areas (yellow circles) surrounded by branching vessels (blue arrow) and grayish scaling (red arrows). Dermoscopy examination from the left calf showed orange structureless areas (yellow circles) with loss of hair follicles. The examination of acid-fast bacilli from the six locations was negative [Figure 6]. Histopathological examination of the lesion biopsy revealed periadnexal granuloma and papillary dermis consisting of epithelioid cells, multinucleated giant cells Langhans, and with rim lymphocytes (lichenoid picture) [Figure 7].
Figure 4: Skin lesions (a) and (b): Multiple ring form erythematous patches with multiple confluent erythematous papules at the margins

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Figure 5: Skin lesion: Solitary erythmatous patches with harsh margins in the left cruris region

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Figure 6: Dermoscopy: (a) Posterior trunk region: Yellowish orange structureless areas (yellow circles) surrounded by branching vessels (blue arrows), fine micro scaling (red arrows), (b) left calf region: Yellowish orange structureless areas (yellow circles) with loss of hair follicles

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Figure 7: Hystopathology: periadnexal granuloma () with epitheloid cell (×400)

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  Discussion Top


Early diagnosis is the main focus in the prevention and control of leprosy so that treatment can be started immediately. This has two goals, namely preventing disability due to leprosy in patients and reducing the period of time, the patient has the potential to transmit leprosy to others.[7] However, early diagnosis of leprosy is still a challenge, negative SSS will not exclude leprosy automatically, especially in the early stages of the disease and in the form of PB.[8] In addition, the clinical manifestations of leprosy in the form of macules or plaques often resemble various other skin diseases such as tinea cruris, pityriasis alba, granulomatous rosacea, granuloma annulare, cutaneous tuberculosis, and sarcoidosis.

Up to now, a clinical diagnosis of leprosy has been obtained based on two of the following three criteria, including (1) skin lesions in the form of hypoesthesia or anesthetic patches, (2) thickening and pain in the peripheral nerves, and (3) smear examination from a positive skin smear. In cases with doubtful conditions, histopathological examination is the standard method for confirmation of leprosy cases.[9] In the case of PB leprosy, the diagnosis is based on a clinical and histopathological basis. In conditions, where a biopsy is difficult to perform such as in children, the facial lesion will not exclude leprosy automatically, facilities, and infrastructure that is not possible, and the patient refuses to take invasive procedures, noninvasive investigations such as dermoscopy can assist in diagnosing leprosy, especially the PB type.[10]

In this case series, two PB leprosy patients were reported with the clinical manifestations of the first patient being a solitary erythematous plaque and the second patient being multiple erythematous macules. The first patient with a solitary erythematous plaque in the right buccal region was initially diagnosed with as nonleprae because the clinical appearance of plaque mimicking lupus vulgaris or a skin malignancy such as squamous cell carcinoma or malignant melanoma. Neurological examination found no enlargement, pain, or impaired sensory or motor nerve function. SSS examination from six locations was also negative. In the second patient, he complained of discrete multiple lenticular-nummular erythematous patches with multiple confluent erythematous papules appearing in the posterior trunk region and in the left cruris region, solitary erythematous patches with plaques with more erythematous margin. Once, the patient was diagnosed with tinea corporis or dermatitis. The patient has been examined for peripheral nerves but found no enlargement or pain or impaired function. SSS examination at six locations was also negative. Hence, in these two patients, a histopathological biopsy was needed to confirm the diagnosis of leprosy. Dermoscopy examination in these two patients is certainly very useful because it can help establish the diagnosis.

Dermoscopy examination is an easy, noninvasive, mild, and portable option for helping to distinguish the clinical condition of leprosy from various other possible differential diagnoses. Gervasio et al. reported that dermoscopic examination is one of the modalities that can accurately identify this disease.[11] Dermoscopy allows for improved visualization of skin lesions. The examiner can see the structure of the epidermis, an image of the dermoepidermal junction, and the papillary dermis to the surface of the reticular dermis with a magnification of 10–70 times depending on the dermoscopy used. Images obtained from the dermoscopy examinations can be stored in a digital camera or mobile phone so that the images can be evaluated further later.[11] Research by Kakhita reports that significant dermoscopy changes have been observed and can be a modality for the early diagnosis of leprosy.[10] This is very useful, especially in conditions where the histopathological examination is difficult, such as in pediatric patients, facial lesions, refusal of invasive procedures, and unavailability of advice and infrastructure.

Dermoscopy examination of leprosy includes several important criteria that must be assessed, namely (1) scaling and atrophy pattern, (2) arrangement or morphology of blood vessels, (3) color, (4) follicles, sebaceous glands, and adnexal abnormalities, and (5) special feature (hint).[12] The hallmark of dermoscopy findings in leprosy is structureless orange to yellowish areas which is a characteristic sign of all skin granulomatous diseases, such as sarcoidosis, lupus vulgaris, cutaneous tuberculosis, necrobiosis lipoidica, and granuloma annulare.[13] The structureless orange area to yellowish areas may appear focal or diffuse and is formed as a result of a dense granulomatous infiltrate in the dermis that compresses the surrounding tissue so that it looks pale in color to yellowish orange. Dermoscopic findings in both cases showed yellowish-orange structureless areas surrounded with branching vessels as the prominent finding. The presence of vascular structure is also a characteristic of granuloma disease. Vascular dilatation is prominent which may be seen as linear or branching vessels from dermoscopy, indicated suppression of granuloma to vessels. Skin appendages loss such as hair follicle and eccrine duct opening also typically found from dermoscopy finding of leprosy as we found in the second patient and becoming dermoscopic pointers toward leprosy, unlike another granulomatous disease. This happens as the result of Mycobacterium leprae invasion to the skin appendages. We also find microscales on the patches from the first patient that are usually seen from leprosy lesions. The loss or absent pigment network as we found from the first patient are also specific features of dermoscopy to help differentiate from other granulomatous diseases.[14]

Along with the dermoscopy finding, the histopathology from both cases also found the same characteristic for tuberculoid leprosy. Periadnexal granuloma with epitheloid cell is the characteristic of leprosy histopathology features, especially tuberculoid type. Normal epidermal with noncaseating dermal granulomatous process composed mainly of epitheloid cell (activated macrophages). Commonly granuloma infiltrates invade peripheral nerve, sweat glands, and arrectores pilorum muscle.[14] The histopathology finding from both cases supports the diagnosis of PB leprosy.


  Conclusion Top


A wide spectrum of clinical findings of leprosy along with unclear neurological involvement and negative SSS test become a great diagnostic challenge for paucibacillary leprosy. Dermoscopy, as a noninvasive tool together with histopathology, features are both very helpful to asses PB leprosy. Specific characteristics of dermoscopic findings in granulomatous disease such as yellowish to orange structureless area and vascular structure are commonly seen. The presence of dermal appendages paucity in the form of loss of hair follicles or eccrine duct with pigmentary disturbance in the form of loss or absent pigment network typically helps to differentiate from other granulomatous diseases. However, histopathology is still the major tool to asses uncertain diagnoses for leprosy, and yet further studies of dermoscopy alone as work-up tools for leprosy and differentiate the various type of leprosy are needed.

Limitation

Larger research samples and prospective research methods are needed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given their consent for their images and other clinical information to be reported in the journal. The patient understands that their initial and name will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Henry M, GalAn N, Teasdale K, Prado R, Amar H, Rays MS, et al. Factors contributing to the delay in diagnosis and continued transmission of leprosy in brazil an explorative, quantitative, questionnaire based study. PLoS Negl Trop Dis 2016;10:e0004542.  Back to cited text no. 1
    
2.
Salgado CG, de Brito AC, Salgado UI, Spencer JS. Leprosy. In: Fitzpatrick's Dermatology. 9th ed., Vol. 2. New York: McGraw Hill; 2019. p. 2892-924.  Back to cited text no. 2
    
3.
Mohta A, Jain SK, Agrawal A, Kushwaha RK, Sharma P, Sethia K, et al. Dermoscopy in leprosy: A clinical and histopathological correlation study. Dermatol Pract Concept 2021;11:e2021032.  Back to cited text no. 3
    
4.
World Health Organization. WHO Expert Committee on Leprosy. Geneve, Switzerland: World Health Organ Tech Rep Ser; 2012. p. 968.  Back to cited text no. 4
    
5.
Fragozo-Ramos MC, Cano-Pérez E, Sierra-Merlano RM, Camacho-Chaljub F, Gómez-Camargo D. Clinical, histopathological, and molecular characterization of leprosy in an endemic area of the Colombian Caribbean. Int J Mycobacteriol 2021;10:155-61.  Back to cited text no. 5
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6.
Ansari AS, Saxena K, Singh KK, Choudhary A, Singh A, Tripathi AK, et al. Clinicobacteriological evaluation of leprosy patients with 1-5 skin lesions. Int J Mycobacteriol 2020;9:209-11.  Back to cited text no. 6
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7.
Bennett BH, Parker DL, Robson M. Leprosy: Steps along the journey of eradication. Public Health Rep 2008;123:198-205.  Back to cited text no. 7
    
8.
Mahajan V, Mahajan VK. Slit-skin smear in leprosy: Lest we forget it ! Indian J Lepr 2014;85:177-83.  Back to cited text no. 8
    
9.
Katoch VM. Advances in the diagnosis and treatment of leprosy. Expert Rev Mol Med 2002;4:1-14.  Back to cited text no. 9
    
10.
Ambujam S, Kakitha R. Dermoscopic characteristics of newly diagnosed Hansen's disease: A prospective descriptive study. SBV J Basic Clin Appl Heal Sci 2021;3:144-7.  Back to cited text no. 10
    
11.
Gervasio MK, Obbus SF V, Camaclang-Balmores ML, Siripunvarapon AH, Dofitas BL. Dermoscopic patterns in relation to the clinicopathologic manifestations of leprosy. Acta Med Philipp 2021;55:516-22.  Back to cited text no. 11
    
12.
Chopra A, Mitra D, Agarwal R, Saraswat N, Talukdar K, Solanki A. Correlation of dermoscopic and histopathologic patterns in leprosy – A pilot study. Indian Dermatol Online J 2019;10:663-8.  Back to cited text no. 12
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13.
Chauhan P, Adya KA. Dermatoscopy of cutaneous granulomatous disorders. Indian Dermatol Online J 2021;12:34-44.  Back to cited text no. 13
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14.
Vinay K, Kamat D, Chatterjee D, Narang T, Dogra S. Dermatoscopy in leprosy and its correlation with clinical spectrum and histopathology: A prospective observational study. J Eur Acad Dermatol Venereol 2019;33:1947-51.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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