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Leprosy: a case series and review.

Article Excerpt
Abstract: Hansen disease, historically known as leprosy, is caused by Mycobacterium leprae. The disease is rare in the United States but remains endemic among certain immigrant populations, and may manifest years after infection. The US military has a number of active duty troops originally from endemic countries. Recently, three US soldiers with Hansen disease were evaluated at Walter Reed Army Medical Center. The mean time to diagnosis was 8 months (range, 2 to 18 months). All three patients were initially misdiagnosed and treated for other skin infections or contact dermatitis. These cases illustrate the importance of prompt recognition and treatment of Hansen disease to prevent permanent disability and disfigurement. The clinical presentation, diagnosis, classification, and currently recommended therapeutic regimens for Hansen disease are discussed.

Key Words: Hansen disease, immigrant, leprosy, military

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Hansen disease is rare in the United States, with a declining incidence since the 1980s and only 102 new cases reported in 1998. (1) Although a small number of endemic cases come from Hawaii, Texas, and Louisiana, the majority of cases (85%) are reported among immigrant or refugee populations. (1)

Physicians can encounter leprosy in any situation, but certain practice settings favor its appearance. The first results from the Compact of Free Association with the United States, which permits indigenous people from the Western Pacific Islands to join the US military. Because of the long incubation period (3 months to 40 years, with an average incubation period of 2 to 4 years), infection with Mycobacterium leprae may not be evident at the time of enlistment. (1) Similarly, immigrants can be a source of imported cases from endemic countries. The expanding role for the United States in managing refugee populations is likely to increase contact with persons infected with M leprae as well.

During a recent 1-month period, three patients were evaluated at Walter Reed Army Medical Center (WRAMC) for leprosy. All three patients were initially misdiagnosed and had been treated for some other condition (ie, contact dermatitis or Tinea corpora). The ability to recognize the diagnosis and provide prompt therapy is essential to prevent the long-term morbidity and disfigurement associated with leprosy. The three cases are presented, followed by a discussion regarding the diagnosis, classification, and currently recommended treatment regimens for Hansen disease.

Case Reports

Patient 1

Patient 1 was a 26-year-old male soldier originally from Pohnpei, Micronesia, who initially presented to his Troop Medical Clinic (TMC) at Fort Gordon, Georgia, complaining of a rash on his abdomen. He described the rash as a "red ring" with central clearing, which spread over his trunk and became pruritic. Both Lyme disease and allergic reaction were considered; initial empiric therapy consisting of a topical steroid, and hydroxyzine was prescribed. The lesions persisted and the patient developed paresthesias on the dorsa of his feet, calves, hands, and face, as well as bilateral lower extremity edema. Biopsy tissue showed superficial and deep granulomatous inflammation in...