SCIENTIFIC
A Case of Zoonotic Leprosy in West Virginia
AUTHORS : Joy J . Juskowich , MD
Assistant Professor , Department of Medicine , Sections of Hospital Medicine and Infectious Diseases , West Virginia University
William L . Hall , MD
Dermatologist , Private Practice Associated with Mon Health Medical Center
Katrin Kiavash , MD , AP / CP
Assistant Professor , Department of Pathology , Anatomy , and Laboratory Medicine , West Virginia University
Arif R . Sarwari , MD , MSc , MBA
Professor and Chair of Department of Medicine , Section of Infectious Diseases , West Virginia University
NON-AUTHOR CONTRIBUTOR : P . Rocco LaSala , MD
Associate Professor and Director of Clinical Laboratories , Department of Pathology , Anatomy , and Laboratory Medicine , West Virginia University
CASE PRESENTATION
An immunocompetent 64-year-old woman originally from New York , living in West Virginia ( WV ) since late childhood , presented with a one-year history of progressively worsening maculopapular rash and peripheral neuropathy . The patient initially developed a bruise-like rash on her right leg that enlarged and spread to her upper back over a period of several months . She underwent lumbar decompression and instrumented fusion for presumed spinal stenosis , primarily due to worsening burning and numbness of toes on both feet . Postoperatively , the rash became more maculopapular and extended to involve bilateral thighs , upper extremities , remaining torso , and face . Symmetric peripheral neuropathy persisted . Physical examination was normal except for her integumentary and nervous systems . Visual inspection re-
ABSTRACT
INTRODUCTION
vealed a diffuse maculopapular rash with areas of plaques and scales most prominent on the patient ’ s back , extremities , and face ( Figure 1 ). Careful evaluation revealed thinning of hair , madarosis , and left ear lobe thickening and nodularity . Neurologic examination revealed decreased pinprick sensation involving bilateral soles of her feet but no anesthetic patches or peripheral nerve enlargement .
Laboratory tests , including complete blood cell count with differential , comprehensive metabolic panel , and C-reactive protein , were unremarkable except for mild hypercalcemia related to her underlying primary hyperparathyroidism . Histopathology of upper-back skin biopsies revealed wellformed , non-caseating epithelioid granulomas throughout the dermis consistent with granulomatous dermatitis on hematoxylin and eosin ( H & E ) stain and scarce acid-fast bacilli ( AFB ) on standard AFB and Fite stains ( Figure 2 ) on two separate occasions . AFB tissue cultures were negative .
The patient disclosed traveling to her son ’ s farmhouse in rural Texas multiple times over the past three years and seeing several armadillos around the yard . A diagnosis of tuberculoid leprosy was made based on the patient ’ s history of armadillo exposure
Leprosy , caused by the acid-fast bacillus Mycobacterium leprae , is a chronic infectious disease that primarily affects skin and peripheral nerves . While it is now considered a rare disorder , nine-banded armadillos recently emerged as a source of zoonotic leprosy in the southern United States ( US ). We present a patient with zoonotic leprosy diagnosed in West Virginia ( WV ). An immunocompetent 64-year-old woman , living in WV since late childhood , presented with a one-year history of progressively worsening maculopapular rash and peripheral neuropathy . Skin biopsies from her upper back on two separate occasions revealed well-formed , non-caseating epithelioid granulomas and scarce acid-fast bacilli . The patient had traveled to her son ’ s farmhouse in rural Texas multiple times over the past three years and disclosed seeing several armadillos around the yard . She was diagnosed with tuberculoid leprosy and responded well to dapsone and rifampin . Leprosy is an underrecognized and underdiagnosed disease . Within the last decade , two armadillorelated strains of Mycobacterium leprae have been identified . Awareness of zoonotic leprosy is important for prompt diagnosis and treatment to minimize disability .
and the histopathology results of her skin biopsies . After starting therapy with dapsone and rifampin , her skin lesions flatten ed and faded ( Figure 1 ). Peripheral neuropathy of both feet , attributed to tuberculoid leprosy , persisted despite initiation of treatment . Dapsone and rifampin were prescribed for a total duration of one year .
DISCUSSION
Leprosy is a chronic infectious disease that primarily affects skin and peripheral nerves . 1 While written descriptions of leprosy have spanned over 2,000 years , Mycobacterium leprae was first discovered as the cause of leprosy in 1873 by the Norwegian physician Gerhard Henrik Armauer Hansen . Therefore , leprosy is also referred to as Hansen ’ s disease . In earlier times , fear and stigma associated with leprosy lead to obligatory isolation of affected patients . 2 , 3 The first breakthrough in treatment was the discovery of dapsone in the 1940s , which was followed by the development of rifampicin and clofazimine in the early 1960s . Multidrug antimicrobial therapy , recommended by the World Health Organization ( WHO ) since 1981 , and targeted health initiatives have greatly decreased global disease burden over recent decades . 4 Up to 95 % of people are naturally resistant to infection with Mycobac-
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