|Year : 2014 | Volume
| Issue : 3 | Page : 392-395
Histoid leprosy in type II reaction with neural abscess: Treated with ulnar nerve decompression and anterior transposition
Milind A Patvekar1, Sanjay Dev2, Alia Rizvi1, Rohit Malhotra2
1 Departments of Dermatology, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, (Dr. D.Y. Patil Vidyapeeth) Pimpri, Pune, Maharashtra, India
2 Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, (Dr. D.Y. Patil Vidyapeeth) Pimpri, Pune, Maharashtra, India
|Date of Web Publication||18-Mar-2014|
Milind A Patvekar
B-204, QueensTown Society, S.No.3876, Udyog Nagar, Opp Lokmanya Hospital, Chinchwad, Pune - 411 033, Maharashtra
Source of Support: None, Conflict of Interest: None
A 40-year-old male, known case of histoid leprosy on multidrug therapy since 10 months, presented with erythema nodosum leprosum since 15 days. Examination findings revealed multiple, irregular, bilateral, symmetrically distributed shiny nodules and plaques all over the body. Bilateral radial, ulnar, radial cutaneous, and lateral popliteal nerves were thickened. The right ulnar nerve was exclusively tender indicative of an abscess, for which decompression and anterior transposition of ulnar nerve was performed. Steroids were given parenterally followed by oral steroids in a dose of 60 mg/day and tapered gradually with good prognosis. In addition, thalidomide in a dose of 300 mg/day was also started.
Keywords: Anterior transposition, histoid leprosy, ulnar nerve
|How to cite this article:|
Patvekar MA, Dev S, Rizvi A, Malhotra R. Histoid leprosy in type II reaction with neural abscess: Treated with ulnar nerve decompression and anterior transposition. Med J DY Patil Univ 2014;7:392-5
|How to cite this URL:|
Patvekar MA, Dev S, Rizvi A, Malhotra R. Histoid leprosy in type II reaction with neural abscess: Treated with ulnar nerve decompression and anterior transposition. Med J DY Patil Univ [serial online] 2014 [cited 2020 Jan 29];7:392-5. Available from: http://www.mjdrdypu.org/text.asp?2014/7/3/392/129007
| Introduction|| |
Histoid leprosy is a distinct and a rare variant of lepromatous leprosy, having characteristic skin lesions, histopathology, and bacterial morphology. The term histoid leprosy was introduced by Wade in 1963.  It presents clinically as a well-demarcated, cutaneous, and subcutaneous nodules similar to dermatofibroma.  The lesions are predominantly present on the lower part of the back and over the bony prominences, especially over the elbows and knees. The other sites affected are, posterior and lateral aspects of arms, buttocks, thighs, and dorsum of hands. 
On histopathological examination, the epidermis shows grenz zone and the dermis shows numerous spindle-shaped histiocytes, with pyknotic nuclei and cytoplasm exhibiting foamy changes with vacuolation. The dermis also reveals unusually large number of acid fast bacilli. 
It occurs in patients with dapsone monotherapy earlier or incompletely treated leprosy with multidrug therapy (MDT). It may also occur due to de novo infection with drug-resistant bacilli. 
Incidence of histoid leprosy was reported to be 3.2% in a study conducted by Seghal et al., in 100 multibacillary leprosy.  Erythema nodosum leprosum (ENL) reaction has rarely been documented in histoid leprosy. The severe reaction leads to nerve enlargement, pain and tenderness and paralysis. Sometimes, nerve abscesses may form requiring drainage. 
| Case Report|| |
A 40-year-old male, known case of histoid leprosy was on multibacillary regime since 10 months. The patient was diagnosed as histoid leprosy 1 month before starting the treatment. The patient stopped taking the treatment for last 1 month, when he presented with multiple progressive tender nodules on the face, trunk, buttocks, and extremities with numbness and tingling sensation over right forearm and hand in the distribution of ulnar nerve since 15 days [Figure 1]. He also complained of fever, malaise, and bodyache. Examination findings revealed multiple, bilateral, symmetrical, irregular, and shiny cutaneous nodules over the above-mentioned sites. The skin over anterior aspect of both forearms and lower legs showed ichthyotic changes. Bilateral radial, radial cutaneous, and lateral popliteal nerves were uniformly thickened with an extremely tender and nodular right ulnar nerve. Flexion of metacarpophalangeal joints against resistance revealed weakness of small muscles of right hand, like lumbricals and interossei.
Skin biopsy was taken from a nodule over the lower back region for histopathology. The skin section showed grenz zone in epidermis. The superficial dermis revealed plenty of histiocytes with foamy cytoplasm and numerous acid fast bacilli.
The patient was started on parenteral prednisolone followed by oral prednisolone 60 mg/day for the management of severe ENL and neuritis. The steroids were gradually tapered with 10 mg/day decrements every 2 weeks and discontinued after 4 months. In addition to this, thalidomide and clofazimine in a dose of 300 mg/day were also added. Having continued the treatment for 2 weeks the cutaneous lesions showed remarkable improvement with persistent pain around the elbow. There was associated neurological impairment with an exclusively tender ulnar nerve indicative of an abscess, for which a decision of nerve decompression was undertaken.
Under general anesthesia and tourniquet application in the supine position a right elbow posterolateral approach to the ulnar nerve was taken. The incision was at midpoint at medial epicondyle 3 cm proximal and 3 cm distal to it. The nerve was found to be thickened and edematous [Figure 2]. The nerve was palpated first which had bulbous thickening at several places. The nerve sheath was incised on the thickened nerve which yielded frank pus [Figure 3]. The pus was taken for acid fast bacilli staining and for culture sensitivity. The staining of material revealed plenty of Mycobacterium. leprae, whereas culture was negative for bacterial growth. The whole of the ulnar nerve sheath over its entire exposed area was decompressed. The nerve was subsequently transposed on the anterior forearm after making it free between the two heads of flexor carpi ulnaris [Figure 4]. The transposed nerve was anchored over the deep fascia with interrupted sutures after making sure that nerve was not strangulated [Figure 5]. The tourniquet was released and hemostasis was achieved. And finally, skin closure was done with interrupted sutures [Figure 6].
|Figure 5: Transposed nerve anchored over the deep fascia with interrupted sutures|
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|Figure 6: Skin closure with interrupted sutures showing perfect wound healing|
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The post-operative period was uneventful. The wound healing was perfect. There was no tenderness of the ulnar nerve. The paraesthesia over the hand subsided and patient recovered well. The patient was discharged with advice to continue MDT for another year.
| Discussion|| |
In India, incidence of histoid leprosy has been estimated to be between 2.79% and 3.60%. It is not uncommon in South India. There is a male preponderance, and the average age at diagnosis is between 21 and 40 years.  The incidence of histoid leprosy was found by Singh et al. to be 8.7% among lepromatous leprosy and 1.2% among all leprosy patients.  Histoid leprosy clinically simulates xanthomas, neurofibroma, dermatofibroma, reticulohistiocytosis, or cutaneous metastasis. Each of them can be differentiated from the histoid leprosy on the basis of its characteristic histopathology, the absence of lepra bacilli on slit skin smear, and nerve thickening.  Histoid leprosy occurs in patients either on dapsone monotherapy, with dapsone resistance, supervised MDT or in untreated lepromatous patients. De novo cases have also been reported.  Ebenezer et al. described a patient who developed Histoid Hansen after 7 years of supervised MDT. 
Clinically, it is characterized by multiple, smooth, painless, firm skin colored to yellow brown nodules on normal appearing skin. The nodules may involve face, back, limbs, and bony prominences, as well as mucous membranes in severely affected patients. Ears may be unaffected. Histoid lesions have also been reported to present along the course of the peripheral nerve trunks and cutaneous nerves.  Classical histopathological findings include epidermal atrophy as a result of dermal expansion of the underlying leproma and a grenz zone located immediately below the epidermis.  The leproma consists of fusiform histiocytes arranged in a tangled or storiform pattern containing acid fast bacilli. There are three histologic variants of Histoid Hansens: Pure fusocellular, fusocellular with epitheloid component, and fusocellular with vacuolated cells. The third pattern is most commonly observed.  Histoid leprosy is managed by initially giving the range of motion therapy, with rifampicin 600 mg, ofloxacin 400 mg, and minocycline 200 mg, which is followed by WHO MB-MDT therapy. 
Being a rare variant of lepromatous leprosy in which ENL is still rarer to find. This case required surgical intervention in order to prevent further deterioration of nerve function.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]