A previously healthy 32 years old man, originally from Ethiopia, presented with fever, rash and neuropathy

    Clinical History

    A previously healthy 32 years old male, originally from Ethiopia, presented to our hospital with fever, rash, and neuropathy. The patient reported a 4 years history of paresthesia which started in his feet and progressed up his legs and bilateral upper extremities. He also complained of worsening weakness and weight loss. He denied any personal or family history of autoimmune disease, but did report that his mother had very similar symptoms, beginning in her 30s. 

    Physical exam showed scleral injection, madarosis, lagopthalmos, hypopigmented macules and plaques on the back, a retiform hyperpigmented patch along the cervical and thorac spine, a hyperpigmented plaque on the left abdomen, erosions on bilateral elbows, and two hyperpigmented atrophic plaques on the right knee.  

    Initial clinical impression was that the patient’s underlying issue was a neurologic condition, infectious or inflammatory. Differential diganosis included autoimmune disease, HTLV-1 associated myelopathy, amyloidosis, and a wide range of infectious etiologies. Biopsies were performed on the left abdomen and right knee. 

    Pathology Findings  

    The skin biopsies showed focal non-necrotizing granulomatous inflammation composed of lymphocytes, histiocytes, and giant cells involving nerve fibers in the mid and deep dermis. The epidermis and upper dermis were unremarkable, except for a scar in the right knee lesion. 

    FITE stain demonstrated many intraneural and few extraneural acid-fast bacilli in both biopsies. Additional stains were also performed; Wright-Giemsa, PAS, AFB, Warthin-Starry, and an immunostain for T. pallidum were all negative. These findings supported the diagnosis of leprosy.  Based on the load of organisms and clinical presentation, the case can be best classified as a borderline lepromatous leprosy.