Images in Clinical Tropical Medicine Non-Trophic Cutaneous Ulcers in Lepromatous Leprosy

A 44-year-old woman had progressive burning parasthesias and sensory loss in both upper and lower limbs, followed by weakness of distal muscles of the hands and feet for four years. She had redness and swelling of both hands and feet, multiple painless ulcers over the dorsum of the fingers (Figure 1A) and feet (Figure 1B), and thickened, non-tender, bilateral, ulnar, superficial cutaneous branch of radial and common peroneal nerves. She also had pre-dominant small fiber sensory polyneuropathy in a glove and stocking pattern, intrinsic muscle weakness of the hands and feet, and intact deep tendon reflexes. Results of hema-tologic and biochemical tests were within references ranges. Tests results for vasculitis and viral markers were negative. A nerve conduction study showed asymmetrical predomi-nantly axonal sensorimotor polyneuropathy (Figure 3) and absent waveforms on sympathetic skin response testing on both upper and lower limbs. A split skin smear was positive for acid-fast bacilli by Ziehl-Nielsen staining (Figure 2A, B). A skin biopsy from the leg showed dermal perivascular lymphocytic infiltrates, nerve twig inflammation, and posi-tive staining for lepra bacilli. Glove and stocking sensory loss in lepromatous leprosy is caused by involvement of small dermal sensory and auto-nomic nerve fibers,1 whereas non-trophic ulcers are caused by cutaneous vasculitis and small fiber involvement by lepra bacilli.1,2 The patient was given a multi-bacillary regimen2 (dapsone, 100 mg/day; rifampicin, 600 mg/day; and clofazimine, 50 mg/day) and showed symptomatic healing of cutaneous ulcers and reduction of burning paraesthesias at two-months follow-up