NEWS & EVENTS

Case of the Month - May 2016

Dr Juno Thomas on behalf of the Infection Control Society of South Africa
A 54-year-old female is referred by her general practitioner (GP) to a physician in private practice for assessment and further management. She has been asthmatic since childhood, and was diagnosed with hypertension seven years previously. Her asthma-related symptoms have steadily worsened over the past three months despite numerous changes in therapy.

On her first visit to the physician, the patient reports that apart from the poorly controlled asthma, she is also concerned about a persistent ‘rash’ on her face.

The ‘rash’ began five months before, initially as a single lesion on the right cheek, but a month later a second lesion appeared on her nose. The GP initially thought it was likely to be a drug-related adverse reaction, but as the lesions progressed and enlarged he diagnosed it as Tinea corporis (ringworm). The patient had been applying topical corticosteroid and terbinafine creams for two months with no improvement in the lesions, so the GP prescribed systemic (oral) terbinafine treatment one month previously. The lesions had not improved and the patient reported that they were steadily increasing in size. She also mentioned that her nose sometimes felt numb.

Apart from further investigation and management of her underlying asthma and hypertension, the physician suggested a skin biopsy of the rash. He agreed with the GP’s diagnosis of Tinea corporis, but was concerned that there had been no improvement despite prolonged topical and systemic antifungal therapy.

One week later, the biopsy of both skin lesions was performed. Meanwhile, the topical and oral terbinafine treatment was continued.

The histology report of the biopsies reads as follows:
  • Skin biopsy left nose
  • Epidermis shows irregular acanthosis and hyperkeratosis
    Subepidermis shows extensive granulomatous inflammation with multinucleated giant cells, but no foci of necrosis
    Ziehl-Neelsen stain for acid-fast bacilli is negative
    PAS stain for fungal organisms is negative
    Wade Fite stain positive with scanty acid-fast bacilli
  • Skin biopsy right cheek
  • Epidermis shows irregular acanthosis
    Subepidermis shows extensive non-necrotising granulomatous inflammation
    Ziehl-Neelsen stain for acid-fast bacilli is negative
    PAS stain for fungal organisms is negative
    Wade Fite stain positive with scanty acid-fast bacilli

    Conclusion skin biopsies with features of non-necrotising granulomatous inflammation plus a positive Wade Fite stain are consistent with the diagnosis of tuberculoid leprosy.


Question 1: Is the patient’s clinical presentation consistent with a diagnosis of leprosy?


Continue to Answer 1

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