LEPROMATOUS LEPROSY WITH EXTENSIVE TRUNCAL SEBORRHEIC KERATOSES AND ACRAL VERRUCA VULGARIS
Authors: D'SOUZA MARIETTE , GARG BHAGAT R. , REDDY BELUM S.N. , RATNAKAR CHIGANTI 
Published: May 2007

A 37‐year‐old man came to us with asymptomatic dark colored warty iesions of 3V2 years' duration. The lesions started on the dorsa of the feet and hands and progressively increased in size and number to cover more than 60% of these areas. Later, they spread to other parts of the body. There was no history of sudden loss of weight or appetite, change in bowel habits, or of major illness in the past. The patient had not taken any medication.

A general and systemic examination of the patient revealed no abnormality. On dermatological examination, hyperpigmented well‐defined, verrucous papules and plaques of varying sizes were seen on the extremities, almost covering the dorsa of the hands and feet (Figs. 1–3). Small flattopped hyperpigmented papules with a smooth surface and “stuck‐on” appearance were present on the trunk (Fig. 4). The rest of the body had scattered hyperpigmented papules and plaques, up to 2 × 2 cm in size with a minimally verrucous surface.

The patient also had a shiny appearance of the face, infiltration of the ear lobes, with mild ichthyosis of the limbs. Examination of the peripheral nerves revealed bilateral thickening without tenderness or sensory loss. Slit smears for acid‐fast bacilli from the earlobe and normal skin showed a bacteriological index of 5+ and 2+, respectively.

A diagnosis of lepromatous leprosy with extensive verruca vulgaris and seborrheic keratoses was made. Biopsies of the normal‐looking skin, the flat truncal lesions, and the verrucous lesions on the extremities were taken.

Histopathologic examination of the trunk lesions showed hyperkeratosis and acanthosis with interwoven tracts of basaloid cells and horn cysts, indicative of the acanthotic type of seborrheic keratosis (Fig. 5). Below the epidermis there was a clear zone of dermis. A foamy macrophage granuloma was seen in the deeper dermis; M. leprae with Fite‐Faraco staining was demonstrated.

On histopathologic examination the acral lesions showed hyperkeratosis, acanthosis, and papillomatosis. The rete ridges were elongated and bent inwards and typical vacuolated cells were seen in some areas, indicative of verruca vulgaris (Fig. 6).

The biopsy from a lesion on the arm revealed seborrheic keratosis and verruca vulgaris in continuity along the epidermis with a foamy macrophage granuloma in the lower dermis (Fig. 7).

Mycobacterium leprae were demonstrable in all the sections. Thus, the histopathology of the lesions confirmed a diagnosis of lepromatous leprosy with acral verruca vulgaris and truncal seborrheic keratosis.

The patient was further investigated and baseline parameters including urine and stool examination, hemogram, blood sugar, and renal and hepatic function tests revealed no abnormality. Keeping in mind the sign of Leser‐Trelat, the patient was also investigated for any focus of malignancy. Gastroscopy, x‐ray of the chest, and other tests were normal. The Mantoux and blood serology for H(v were negative.

The patient was started on antileprosy treatment according to the WHO Multidrug Regimen and was also given a course of levamisole. Minimal response was noted. Eighteen months later the patient returned to the hospital and a 50% regression of the acral lesions was seen. A few lesions were also cauterized by electrocautery and the response was good.