Case and Research Letters
Borderline Tuberculoid Leprosy in Erythema Nodosum Leprosum Reaction Mimicking Sweet's Syndrome
Lepra tuberculoide borderline en paciente con reacción lepromatosa tipo eritema nudoso simulando un síndrome de Sweet
Servicio de Dermatología, Facultad de Medicina, Hospitaly Centro de Investigación Dr. V.P., Nashik, India
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Pawar, V. Zawar, S. Kumavat" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Pawar" "email" => array:1 [ 0 => "manojpawar624@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Zawar" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Kumavat" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Facultad de Medicina, Hospitaly Centro de Investigación Dr. V.P., Nashik, India" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lepra tuberculoide borderline en paciente con reacción lepromatosa tipo eritema nudoso simulando un síndrome de Sweet" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 759 "Ancho" => 1305 "Tamanyo" => 161103 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histology showing infiltration of neutrophils, lymphocytes and plasma cells at the dermo-epidermal junction. Deeper dermis showing distorted epithelioid cell granulomas in fibrinoid necrosis and inflammatory infiltrate of neutrophils, lymphocytes, macrophages and plasma cells. (A- Original magnification X 100, B- Original magnification X 400, Haematoxylin and Eosin stain).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">An 11-year-old Indian boy presented with sudden onset of tender, erythematous and edematous plaques with slight vesiculations over face, upper and lower extremities associated with high grade fever and arthralgia along with edema over the hands and feet for 10 days (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B). His past and family history was non-contributory. On examination he was febrile (39 °C) and his both ulnar nerves were thickened and tender, however the sensations over the lesions were intact. Systemic review and general examination were normal. Laboratory investigations revealed leukocytosis with neutrophilia, and raised ESR; whereas rest all investigations were within normal limits. Biopsy of the lesion revealed infiltration of dermo-epidermal junction by neutrophils, lymphocytes, whereas deeper dermis and subcutaneous tissue showed epitheloid granulomas with fibrinoid necrosis and inflammatory infiltrates consisting neutrophils, lymphocytes and macrophages suggestive of borderline tuberculoid leprosy (BT) in type 2 lepra reaction (T2LR) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Slit-skin smear taken from the lesion for the acid-fast bacilli was negative. Patient was given multidrug therapy-paucibacillary (MDT-PB) (rifampicin 450 mg one a month and dapsone 50 mg daily) as per WHO guidelines, along with oral steroid 1 mg/kg/per day and tapered according to the response. His skin lesions and constitutional symptoms improved significantly (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">T2LR is an immune complex mediated complication of lepromatous leprosy (LL) and sometimes borderline lepromatous leprosy (BL) and most of it occurs during the first year of MDT.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It’s characterized by sudden crops of red, tender nodules or plaques, which occasionally become vesicular, pustular, bullous, or necrotic.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Systemic inflammation in T2LR may affect the nerves, eyes, joints, testes, and lymph nodes. Erythema nodosum leprosum (ENL) is the most common manifestation of T2LR. LL and a bacillary index greater than 4+ are the major risk factors, whereas infections, vaccination, stress pregnancy, lactation, and puberty have also been implicated in T2LR.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In our patient, the lesions closely mimicked as that of Sweet’s syndrome and presence of fever along with neutrophilia, raised ESR (which are minor criteria to diagnose Sweet’s syndrome)<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> added more dilemma. As lepra reactions are followed by surge of inflammatory cells, findings such as fever, leukocytosis, neutrophilia, raised ESR and CRP are common to occur. Moreover, on histology there were numerous neutrophils in the dermis, which is a histological feature of Sweet’s syndrome. Also steroid is quite effective in both the diseases; hence one might get deceived by the improvement of patient’s symptoms. Anesthesia over cutaneous lesions and enlarged and tender peripheral nerves point towards leprosy; and AFB positive bacilli on SSS and specific histopathologic findings aid in confirming the diagnosis. In our patient thickened and tender nerves and typical histology clinched the diagnosis of ENL. Interestingly, in our case, the reactional lesions were the presenting symptoms, as patient did not have a preceding diagnosis of leprosy, whereas most reported cases mimicking Sweet’s syndrome have prior diagnosis of BL or LL.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3–5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Corticosteroid is the drug of choice in T2LR, whereas thalidomide is the drug of choice for severe ENL. MDT should be started immediately or should be continued if a patient is already taking it. Corticosteroids suppress the inflammatory immune response to <span class="elsevierStyleItalic">M.leprae</span> antigens and also reduce intraneural and cutaneous edema.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3–5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Awareness of Sweet’s syndrome like T2LR and its prompt diagnosis and treatment is essential to prevent its dreaded sequelae in potentially treatable cases.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pawar M, Zawar V, Kumavat S. Lepra tuberculoide borderline en paciente con reacción lepromatosa tipo eritema nudoso simulando un síndrome de Sweet. Actas Dermosifiliogr. 2021;112:75–77.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 760 "Ancho" => 1305 "Tamanyo" => 177594 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, B: Erythematous and edematous plaques over the face, some of them showing slight vesiculations.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 759 "Ancho" => 1305 "Tamanyo" => 161103 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histology showing infiltration of neutrophils, lymphocytes and plasma cells at the dermo-epidermal junction. Deeper dermis showing distorted epithelioid cell granulomas in fibrinoid necrosis and inflammatory infiltrate of neutrophils, lymphocytes, macrophages and plasma cells. (A- Original magnification X 100, B- Original magnification X 400, Haematoxylin and Eosin stain).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 749 "Ancho" => 1305 "Tamanyo" => 263312 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A, B: Complete resolutions of the lesions after MDT therapy and oral steroids at 4 weeks.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rare atypical presentations in Type 2 lepra reaction: a case series" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P. 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"fecha" => "2018" "volumen" => "7" "paginaInicial" => "97" "paginaFinal" => "100" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29516895" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Type 2 leprosy reaction with Sweet’s syndrome-like presentation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F.C. Chiaratti" 1 => "E.L. Daxbacher" 2 => "A.B. Neumann" 3 => "T. Jeunon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1590/abd1806-4841.20164111" "Revista" => array:6 [ "tituloSerie" => "An Bras Dermatol." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 11 | 17 |
| 2024 October | 77 | 46 | 123 |
| 2024 September | 83 | 30 | 113 |
| 2024 August | 115 | 64 | 179 |
| 2024 July | 103 | 56 | 159 |
| 2024 June | 94 | 44 | 138 |
| 2024 May | 91 | 39 | 130 |
| 2024 April | 96 | 33 | 129 |
| 2024 March | 101 | 45 | 146 |
| 2024 February | 80 | 30 | 110 |
| 2024 January | 87 | 34 | 121 |
| 2023 December | 86 | 35 | 121 |
| 2023 November | 90 | 29 | 119 |
| 2023 October | 90 | 31 | 121 |
| 2023 September | 82 | 26 | 108 |
| 2023 August | 62 | 27 | 89 |
| 2023 July | 91 | 41 | 132 |
| 2023 June | 103 | 24 | 127 |
| 2023 May | 90 | 32 | 122 |
| 2023 April | 59 | 28 | 87 |
| 2023 March | 83 | 55 | 138 |
| 2023 February | 66 | 38 | 104 |
| 2023 January | 77 | 52 | 129 |
| 2022 December | 65 | 45 | 110 |
| 2022 November | 43 | 36 | 79 |
| 2022 October | 35 | 30 | 65 |
| 2022 September | 48 | 31 | 79 |
| 2022 August | 39 | 44 | 83 |
| 2022 July | 39 | 52 | 91 |
| 2022 June | 46 | 44 | 90 |
| 2022 May | 78 | 42 | 120 |
| 2022 April | 66 | 54 | 120 |
| 2022 March | 82 | 69 | 151 |
| 2022 February | 79 | 45 | 124 |
| 2022 January | 97 | 52 | 149 |
| 2021 December | 55 | 56 | 111 |
| 2021 November | 76 | 62 | 138 |
| 2021 October | 82 | 85 | 167 |
| 2021 September | 69 | 66 | 135 |
| 2021 August | 56 | 51 | 107 |
| 2021 July | 53 | 35 | 88 |
| 2021 June | 71 | 58 | 129 |
| 2021 May | 78 | 77 | 155 |
| 2021 April | 161 | 116 | 277 |
| 2021 March | 66 | 70 | 136 |
| 2021 February | 72 | 73 | 145 |
| 2021 January | 66 | 51 | 117 |
| 2020 December | 45 | 33 | 78 |
| 2020 November | 17 | 4 | 21 |
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