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which had appeared 6&#8239;months earlier&#46; The skin lesions were accompanied by weight loss&#44; general malaise&#44; and fever that had not been measured&#46; The patient was a drug abuser and reported having been in contact with his stepfather&#44; who had been diagnosed with Hansen disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The physical examination revealed multiple skin-colored papules and nodules with an infiltrated appearance&#44; some of which were ulcerated&#44; and others had a central hematic crust&#46; The lesions were located on the upper limbs and back&#46; The lower limbs and buttocks presented papules that coalesced to form brownish-red plaques &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Lack of feeling on palpation was found in all the lesions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Blood tests revealed that the patient was negative for HIV and FTA-ABS&#44; and blood count&#44; liver function&#44; and kidney function were normal&#46; Skin biopsies were taken&#46; Histopathology findings revealed nodular dermal aggregates composed of fusiform histoid cells in a storiform pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and 2B&#41;&#46; Fite-Faraco staining revealed abundant acid-fast and alcohol-fast bacilli &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#46; A diagnosis of histoid leprosy was made&#46; The patient decided to leave the hospital and it was not&#44; therefore&#44; possible to instate treatment&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Histoid leprosy &#40;HL&#41; is a rare variant of lepromatous leprosy&#46; It was first described in 1963 by Wade&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Most reported cases of HL are relapses in patients with multibacillary leprosy or patients receiving inadequate or irregular treatment&#46; De novo cases exist&#44; in which HL develops with no evidence of other types of leprosy&#46; These cases are even more rare&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> as in the case of this patient&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The entity usually presents in men between the ages of 30 and 50&#8239;years&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> Mos5t patients are of low socioeconomic status and have a history of contact with leprosy&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These sociodemographic characteristics concur with those of our patient&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">HL has unique clinical&#44; histologic&#44; and immunologic characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Classical clinical findings are well defined skin-colored or erythematous shiny papules and cutaneous or subcutaneous plaques and nodules arising from normal skin&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The usual location is on the back&#44; buttock&#44; extremities&#44; and face&#46; It rarely involves the ear lobes and&#44; unlike lepromatous leprosy&#44; madarosis is not present&#46; Loss of feeling in the lesions is typical&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Histopathologic findings include epidermic atrophy and a dermis with a Grenz zone and circumscribed collections of fusiform histoid cells distributed in a storiform pattern&#46; Fite-Faraco staining supports the diagnosis by revealing acid-fast and alcohol-fast bacilli&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The findings in our patient agree with those described in the literature&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The pathogenesis of this unusual variant is not fully understood&#46; It is thought to be the result of multiple factors&#44; combining genetic factors&#44; abnormal immune response&#44; and incomplete treatments&#46; A hyperreactive response is thought to exist with increased cellular immunity due to the presence of necrosis and ulceration in some lesions&#44; which is thought to be an effort to combat the <span class="elsevierStyleItalic">Mycobacterium</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This theory may explain the ulceration observed in several of the nodules in our patient&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The histoid lesions contain a high number of bacilli and are therefore reservoirs for resistant strains of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This is a public-health problem&#44; as it makes eradication of the disease difficult&#8212;more so when patients have little access to health care&#44; as in our patient&#44; who was a homeless man and who decided not to undergo treatment&#46; Treatment of HL is that recommended by the World Health Organization &#40;WHO&#41; for multibacillary leprosy&#44; with clofazimine&#44; dapsone&#44; and rifampicin for 12&#8239;months&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Histoid leprosy is a rare variant and is thought to be underdiagnosed&#46; It is important to recognize the atypical forms of Hansen disease in order to make the appropriate diagnosis and prescribe the correct treatment when required&#44; as well as to prevent the physical and psychological damage that patients may suffer&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
Histoid Leprosy: An Enemy Not Yet Eradicated
Lepra histioide, un enemigo aún no erradicado
N. Calvachea,
Corresponding author
, D.A. Ariasb, V.M. Delgadoc
a Servicio de Dermatología, Universidad Libre Cali, Cali, Valle del Cauca, Colombia
b Dermatólogo, Maestrante en Epidemiología, Docente Programa de Especialización en Dermatología, Universidad Libre Cali, Cali, Valle del Cauca, Colombia
c Dermatopatólogo, Docente Programa de Especialización en Dermatología, Universidad Libre Cali, Cali, Valle del Cauca, Colombia
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Histoid leprosy is a rare variant of multibacillary leprosy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It has unique clinical&#44; histologic&#44; and immunologic characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Most cases occur as a relapse of lepromatous leprosy&#44; whereas de novo cases are rarer&#46; The histoid lesions have a high bacillus content&#44; which favors growth of resistant strains and&#44; therefore&#44; represents a public-health problem&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> We report a patient from a poor social environment with clinical and histopathologic characteristics of de novo histoid leprosy&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 35-year-old homeless man from Cali was evaluated due to lesions located on the extremities and back&#44; which had appeared 6&#8239;months earlier&#46; The skin lesions were accompanied by weight loss&#44; general malaise&#44; and fever that had not been measured&#46; The patient was a drug abuser and reported having been in contact with his stepfather&#44; who had been diagnosed with Hansen disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The physical examination revealed multiple skin-colored papules and nodules with an infiltrated appearance&#44; some of which were ulcerated&#44; and others had a central hematic crust&#46; The lesions were located on the upper limbs and back&#46; The lower limbs and buttocks presented papules that coalesced to form brownish-red plaques &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Lack of feeling on palpation was found in all the lesions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Blood tests revealed that the patient was negative for HIV and FTA-ABS&#44; and blood count&#44; liver function&#44; and kidney function were normal&#46; Skin biopsies were taken&#46; Histopathology findings revealed nodular dermal aggregates composed of fusiform histoid cells in a storiform pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and 2B&#41;&#46; Fite-Faraco staining revealed abundant acid-fast and alcohol-fast bacilli &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#46; A diagnosis of histoid leprosy was made&#46; The patient decided to leave the hospital and it was not&#44; therefore&#44; possible to instate treatment&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Histoid leprosy &#40;HL&#41; is a rare variant of lepromatous leprosy&#46; It was first described in 1963 by Wade&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Most reported cases of HL are relapses in patients with multibacillary leprosy or patients receiving inadequate or irregular treatment&#46; De novo cases exist&#44; in which HL develops with no evidence of other types of leprosy&#46; These cases are even more rare&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> as in the case of this patient&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The entity usually presents in men between the ages of 30 and 50&#8239;years&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a> Mos5t patients are of low socioeconomic status and have a history of contact with leprosy&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These sociodemographic characteristics concur with those of our patient&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">HL has unique clinical&#44; histologic&#44; and immunologic characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Classical clinical findings are well defined skin-colored or erythematous shiny papules and cutaneous or subcutaneous plaques and nodules arising from normal skin&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The usual location is on the back&#44; buttock&#44; extremities&#44; and face&#46; It rarely involves the ear lobes and&#44; unlike lepromatous leprosy&#44; madarosis is not present&#46; Loss of feeling in the lesions is typical&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Histopathologic findings include epidermic atrophy and a dermis with a Grenz zone and circumscribed collections of fusiform histoid cells distributed in a storiform pattern&#46; Fite-Faraco staining supports the diagnosis by revealing acid-fast and alcohol-fast bacilli&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The findings in our patient agree with those described in the literature&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The pathogenesis of this unusual variant is not fully understood&#46; It is thought to be the result of multiple factors&#44; combining genetic factors&#44; abnormal immune response&#44; and incomplete treatments&#46; A hyperreactive response is thought to exist with increased cellular immunity due to the presence of necrosis and ulceration in some lesions&#44; which is thought to be an effort to combat the <span class="elsevierStyleItalic">Mycobacterium</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This theory may explain the ulceration observed in several of the nodules in our patient&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The histoid lesions contain a high number of bacilli and are therefore reservoirs for resistant strains of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This is a public-health problem&#44; as it makes eradication of the disease difficult&#8212;more so when patients have little access to health care&#44; as in our patient&#44; who was a homeless man and who decided not to undergo treatment&#46; Treatment of HL is that recommended by the World Health Organization &#40;WHO&#41; for multibacillary leprosy&#44; with clofazimine&#44; dapsone&#44; and rifampicin for 12&#8239;months&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Histoid leprosy is a rare variant and is thought to be underdiagnosed&#46; It is important to recognize the atypical forms of Hansen disease in order to make the appropriate diagnosis and prescribe the correct treatment when required&#44; as well as to prevent the physical and psychological damage that patients may suffer&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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