A 25-year-old Micronesian man from the island of Otia developed erythematous plaques on his legs. He was diagnosed with
erythema nodosum and treated with systemic
prednisone. Two months later, he presented with erythematous nodules on his forehead, cheeks, and chin (Fig. 1). Examination revealed scattered violaceous papules on his chest, arms, forearms, hands, and feet, and deep purple macules on his palms and soles. Laboratory evaluation included negative serologies for human immunodeficiency virus, rapid plasma
reagin, and
hepatitis A, B, and C. Routine histopathology revealed nodular aggregates of histiocytes, plasma cells, and lymphocytes. Histiocytes showed basophilic clusters of organisms within vacuoles, suggesting globi.
Acid-fast
stain revealed numerous
acid-fast-positive rod-shaped organisms. The bacterial index on the Fite
stain was four (bacterial index/Ridley's logarithmic scale, indicating 10-100 bacteria/high power field) (Fig. 2). An
acid-fast
stain obtained from a smear of tissue was positive for
acid-fast bacilli, but no
acid-fast bacilli were cultured. After the first day of treatment with
dapsone 100 mg,
rifampin 600 mg, and
clofazimine 50 mg, the patient complained of burning and
pain in his ankles and wrists. There was intense
erythema within the lesions.
Edema developed in his hands and feet. Consultation with the Gillis W. Long
Hansen's Disease Center in Carville, Louisiana, recommended prompt treatment with
corticosteroids. The
edema of the hands and wrists was treated as a type I reversal reaction with
prednisone 1 mg/kg/day. Subsequently, the
edema and
neuralgia quickly resolved in his distal extremities.