University of Texas Medical Branch, Galveston, TX, USA.
National Hansen's Disease Program, Baton Rouge, LA, USA.
J Investig Med High Impact Case Rep. 2020 Jan-Dec;8:2324709620927884. doi: 10.1177/2324709620927884.
The distinction between persistent infection and immunologic reactions in leprosy is often difficult but critically important since their management is different. We present the case of a 51-year-old Vietnamese female who presented in 2015 with areas of erythema and skin infiltration on face and chest, as well as edema on her hands and feet. Skin biopsy was consistent with lepromatous leprosy. She was treated with rifampin, clarithromycin, and levofloxacin for 2 years. Her lower extremity edema was attributed to type 2 immunological reaction for which she was started on prednisone and methotrexate, but she was lost to follow-up for 19 months. She presented with new skin lesions and pain on her extremities. New biopsies revealed an intense neutrophilic infiltrate in the dermis and acid-fast bacilli focally within cutaneous nerve twigs. As compared with the initial biopsy, the inflammatory infiltrates were diminished and the bacilli had a degenerating appearance. These findings were consistent with type 2 immunological reaction. The patient was treated with thalidomide with improvement in the appearance of the skin lesions. A follow-up biopsy showed lack of neutrophilic infiltrates and decreased number of bacilli. This case illustrates the importance of differentiating between persistent infection and immunologic reactions in leprosy. Clinicians should be aware of these complications. A high index of suspicion and accurate interpretation of skin biopsy results are essential for appropriate diagnosis.
麻风病中持续性感染和免疫反应的区分通常很困难，但至关重要，因为它们的治疗方法不同。我们报告了一名 51 岁越南女性的病例，她于 2015 年出现面部和胸部红斑和皮肤浸润，以及手脚水肿。皮肤活检符合瘤型麻风。她接受了利福平、克拉霉素和左氧氟沙星治疗 2 年。她的下肢水肿归因于 2 型免疫反应，因此开始使用泼尼松和甲氨蝶呤治疗，但她在 19 个月内失去了随访。她出现新的皮肤损伤和四肢疼痛。新的活检显示真皮内有强烈的中性粒细胞浸润，皮肤神经末梢内有局部抗酸杆菌。与初始活检相比，炎症浸润减少，细菌有退化的外观。这些发现与 2 型免疫反应一致。患者接受沙利度胺治疗，皮肤损伤外观改善。随访活检显示中性粒细胞浸润减少，细菌数量减少。这个病例说明了在麻风病中区分持续性感染和免疫反应的重要性。临床医生应该意识到这些并发症。高度怀疑和准确解释皮肤活检结果对于正确诊断至关重要。
