Photo Quiz

Painless Nodular Rash in a Young Man

 

Am Fam Physician. 2017 Aug 1;96(3):189-190.

A 26-year-old man presented with a rash on much of his body that had steadily spread over one year. The rash covered his limbs, including his palms and soles, and his ears (Figures 1 and 2). He did not have associated pain, pruritus, or limb paresthesia. He did not have fevers, chills, night sweats, or weight loss. He was originally from the Marshall Islands and moved to Oklahoma within the six months before presentation. His vaccinations were up to date.

The physical examination revealed painless nodular lesions on his pinnae, arms, legs, hands, and feet. There were no lesions on his trunk or back. He had macular spots on his soles and palms. There were ulcerated nodules on his left wrist, elbows, and ankles.

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Figure 1.


Figure 1.

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Figure 2.


Figure 2.

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Annular psoriasis.

B. Cutaneous leishmaniasis.

C. Hansen disease (leprosy).

D. Keloids.

Discussion

The answer is C: Hansen disease (leprosy). The nodular painless rash on the limbs and, more specifically, the pinnae of the ear is suggestive of Hansen disease. Hansen disease is caused by Mycobacterium leprae infection and affects the skin and peripheral nerves. It is not as highly contagious as previously thought—about 95% of those who are exposed do not develop the disease.1,2 Hansen disease is rare, and most new cases in the United States are among immigrants. It is more common in males.2,3

Hansen disease should be suspected in a patient with hypopigmented patches or red skin nodules. These lesions are typically painless. Lumps or swelling of the earlobes and face is common. Patients may present with paresthesia or numbness in the hands and feet. Late findings are peripheral nerve damage leading to claw fingers, footdrop, or

Author disclosure: No relevant financial affiliations.

Address correspondence to Maya Bass, MD, at mayaalexabass@gmail.com. Reprints are not available from the authors.

REFERENCES

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1. Scollard DM, Stryjewska BM, Prestigiacomo JF, Gillis TP, Waguespack-Labiche J. Hansen's disease (leprosy) complicated by secondary mycobacterial infection. J Am Acad Dermatol. 2011;64(3):593–596....

2. Health Resources and Services Administration. National Hansen's Disease (Leprosy) Program. Hansen's disease data and statistics. https://www.hrsa.gov/hansensdisease/dataandstatistics.html. Accessed January 26, 2017.

3. Moschella SL. An update on the diagnosis and treatment of leprosy. J Am Acad Dermatol. 2004;51(3):417–426.

4. Health Resources and Services Administration. National Hansen's Disease (Leprosy) Program. Recommended treatment regimens. https://www.hrsa.gov/hansensdisease/diagnosis/recommendedtreatment.html. Accessed January 26, 2017.

5. Jones TC, Johnson WD Jr, Barretto AC, et al. Epidemiology of American cutaneous leishmaniasis due to Leishmania braziliensis braziliensis. J Infect Dis. 1987;156(1):73–83.

6. Chike-Obi CJ, Cole PD, Brissett AE. Keloids: pathogenesis, clinical features, and management. Semin Plast Surg. 2009;23(3):178–184.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

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