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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 110-113

Involvement of palms in leprosy: An unusual clinical manifestation


Department of Dermatology and Venereology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission01-Dec-2019
Date of Decision26-Mar-2020
Date of Acceptance15-Apr-2020
Date of Web Publication19-Feb-2021

Correspondence Address:
Naveen Kumar Kansal
Room No. 016414, Department of Dermatology and Venereology, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_44_19

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  Abstract 


Leprosy (Hansen's disease), a chronic granulomatous infection caused by Mycobacterium leprae, frequently affects the areas of skin, which have a relatively low temperature and/or are prone to trauma. Several zones of skin, for example, scalp, palms and soles, groins, genitalia, axillae, eyelids, and perineum, have usually been described as “immune” to lesions of leprosy. However, clinical, bacteriological, and pathologic evidence of involvement of these so-called “immune zones” has rarely been documented. Therefore, now many workers have proposed that these “immune zones” should be called “relatively immune,” rather than “absolute immune.” Hereby, we report a rare case of leprosy with palmar involvement.

Keywords: Absolute immune zones, leprosy, Mycobacterium leprae, relative immune zones, Type 1 lepra reaction


How to cite this article:
Divyalakshmi C, Kansal NK, Joshi PP, Singh D. Involvement of palms in leprosy: An unusual clinical manifestation. Clin Dermatol Rev 2021;5:110-3

How to cite this URL:
Divyalakshmi C, Kansal NK, Joshi PP, Singh D. Involvement of palms in leprosy: An unusual clinical manifestation. Clin Dermatol Rev [serial online] 2021 [cited 2021 Apr 18];5:110-3. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/1/110/309762




  Introduction Top


Leprosy (Hansen's disease) is a chronic infection caused by acid-fast bacillus Mycobacterium leprae, with a high incidence of reactional states known as “lepra reactions” and considerable mutilating potential.[1] The lepra bacillus is known to have an affliction of areas with relatively low temperature, for example, the skin, peripheral nerves, eyes, and testes. However, certain sites of skin such as the scalp, palms and soles, groins, genitalia, eyelids, axillae, and perineum have been usually described as “immune” to lesions of leprosy. Hereby, we report a patient of leprosy with palmar involvement.


  Case Report Top


A 16-year-old male presented with multiple, hypopigmented, hypoesthetic lesions on the abdomen, face, and extremities for the past 2 years. Initially, the lesions appeared on the right leg, which was followed by the involvement of other sites. There were no systemic complaints. The treatment history was significant for the incomplete treatment of leprosy (WHO multibacillary multidrug therapy [MB MDT] for 10 months) and then discontinued. Cutaneous examination revealed multiple, hypopigmented, atrophic, scaly, ichthyotic plaques on the abdomen, arms, forearms [Figure 1], legs, and face. Well-defined plaques with erythematous border were also seen extending from the lateral border of the wrists onto the palmar surface with flattening of the hypothenar eminence. A single, round trophic ulcer with the callused border was seen in the right palm [Figure 2]. There were reduced sensations of temperature, touch, and pain over all the plaques. Examination of the peripheral nerves revealed thickening of the greater auricular, ulnar, radial cutaneous, and common peroneal nerves bilaterally. A clinical diagnosis of borderline tuberculoid (BT) leprosy was considered. Complete blood counts, liver and renal function tests, hepatitis B and C serology, HIV ELISA, urine examination, and chest X-ray revealed no abnormality. Slit-skin smear for lepra bacilli was negative. A skin biopsy for pathological examination from a lesion at the left forearm demonstrated periappendageal, well-formed, epithelioid cell granulomas along with lymphocytic infiltrate and Langhans giant cells in the mid and deeper dermis. Mild perivascular inflammation was also present in the upper dermis [Figure 3] and [Figure 4]. The Wade–Fite stain was found to be negative. The clinicopathologic features were consistent with a diagnosis of BT leprosy. The patient was counseled about the significance of regular leprosy treatment and started on WHO MB MDT for the recommended duration of 1 year.
Figure 1: Atrophic, scaly, ichthyotic plaque on the extensor aspect of the upper extremity

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Figure 2: Well.defined plaque with the erythematous border on the right palm. A single, round trophic ulcer with a callused border is also present

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Figure 3: Skin biopsy showing unremarkable epidermis, with mid and deeper dermis having periappendageal epithelioid granulomas. Mild perivascular inflammation present in the upper dermis (H and E, ×10)

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Figure 4: Well-formed epithelioid cell granulomas along with lymphocytic infiltrate and Langhans giant cells in the mid and deeper dermis (H and E, ×40)

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  Discussion Top


Leprosy (Hansen's disease) predominantly affects the skin and peripheral nerves as the lepra bacillus (M. leprae) prefers a relatively cooler temperature (about <37°C). Due to this reason, leprosy lesions are commonly seen over the face, knees, elbows, gluteal region, dorsal aspects of the extremities, and trunk. However, many areas in skin, for example., axilla, eyelids, genitalia, groins, and scalp, are known to be rarely affected by the disease. These areas have been termed the “immune zones.”[2] The involvement of palms and soles is also rare in leprosy. Palms and soles are relatively cooler than the rest of the body, have a rich nerve supply, and are also more prone to trauma. These factors should have made them more prone to the lesions of leprosy. However, palms and soles are distinct from other areas of the skin in the following ways: first, the palmoplantar epidermal thickness, approximately 1.5 mm, is thicker than that of other superficial skin areas and hence comparatively warmer; and second, there is a significant amount of fibrofatty tissue in the palms and soles, which ensures proper insulation and hence a high nerve bed temperature.[2],[3] As the nerve bed temperature of the palmoplantar region is more than that of other superficial skin regions, this is considered to be the reason why palmoplantar localization of M. leprae is quite less likely.[3],[4],[5]

A detailed literature search, however, revealed only a few cases of palmoplantar involvement by leprosy [briefly reviewed in [Table 1]].[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18] Palmoplantar involvement in leprosy is approximately 3.6%–12.2%, with palmar involvement more than the plantar involvement. It has also been noted that patients with Type 1 lepra reactions are more likely to show the involvement of palms and/or soles. Although the pathomechanism of this phenomenon is not known, it may be because those inapparent lesions are likely to become prominent and clinically more visible during the lepra reactions. In our case also, the palmar lesion was erythematous, indicating a Type 1 lepra reaction.
Table 1: Cases of palmoplantar involvement in leprosy

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It is also worth considering to describe the involvement of other so-called “immune zones.” The involvement of the scalp is known to present as alopecia (termed “leprotic alopecia”), the involvement of the bald scalp, or as an extension of anesthesia from a neighboring lesion. Apparently normal skin of the scalp may also exhibit acid-fast bacilli in pathological sections or on slit-skin smear.[19],[20] The involvement of scrotum has been seen in indeterminate and tuberculoid forms of leprosy. A single, well-defined anesthetic plaque has been reported on the scrotum, preputial skin, and over the penoscrotal fold in tuberculoid leprosy.[2],[21],[22],[23] Leprosy lesions over the genitalia have also been reported in histoid leprosy.[24] The involvement of groins, axillae, perineum, eyelids, the midline of the back, and a transverse band of skin on the lumbosacral area has been occasionally seen by many workers.[25],[26] In fact, no skin area is probably immune to M. leprae, as many studies have documented bacterial and pathological evidence of the disease process even in the clinically uninvolved skin.[27] Bedi et al. studied the skin biopsies of clinically inapparent skin of the scalp, axillae, and groins in twenty lepromatous leprosy patients and found pathological findings in 25% of their patients.[28] Therefore, it is now considered that these areas of skin should be termed as “relative immune” rather than “absolute immune” zones of leprosy.[2],[26]


  Conclusion Top


Our index case emphasizes the fact that a protean disease like leprosy can affect any site of the body, including clinically normal areas, and therefore, the term “relative immune zone” is more appropriate and preferable to “absolute immune zone.”

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kansal NK, Hazarika N, Upadhyaya A, Joshi PP. Umbilicated lesions in a de novo case of histoid leprosy. J Dtsch Dermatol Ges 2019;17:333-5.  Back to cited text no. 1
    
2.
Rajashekar TS, Singh G, Naik LC. Immune zones in leprosy. Indian J Dermatol 2009;54:206-10.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Enna CD, Berghtholdt HT, Stockwell F. A study of surface and deep temperatures along the course of the ulnar nerve in the pisohamate tunnel. Int J Lepr Other Mycobact Dis 1974;42:43-7.  Back to cited text no. 3
    
4.
Sabin TD, Hackett ER, Brand PW. Temperature along the course of certain nerves often affected in lepromatous leprosy. Int J Lepr 1974;42:41.  Back to cited text no. 4
    
5.
Anish SA. The relationship between surface temperature and dermal invasion in lepromatous leprosy. Int J Lepr Other Mycobact Dis 1971;39:848-51.  Back to cited text no. 5
    
6.
Hopkins R, Denney OE, Johansen FA. Immunity of certain anatomic regions from lesions of skin leprosy. Arch Dermatol Syphilol 1929;20:767-79.  Back to cited text no. 6
    
7.
Mukerjee N, Ghosh S, Kundu S. Palmar lesion in a case of leprosy of the tuberculoid type. Int J Lepr 1958;29:245.  Back to cited text no. 7
    
8.
Rajendran N. Palmoplantar lesions in paucibacillary leprosy – Unusual clinical expressions. Indian J Lepr 1987;59:188-90.  Back to cited text no. 8
    
9.
Aggarwal SK, Arora PN, Chattopadhyay SP, Ramakrishnan KR. Primary involvement of sole in leprosy (a case report). Indian J Lepr 1987;59:472-3.  Back to cited text no. 9
    
10.
Arora SK, Mukhija RD, Mohan L, Girdhar M, Sharma SP. A study of palmoplantar lesions in leprosy: A preliminary report. Indian J Lepr 1989;61:206-8.  Back to cited text no. 10
    
11.
Chattopadhyay SP, Rajpathak SD, Gopal AR, Patra AK. Bilateral involvement of sole and palm in leprosy. A case report. Indian J Lepr 1989;61:266-7.  Back to cited text no. 11
    
12.
Pavithran K. Primary involvement of the palms and soles in leprosy – Report of two cases. Indian J Lepr 1990;62:123-5.  Back to cited text no. 12
    
13.
Baslas RG, Gupta M, Arora SK, Mukhija RD, Misra RK. Palmar involvement in histoid leprosy. Indian J Lepr 1992;64:193-5.  Back to cited text no. 13
    
14.
Murthy KP, Sekar B. Plantar lesions in tuberculoid leprosy-a report of three cases. Lepr Rev 1994;65:402-4.  Back to cited text no. 14
    
15.
Grover S, Singh G, Dash K. Primary hyperpigmented palmar lesion: A rare presentation of borderline tuberculoid leprosy. Indian J Lepr 1997;69:191-3.  Back to cited text no. 15
    
16.
Indira D, Kaur I, Sharma VK, Das A. Palmoplantar lesions in leprosy. Indian J Lepr 1999;71:167-72.  Back to cited text no. 16
    
17.
Arakkal GK, Vani S, Kasetty HK, Varala S. Leprosy: An unusual presentation. Int J Med Public Health 2015;5:118-20.  Back to cited text no. 17
  [Full text]  
18.
Sajad P, Hassan I, Bhat YJ, Mubashir S, Imtiyaz S, Qureshi W. Unusual presentation of borderline tuberculoid leprosy. Astrocyte 2015;2:40-1.  Back to cited text no. 18
  [Full text]  
19.
Parikh DA, Oberai C, Ganapati R. Involvement of scalp in leprosy – A case report. Indian J Lepr 1985;57:883-6.  Back to cited text no. 19
    
20.
Fleury RL, Tolentino MM, Opromolla OV, Tonello C. Inapparent lepromatous leprosy in the scalp. Int J Lepr 1973:41;580.  Back to cited text no. 20
    
21.
Dixit VB, Chaudhary SD, Jain VK, Sen R. Primary involvement of scrotum in tuberculoid leprosy. A case report. Indian J Lepr 1990;62:120-2.  Back to cited text no. 21
    
22.
Inamdar AC, Kumar GK. Genital skin lesion in tuberculoid Hansen's disease. Indian J Dermatol Venereal Leprol 1992;58:49.  Back to cited text no. 22
    
23.
Ghorpade A, Ramanan C. Solitary tuberculoid leprosy lesion over penoscrotal fold. Indian J Lepr 1998;70:317-8.  Back to cited text no. 23
    
24.
Nigam PK, Singh G. Mucosal and genital lesions in histoid leprosy. Int J Dermatol 1990;29:207-8.  Back to cited text no. 24
    
25.
Jayakumar J, Aschhoff M, Renuka G, Meyers WM. Involvement of scalp, axillae and groins in lepromatous leprosy. Indian J Lepr 1992;64:541-4.  Back to cited text no. 25
    
26.
Sahni U, Reddy BS, Malik R. Clinicopathological study of so called immune zones in leprosy. Lepr India 1982;54:256-62.  Back to cited text no. 26
    
27.
Kaur S, Kumar B. Study of apparently uninvolved skin in leprosy as regards bacillary population at varying sites. Lepr India 1978;50:38.  Back to cited text no. 27
    
28.
Bedi TR, Kumar B, Kaur S. Histopathologic study of clinically normal appearing skin in lepromatous leprosy. Lepr India 1979;51:78-80.  Back to cited text no. 28
    


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