Clinical Tropical Medicine 
Christian Medical College, Vellore, Tamilnadu, India

History

A 51 year old retired policeman from Bhutan with skin lesions and swelling of the face X 9 yrs. Initial lesion - a pustule right side of upper lip. Progressed to involve entire lip, nose, forehead and chin. No past history or contact with patients with Tuberculosis or Hansen's disease or visceral Leishmaniasis. He had been diagnosed variously as tumid LE,tuberculosis and Hansen’s disease and treated with steroids, dapsone, antifungals and antibiotics in the past with no improvement or relief. He noted a worsening of the skin lesions for the last 3 months.

On Examination

Moderately built, well nourished. BP 110/70; Pulse 78 min. No SLNE. Erythematous skin lesions with plaques – over the right eyelid causing ptosis, left orbital margin, cheek, lips and chin. Edema of both lips. Rhinophyma of the nose. Palate involved – patchy involvement. Tongue and buccal mucosa normal.

Systems Exam: Normal

Verbal permission has been obtained from the patient and his son to project these photographs

Investigations

WBC                                      8-10                          

RBC                                       1-2                            

Epithelial Cell                        prt                             

Crystals                                  nil                              

Creatinine                              1.4                              mg%

                                                                                 

WBC Differential                                                    

Neutrophils                            80                               %

Eosinophils                            4                                 %

Basophils                               1                                 %

Lymphocytes                         10                               %

Monocytes                             5                                 %

                                                                                 

LFT                                                                          

Bilirubin Total                        1.8                              mg%

Direct                                     1.2                              mg%

Protein Total                          6.1                              g%

Albumin                                 2.9                              g%

SGOT                                    19                               U/L

SGPT                                     15                               U/L

                                                                                 

CRP                                       <3.19                         mg/L

Stool Occult Blood                Negative                   

Quantiferon - TB Gold          Positive [2.64]          

Blood Borne Virus Screen     Negative                   

C ANCA & P ANCA           <2   /   <2                  

VDRL                                    Non Reactive             

Bone Marrow: Moderately hypercellular marrow with moderate eosinophilia and mild diffuse plasmacytosis. No LD bodies seen in the smears examined.  Routine, fungal and mycobacterial cultures were negative.

Tissue (Skin) biopsy – atrophic epidermis with occ. Dermatophytes, interstial and perifollicular granulomatous inflammation

Tissue culture was negative for AFB or fungal elements. On Acanthamoeba Culture of the skin: No Free Living Amoeba  seen.  Multiple slit skin smears were negative for AFB.

 Chest Xray and ultrasound of the abdomen were normal.          

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