Leprosy (Hansens Disease)

Clinical

Chronic infection by Mycobacterium leprae. The organism has low infectivity and a long
incubation period (average 5 years). It affects skin, nasal mucosa, and peripheral nerves. Leprosy
infection can be divided into two subtypes, depending on host immunity. Tuberculoid leprosy
results from a strong T-cell response and is a relatively stable form. Clinically, lesions are well-
defined red-brown anesthetic plaques on trunk and limbs. Enlarged nerves may be noted.
Lepromatous leprosy results from deficient T-cell immunity and a poor host response. Cutaneous
lesions are symmetrical, hypoesthetic, and may be macular, infiltrative-nodular, or diffuse. Facial
involvement may give leonine facies. Reactional leprosy can be a reversal reaction or a
downgrading reaction. Erythema nodosum leprosum is a type 2 reversal reaction that shows
histologically a leukocytoclastic vasculitis.

Histology
Tuberculoid leprosy has well-formed granulomas along neurovascular bundles with dense
peripheral lymphocytic infiltrate. Acid-fast bacilli are rarely found with Fite stain, even in nerves
(Fig. 10.3).

Lepromatous leprosy typically has a grenz zone, separating the epidermis from an extensive
dermal infiltrate of macrophages stuffed with bacilli. Because of the poor host response, the
macrophages are not activated to form granulomas. Accumulations of bacilli within
macrophages, visible as basophilic material in the cytoplasm on H&E stain, are called globi. Fite
stain reveals numerous organisms (Fig. 10.4).

Differential Diagnosis

To differentiate sarcoidosis from tuberculoid leprosy with a negative Fite stain, an S-100 protein
stain may demonstrate a nerve in the center of the granulomas and thus favor tuberculoid leprosy.

Tertiary Syphilis

Clinical
Generalized disease with skin/mucosal lesions and cardiovascular and neurological
manifestations. Occurs years after initial infection. Two types of skin lesions. Superficial nodular
lesions are red-brown scaly nodules with a serpiginous advancing border. Gummatous lesions are
subcutaneous swellings that ulcerate.

Histology
Marked endothelial swelling in both forms. Gummas have granulomas with large areas of
acellular (gummatous) necrosis. The surrounding chronic inflammation includes plasma cells.
Nodular lesions show hyperkeratosis overlying an atrophic epidermis and a superficial and deep
mixed inflammatory infiltrate containing plasma cells and granulomas.

Fig 10.3. Tuberculoid leprosy: Linear non-necrotizing granulomas along nerve tracks. Fite
stain is often negative in this type of leprosy.

Stains
Silver stains for spirochetes are usually negative.