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Case Report

Lazarine Leprosy: A Unique Phenomenon of Leprosy

Vaishali Wankhade1, Vrutika Shah2, Rajesh P. Singh1, Dharitri Bhat3
Departments of Dermatology, Venereology and Leprosy and 3Pathology, Government Medical College, Nagpur, 2Department of Dermatology, Venereology and
1

Leprosy, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Abstract
Leprosy, a chronic granulomatous disease, has been known since ages but even today continues to baffle the clinicians with a wide spectrum
of clinical, histopathological, and immunological characteristics. Leprosy reactions are mainly of two types, namely, Type 1 and Type 2. In
Type 1 leprosy reaction, the preexisting lesions become erythematous, edematous, and rarely ulcerate. Ulcerating Type 1 reaction is called
lazarine leprosy. Ulcerations may occur in borderline tuberculoid (BT) pole or borderline lepromatous pole but more common in BT pole.
In this postelimination era of leprosy, we report an interesting case report of BT Hansen’s disease with Type 1 lepra reaction with ulceration,
namely, lazarine leprosy.

Keywords: Lazarine, lepra reaction, tuberculoid, ulceration

Submitted: 01-Jun-2020 Revised: 01-Jul-2020 Accepted: 07-Jul-2020 Published: 28‑Aug‑2020

Introduction
Lazarine leprosy, namely, ulcerating Type 1 reaction, was first
described in 1852 by Raphael Lucio and Ignacio Alvarado.[1]
Type 1 lepra reaction is a cell‑mediated immune reaction seen
in borderline forms of leprosy; the preexisting lesions become
erythematous, edematous, and rarely ulcerate. In 1930, in the
Fifth International Congress of Leprosy, it was concluded
that lazarine leprosy can occur in tuberculoid pole because of
high inflammation and in lepromatous pole because of high
bacillary load.[2]
Case Report
A 69‑year‑old male presented to our outpatient department
(OPD) with multiple, asymptomatic, reddish, raised lesions
all over the body for 4 months. No history of fever, tingling
numbness of hands and feet, weakness of hands and feet,
epistaxis, or redness of the eyes was present. A  history of
irregular treatment taken in the form of white‑ and red‑colored
blister packets for 2–3 months was present. General examination
was within normal limits. The body mass index of the patient was
23.3 kg/m2. On cutaneous examination, multiple, erythematous,
dry, scaly, annular plaques with well‑defined, inner borders
and sloping outer border giving an inverted saucer‑shaped
appearance were seen over the chest, back, bilateral upper and
lower limbs, and soles. There were sensory impairment and
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loss of hair over the lesions. On motor examination, book test,
card test, and Froment’s sign were positive on the right hand,
indicating the involvement of the deep branch of the ulnar
nerve. Peripheral nerve examination is tabulated in Table 1.
The slit‑skin smear (SSS) performed from the right earlobe, left
eyebrow, and the plaque over the chest was positive for acid‑fast
bacilli. Morphological index  (MI) showed all fragmented
bacilli, and bacteriological index (BI) was 1+. Histopathology
from the periphery of the plaques over the left thigh and chest
showed peri‑adnexal dense infiltrate with superficial and deep
dermal granulomas consisting of predominantly epithelioid
cells, lymphocytes, few neutrophils, and macrophages, with
eosinophilic cytoplasm suggestive of borderline tuberculoid (BT)
Hansen’s disease. Based on the above findings, the patient was
diagnosed as a case of BT Hansen’s disease and was started
on multibacillary multidrug therapy  (MBMDT). Four weeks
Address for correspondence:
Dr. Vrutika Shah,
B/1103, Apollo Pride Enclave Complex, Opp. Thane Bharat Sahakari Bank,
Vishnunagar, Thane-West, Maharashtra, India.
E-mail: vrutikashah25@gmail.com
ORCID:
https://orcid.org/0000‑0001‑6543‑7244
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DOI: How to cite this article: Wankhade V, Shah V, Singh RP, Bhat D.
10.4103/ijmy.ijmy_104_20 Lazarine leprosy: A unique phenomenon of leprosy. Int J Mycobacteriol
2020;9:329-31.

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Wankhade, et al.: Lazarine leprosy

after taking MBMDT, the patient presented to our OPD with presentations in leprosy are often seen due to partial and
spontaneous ulcerations over the preexisting lesions. No history delayed treatment. These lead to high morbidity among the
of any new lesions was present. Constitutional symptoms patients and a major risk for transmission and disabilities.
were absent. Cutaneous examination revealed nontender Two types of ulcers are seen in Hansen’s disease, namely,
ulcers with well‑defined margins and a clear base appearing leprous ulcers and trophic ulcers.[3] Trophic ulcers are seen
on the preexisting plaques over the chest [Figure 1a] and due to sensory impairment, whereas leprous ulcers are seen
back [Figure 1b]. The floor was covered with reddish granulation
tissue, and the surrounding skin was hyperpigmented. The
ulnar nerves and common peroneal nerves were bilaterally
thickened  (Grade 1) and nontender, with the right more
thickened than the left. Hematological investigations revealed
low hemoglobin (Hb – 8.8 g/dL) and low hematocrit (26%).
The mean corpuscular volume  (90.7 fL), mean corpuscular
hemoglobin (MCH) (30.6 pg), MCH concentration (33.8 g/dL),
and red cell distribution width  (14.1%) were within normal
limits. Serum reticulocyte count was 1%. Peripheral blood smear
showed mild hypochromasia and microcytosis with rest of the
picture being normal. Due to financial constraints, investigations
a b
such as serum iron studies could not be performed. Based on
the above blood picture, a diagnosis of iron deficiency anemia Figure 1: (a and b) Multiple, nontender ulcers with well‑defined margins
was made by the physician. Other investigations such as fasting and a clear base appearing over the preexisting plaques over the
chest (black arrow) and back (red arrow)
and postprandial blood glucose levels, liver function test (total
protein level was 6.3 g/dL and serum albumin level was 4.5
g/dL), renal function test, and urine routine microscopy were
within normal limits. Venereal Disease Research Laboratory and
HIV ELISA tests were nonreactive. Pus culture revealed growth
of Staphylococcus  aureus. Blood culture grew no organism.
SSS performed from the right earlobe, left eyebrow, and the
papule over the back was positive. MI showed all fragmented
bacilli, and BI was 1+. Histopathology from the periphery of the
ulcerated plaque of the chest and upper back [Figure 2] showed
mild hyperkeratosis, focal parakeratosis, and focally thinned‑out
epidermis with normal rete ridges. The subepidermal zone was
variably infiltrated. Reticular dermis showed multiple discrete Figure 2: Granulomas composed of epithelioid histiocytes, lymphocytes,
and mostly coalesced epithelioid cell granulomas composed multiple foreign body and Langhans (black arrow) giant cells, with few
of epithelioid histiocytes; lymphocytes; and multiple, large, neutrophils present (H and E, ×10 and ×40)
multinucleated (Langhans and foreign‑body type) giant cells.
Few foci showed neutrophils. Similar infiltrate was seen to
extend to the deep dermis and subcutaneous tissue. There was no
evidence of any vessel wall damage or macrophages or collagen
disruption. Similar histopathology findings were observed from
biopsy of the periphery of the plaque over the right sole. On
clinicopathological correlation, a diagnosis of BT Hansen’s
disease with ulcerative Type  1 lepra reaction, i.e., lazarine
leprosy, was made. The patient was started on oral prednisolone
40 mg once daily in the morning after breakfast and tapered
after every 2 weeks to 30 mg, 20 mg, 15 mg, 10 mg, and 5 mg
and then discontinued. Oral amoxicillin/clavulanic acid 625 mg
three times a day was given for 10 days and then discontinued.
After 3 weeks of treatment, the ulcers healed with hypochromic
atrophic scars with a hyperpigmented border [Figure 3].

Discussion Figure 3: Pre‑ and post‑treatment photographs of the ulcers healing

The term “lazarine leprosy” designates a severe, widespread, with hypochromic atrophic scars and hyperpigmented borders over the
ulcerative phenomenon in patients with leprosy.[3] Atypical chest (red arrows) and back (black arrows)

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Wankhade, et al.: Lazarine leprosy

and circulatory signs; very prominent varicose veins; absence

Table 1: Peripheral nerve examination
of eye lesions; and an absolute absence of nodules.[1,8] Our
Nerve Thickening Tender patient had tingling of hands and feet. Polymerase chain
Supraorbital nerve Not thickened Nontender reaction can help in identifying leprosy diagnosis in
Supratrochlear nerve Not thickened Nontender suspected patients with clinically atypical lesions, presenting
Infraorbital nerve Not thickened Nontender with negative baciloscopy and indecisive histopathology.[9]
Great auricular nerve Not thickened Nontender Diagnosis at an early stage is absolutely essential for earlier
Radial nerve Not thickened Nontender treatment to prevent leprosy‑related disabilities and its benefit
Ulnar nerve Grade 1 thickened Nontender for termination or control of infection transmission.[10]
Radiocutaneous nerve Not thickened Nontender
Median nerve Not thickened Nontender
Anterior cutaneous nerves of thigh Not thickened Nontender Conclusion
Common peroneal nerve Grade 1 thickened Nontender Thus, even today as we are trying hard to eradicate leprosy,
Anterior tibial nerve Not thickened Nontender newer forms of presentation continue to crop. In an
Posterior tibial nerve Not thickened Nontender endemic country like India, we still need to have an open
eye to recognize the varied manifestations of leprosy so
due to alteration in the immune status of these patients or the as to ensure prompt diagnosis and treatment, which can
excessive load of bacilli in these tissues. In tuberculoid pole, reduce the morbidity in potentially treatable patients. We
the major cause of lesional ulceration is Type 1 lepra reaction, present this case of lazarine leprosy on account of its rare
i.e., lazarine leprosy due to alteration in the immune status of occurrence and its association with anemia and superadded
the patient. In lepromatous pole, lesional ulceration is seen in infection along with the involvement of torso which is rare
lesions of erythema nodosum leprosum necroticans (Type 2 in lazarine leprosy.
lepra reaction) or rarely lazarine leprosy due to high bacillary Declaration of patient consent
load in the lesions. The authors certify that they have obtained all appropriate
Type 1 reaction is a delayed‑type of hypersensitivity, where patient consent forms. In the form, the patient has given his
the preexisting lesions become erythematous, edematous, and consent for his images and other clinical information to be
rarely ulcerate. This rare ulcerating type of Type 1 reaction reported in the journal. The patient understands that his name
is called lazarine leprosy. The exact pathogenic mechanism and initial will not be published, and due efforts will be made
of lazarine leprosy is unknown, but various factors have to conceal his identity, but anonymity cannot be guaranteed.
been implicated such as breakdown of local immunity, Financial support and sponsorship
increased proliferation of bacilli, and severe tissue edema.[4] Nil.
Protein malnutrition has been suggested to play a main role
in the pathogenesis of ulceration. [3] Protein malnutrition Conflicts of interest
leads to an enhanced susceptibility to secondary pathogens, There are no conflicts of interest.
such as streptococci and staphylococci, which results from
concomitant debilitation of humoral antibody mechanisms.[5] In References
few cases, lazarine leprosy has also been seen in BT Hansen’s 1. Lucio  R, Alvarado  I. Opusculo Sobre el Mal de San Lazaro o
disease without any malnutrition or immunosuppression.[6] Elephantiasis de Los Griegos. México: Murguía e Cia; 1852. p. 53.
In our patient, there was evidence of superadded bacterial 2. Pardo‑Castello  V, Caballero  GM. Lazarine leprosy: A  peculiar
infection along with anemia but no other evidence of protein monosymptomatic form of leprosy. Arch Derm Syph 1931;23:1‑11.
3. Nanda  S, Bansal  S, Grover  C, Garg  V, Reddy  BS. Lazarine
malnutrition or immunosuppression. leprosy‑revisited? Indian J Lepr 2004;76:351‑4.
In this form of leprosy, there are no localized skin infiltrations.[1] 4. Sunandini  PA, Prasad  PG, Chalam  KV, Padmasri  Y. Type  1 Lepra
Reaction With Ulceration  (Lazarine Leprosy) Two interesting case
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6. Salafia A. Lazarine leprosy–revisited. Indian J Lepr 2005;77:182‑3.
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our patient, however, the trunk was also involved. Tingling 8. Saúl A, Novales  J. Lucio‑Latapí leprosy and the Lucio phenomenon.
of hands and feet, hypo‑ or anhidrosis, alopecia of eyelashes Acta Leprol 1983;1:115‑32.
9. Naaz  F, Mohanty  PS, Bansal  AK, Kumar  D, Gupta  UD. Challenges
and eyebrows, smooth and rosy skin are also reported in these beyond elimination in leprosy. Int J Mycobacteriol 2017;6:222‑8.
patients.[1] Other clinical and systemic manifestations include 10. Govindharaj P, Srinivasan S, Darlong J. Perception toward the disease
saddle‑nose deformity; rhinitis; gastrointestinal, respiratory, of the people affected by leprosy. Int J Mycobacteriol 2018;7:247‑50.

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