[Downloaded free from http://www.marinemedicalsociety.in on Monday, May 17, 2021, IP: 180.254.75.

96]

Case Report

A Case of Hansen’s Disease Masquerading as Polymorphous

Light Eruption
Lt Col Vikas Pathania, Lt Col Prerna Shankar1, Surg Cdr Divya Shelley2, Col Sukriti Baveja3, Maj Anwita Sinha3
Department of Dermatology, Command Hospital (SC), 2Department of Pathology, AFMC, 3Department of Dermatology, Command Hospital,
1
Station Health Organization, Pune, Maharashtra, India

Abstract
Hansen’s disease is a chronic, relapsing, infective granulomatous skin disease with protean manifestations imitating many benign dermatological
conditions. This not only poses a diagnostic dilemma to the treating physician but also often delays the diagnosis and treatment. We report one
such case of Hansen’s disease imitating a polymorphous light reaction suspected and detected incidentally on the lack of response to treatment
of the “apparently benign photodermatoses.”

Keywords: Hansen’s disease, photodermatoses, polymorphous light eruption

Introduction topical gels and creams with some transient improvement.

Leprosy is a chronic granulomatous condition caused by
Mycobacterium leprae and spread most likely by airborne
route in close contacts. Although the diagnosis of Hansen’s
disease is often clinical, at least initially, the cardinal signs
for confirming the diagnosis include the presence of an
anesthetic skin lesion, peripheral nerve enlargement, and/
or demonstration of M. leprae in skin smears.[1] However,
clinical presentation can more often than not be varied in
different spectrum of the disease including lepra reactions and
mimic a large variety of lesions from other dermatoses. The
problem is further compounded when the clinical presentation
does not conform with the cardinal signs, thereby delaying
diagnosis and treatment. We report a case of Hansen’s disease
in a 42‑year‑old man simulating polymorphous light eruption.
Case Report
A 42‑year‑old male, resident of Maharashtra, presented
with complaints of red raised itchy rash over the face of
11‑month duration. Initially, he noticed a coin‑sized red
raised lesion which progressed over a period of 6 weeks to
involve the entire left cheek. The patient initially resorted
to self‑medication in the form of application of various
Submission: 03-11-2018 Accepted: 17-12-2018
Access this article online
Quick Response Code:
Website:
www.marinemedicalsociety.in
Subsequently, over the next 8 months, he developed similar
lesions over the right cheek as well. There was no history
of numbness in the lesions, light‑colored numb patches
elsewhere on the body, redness of eyes, and swelling of hands
or feet. The lesions were associated with itching and burning
sensation with aggravation of symptoms on sun exposure.
There was, however, no history of oral ulcers, fever or joint
pains, and swelling. The patient reported to a dermatologist
where a skin scraping for KOH mount was found negative for
dermatophytosis. An initial skin biopsy done during the same
review from the patch over the left cheek was descriptive,
and following a negative ANA screen, the patient was
managed empirically for polymorphous light eruption with
topical steroids, sunscreens, and sun‑protective measures.
However, after an initial symptomatic improvement, the
patient offered no relief with medication. On presenting to
us, dermatological examination revealed the involvement
of both cheeks (left more than right) in the form of multiple
erythematous to violaceous, norm esthetic, normotrichic,
polysized papules, and plaques coalescing at places to suggest
Address for correspondence: Lt Col (Dr) Vikas Pathania,
Command Hospital (SC), Pune ‑ 411 040, Maharashtra, India.
E‑mail: vikascongo@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix,
tweak, and build upon the work non-commercially, as long as appropriate credit is given and
the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Pathania V, Shankar P, Shelley D, Baveja S,

10.4103/jmms.jmms_70_18 Sinha A. A case of Hansen’s disease masquerading as polymorphous light
eruption. J Mar Med Soc 2019;21:196-8.

196 © 2019 Journal of Marine Medical Society | Published by Wolters Kluwer - Medknow
[Downloaded free from http://www.marinemedicalsociety.in on Monday, May 17, 2021, IP: 180.254.75.96]

Pathania, et al.: A case of Hansen’s disease masquerading as PLE

an arcuate morphology, with the largest plaque over the left
cheek measuring 12 cm in diameter, extending from the left
angle of mandible to the left angle of mouth horizontally and
from the left lower eyelid to the upper one‑third of the left
side of the neck vertically [Figure 1]. There was no nerve
to patch or thickened peripheral nerves. Histopathologic
examination of a repeat skin biopsy from the patch over
the left cheek revealed an atrophic epidermis with the
dermis showing numerous periadnexal, perifollicular, and
perineural noncaseating epithelioid granulomas with a rich
lymphocytic cuff around them with few giant cells but no
acid‑fast bacilli  (AFB[L]) on the modified Ziehl–Neelsen
stain and slit‑skin smears [Figures 2 and 3]. Based on
histopathology, a diagnosis of Hansen’s disease (borderline
tuberculoid) was made. The patient was started on three
drugs, multidrug therapy (MDT) in the form of tablet
dapsone 100 mg daily, capsule clofazimine 50 mg daily, and
capsule rifampicin 500 mg and capsule clofazimine 300 mg
monthly supervised to which he responded well in the form
of subsidence of lesions within 1 month and is currently on
the follow‑up [Figure 4].
Discussion
Hansen’s disease is a chronic relapsing disease infecting the
skin and peripheral nerves. Lesions of leprosy can show a
wide range of morphologies such as macules (erythematous
or hypopigmented), papules, plaques, and nodules. Infiltrative
lesions can further cause surface changes in the form of
dryness and hypotrichosis by destruction of appendages
of the skin. Acute inflammatory lesions and limb swelling
can result from reactionary episodes.[2] Polymorphous light
eruption is a common, sunlight‑induced photodermatoses
characterized with pruritic, erythematous papular, plaque,
and vesicular lesions occurring over the photoexposed areas
within hours of exposure to ultraviolet radiation and complete
resolution over few weeks.[3] Our patient presented with slowly
progressive erythematous to violaceous papules and plaques

Figure 1: Multiple erythematous to violaceous, norm esthetic, Figure 2: H and E scanner view showing an atrophic epidermis with
normotrichic, polysized papules, and plaques over the left cheek dermis showing numerous periadnexal and perineural epithelioid
granulomas

Figure 3: H and E high‑power view (×10) showing noncaseating

epithelioid granulomas with a rich lymphocytic cuff around them with Figure 4: Resolution of lesions over the left cheek after 1 month of
few giant cells multidrug therapy

Journal of Marine Medical Society  ¦  Volume 21 ¦ Issue 2 ¦ July-December 2019 197

[Downloaded free from http://www.marinemedicalsociety.in on Monday, May 17, 2021, IP: 180.254.75.96]
Pathania, et al.: A case of Hansen’s disease masquerading as PLE
with photoaggravable pruritus over the face. The cardinal
signs of Hansen’s disease require the presence of hypoesthesia,
peripheral nerve thickening, and demonstration of AFB in
tissue smears, all of which were lacking in this case. Moreover,
the uniform presence of pruritus and consistent history of
photoaggravation of symptoms was striking enough to throw
the diagnostic algorithm off track, at least initially. Although
pruritus and burning in lepromatous lesions have been
described in the literature, the occurrence of photoaggravable
pruritus over the lesion was novel. [4‑6] The absence of
AFB (L) in skin smears as well as an inconclusive initial
histopathology further delayed the diagnosis. Differential
diagnosis of erythematous macules includes early morphea,
fixed drug eruption, Lyme’s disease, pityriasis rosea, roseolar
syphilide, seborrheic dermatitis, and tinea incognito while
that for papules and plaques include granuloma annulare,
granuloma multiforme, lupus vulgaris, psoriasis, sarcoidosis,
secondary syphilis, and urticaria.[1,2] In this case, we had
considered the clinical differential diagnosis of tinea faciei/
incognito, polymorphous light eruption, facial psoriasis,
cutaneous sarcoidosis, lupus miliaris disseminatus faciei,
and leprosy. Other similar mimicking conditions described
in literature include angioedema, cutaneous lymphomas,
erythema multiforme, single plaque lepromatous leprosy,
verrucous lesions, nonhealing ulcer, infiltrated linear lesions,
and vesiculobullous lesions.[7‑9] The novelty of the case is
highlighted by the fact that not only did it pose a diagnostic
dilemma by virtue of lacking the cardinal signs of leprosy but
also that it closely simulated a totally unrelated, fairly common
photodermatoses in its clinical behavior. This reemphasizes
the importance of keeping a high index of suspicion for
Hansen’s disease in otherwise benign photodermatoses
but unresponsive to routinely prescribed treatment for the
condition.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
198 Journal of Marine Medical Society  ¦  Volume 21  ¦  Issue 2  ¦  July-December 2019
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Prasad P, Kaviarasan P. Classification, clinical features, and differential
diagnosis. In: Sacchinanand S, Oberoi C, Inamadar AC, editors. IADVL
Textbook of Dermatology. 4th ed. Mumbai, India: Bhalani Publishing
House; 2015. p. 3089‑119.
2. Sharma N, Mahajan V. Differential diagnosis of dermatological disorders
in relation to leprosy. In: Kumar B, Kar HK, editors. IAL Textbook of
Leprosy. 2nd ed. New Delhi: Jaypee Brothers Medical Publishers (P)
Ltd.; 2016. p. 298‑313.
3. Vandergriff  TW, Bergstresser  PR. Abnormal responses to ultraviolet
radiation: Idiopathic, probably immunologic, and photoexacerbated. In:
Wolff  K, Goldsmith  LA, Katz  SI, Gilchrest  BA, editors. Fitzpatrick’s
Dermatology in General Medicine. 8th ed. United States of America:
McGraw‑Hill Companies; 2012. p. 1049‑53.
4. Sousa AR, Costa CO, Queiroz HM, Gonçalves PE, Gonçalves HS.
Leprosy simulating lichenoid eruption: Case report and literature
review. An Bras Dermatol 2010;85:224-6.
5. Raiol TK, Volpato SE, Guimarães Pde B, Lopes ML, Takano DM,
Santana JM, et al. Atypical lesions in relapsed leprosy. An Bras
Dermatol 2014;89:808‑11.
6. Sánchez-Orta A, Albízuri Prado MF, González Pessolani T,
Sendagorta Cudós E. Pruritic Lesions During Pregnancy: An Unusual
Presentation of a Rare Variant of Multibacillary Leprosy. Actas
Dermosifiliogr 2016;107:352-4.
7. Vineetha  M, Seena  P, Sobhana  KK, Celine  MI, Letha  V. Atypical
manifestations of leprosy – A case series. Indian J Lepr 2016;88:1‑6.
8. Yuchua‑Guillen A, Dofitas BL. Atypical Hansen’s disease presenting as
florid verrucous plaques on the lower extremities: A case report. Int J
Dermatol 2012;51:697‑701.
9. Das S, Roy A, Kar C, Giri P. Atypical presentation of leprosy: A report
of two cases. Indian J Dermatol 2007;52:198.