EXTRAORDINARY CASE REPORT

Oral Lesions in Leprosy Revisited: A Case Report

A. K. Dhawan, MD, Prashant Verma, MD, and S. Sharma, MD*

Abstract: There is a scarcity of the histopathologically proven lesions

of leprosy in the oral cavity, in the world literature. A 55-year-old man
had come with a complaint of asymptomatic nodular lesions in the
oral cavity. Cutaneous lesions and peripheral nerve examination were
suggestive of lepromatous leprosy. Histopathologic examination of
a nodule on the palate demonstrated diffuse macrophagic granulomas
and acid-fast bacilli.
Key Words: oral cavity, leprosy
(Am J Dermatopathol 2012;34:666–667)

INTRODUCTION
Oral cavity is often overlooked in the clinical examina-
tion of a leprosy patient. The oral lesions are encountered FIGURE 1. Oral leprosy depicting erythematous nodules
usually in the context of long-standing untreated lepromatous present over the palate and lips.
pole of the spectrum of leprosy. However, the evidence of oral
lesions in the literature is largely clinical. Histopathology is
paramount to establish the causal association between an oral globi (Fig. 3). Accordingly, a diagnosis of lepromatous leprosy (LL)
lesion and leprosy. Furthermore, oral lesions may act as was made.
a source of transmission of Mycobacterium leprae.
DISCUSSION
In contrast to the cutaneous lesions, there is a dearth of
CASE REPORT literature on oral lesions in leprosy. Oral lesions usually appear
A 55-year-old man presented with asymptomatic multiple as ulcerations of the hard or soft palate.1–4 The greater
nodules involving palate and lip for the past 1 year. The patient took frequency of lesions, especially, along the midline of the palate
treatment in the form of topical steroids and multivitamins without
any improvement. He was a known case of diabetes mellitus and was
on oral hypoglycemics. Family and personal history were
unremarkable.
Physical examination revealed multiple, soft, pink-colored
nodules involving hard and soft palate and lip (Fig. 1) varying in size
from 3 to 5 mm. Multiple shiny papules and nodules were present
symmetrically on back, chest, abdomen, both upper and lower limbs,
and face. Multiple peripheral nerves were symmetrically enlarged
besides a glove and stocking anesthesia along all the extremities.
Histopathologic findings from a lesion on the palate revealed
subepithelial macrophagic granulomas (Fig. 2). Fite–Faraco staining
of the sections showed numerous acid-fast lepra bacilli in the form of

From the Department of Dermatology and STD and Department of Pathology*,

University College of Medical Sciences and Guru Teg Bahadur Hospital,
University of Delhi, Delhi, India.
The authors report no conflicts of interest to disclose.
Reprints: Prashant Verma, MD, Department of Dermatology and STD,
University College of Medical Sciences and Guru Teg Bahadur Hospital,
Delhi University, Delhi 110095, India (e-mail: drprashant_derma@yahoo.
co.in). FIGURE 2. Oral leprosy demonstrating subepithelial macro-
Copyright Ó 2012 by Lippincott Williams & Wilkins phagic granulomas (H&E, 340). H&E, hematoxylin and eosin.

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Am J Dermatopathol  Volume 34, Number 6, August 2012
FIGURE 3. Oral leprosy illustrating acid-fast lepra bacilli and
globi (Fite–Faraco, 3100).
has been attributed to 2 air currents, nasal and oral, which
traverse the anatomical zone. This phenomenon is responsible
for its lower temperature, 1°C–2°C below that of body
temperature.5 The present case too had nodular lesion in the
midline of the palate. Tongue, uvula, and gingiva are the other
mucosal surfaces that may be afflicted by leprosy. Various
types of lesions reported are infiltration; reddish or yellow
reddish nodules, sessile or pedunculated, varying from 2 to
10 mm; ulceration; and perforation. Lip involvement may
result in notable enlargement, cheilitis granulomatosa.2–4 In
the present case, nodules were remarkable on the lips. It has
been stated that no lesions/alterations in the oral mucosa are
specific to leprosy, and any lesion must be biopsied to establish
a causal association,6 as the original studies of the diagnosis of
such lesions were established only through clinical examina-
tion or bacilloscopy. Few authors did histopathologic
examination of detected lesions.3,7–9 This may be one of the
explanations for the disagreement in frequency rates of oral
involvement in leprosy seen in literature,6 which varies from
absent up to 57.5%.1,3,10–15 Accordingly, the lesions in the oral
cavity may be classified6 as either specific (demonstrating
acid-fast bacilli) or nonspecific (absence of bacilli). In general,
oral involvement only appears in the advanced stages of LL.
Rarely, patients with paucibacillary leprosy may manifest oral
lesions. In a histopathologic study,16 comprising 30 patients
with paucibacillary leprosy, 8 nonspecific chronic inflamma-
tory reactions and 1 granulomatous inflammatory process
without acid-fast bacilli were detected.
q 2012 Lippincott Williams & Wilkins
Oral Lesions in Leprosy Revisited
Hematogenous or lymphatic dissemination of M. leprae
has been suggested as a possible route of transmission of
bacilli to the oral cavity.8 Another possibility for the develop-
ment of oral lesions is continuity, with nasal lesions possibly
being precursors of oral lesions.1 It has been suggested that
the route of transmission may increase in endemic areas when
the oral mucosa is affected because viable bacilli have been
detected at these sites.1 Thus, it is imperative to examine the
oral cavity, because in advanced leprosy, the mouth cannot
only acquire the characteristics of a reservoir of bacilli and
thus may act as an important risk factor for transmission of
the illness, but also a patient may present to a physician
with oral complaints only, where it becomes paramount to
recognize the lesions.
REFERENCES
1. Girdhar BK, Desikan KV. A clinical study of the mouth in untreated
lepromatous patients. Lepr Rev. 1979;50:25–35.
2. Bucci F Jr, Mesa M, Schwartz RA, et al. Oral lesions in lepromatous
leprosy. J Oral Med. 1987;42:4–6.
3. Scheepers A, Lemmer J, Lownie JF. Oral manifestations of leprosy. Lepr
Rev. 1993;64:37–43.
4. Costa A, Nery J, Oliveira M, et al. Oral lesions in leprosy. Indian J
Dermatol Venereol Leprol. 2003;69:381–385.
5. Brand PW. Temperature variation and leprosy deformity. Int J Lepr. 1959;
27:1–7.
6. de Abreu MA, Michalany NS, Weckx LL, et al. The oral mucosa in
leprosy: a clinical and histopathological study. Braz J Otorhinolaryngol.
2006;72:312–316.
7. Sharma VK, Kaur S, Radotra BD, et al. Tongue involvement in
lepromatous leprosy. Int J Dermatol. 1993;32:27–29.
8. Soni NK. Leprosy of the tongue. Indian J Lepr. 1992;64:325–330.
9. Kumar B, Yande R, Kaur I, et al. Involvement of palate and cheek in
leprosy. Indian J Lepr. 1988;60:280–284.
10. Bechelli LM, Berti A. Lesões lepróticas da mucosa bucal: estudo clı́nico.
Rev Bras Leprol. 1939;7:187–199.
11. Mela B, Casotti L. Sulle manisfetazioni orali e mascellari sulla lebbra.
Stomatol Ital. 1939;1:755–763.
12. Porto M. Lesões Orais na Lepra: Estudo Clı́nico [thesis]. Araraquara,
Brazil: Universidade de São Paulo, Faculdade de Farmácia e Odontologia;
1965.
13. Lighterman I, Watanabe Y, Hidaka T. Leprosy of oral cavity and adnexa.
Oral Surg Oral Med Oral Pathol. 1962;15:1178–1194.
14. Brasil J, Opromolla DVA, Souza-Freitas JA, et al. Incidência de alteracxões
patológicas da mucosa bucal em pacientes portadores de hansenı́ase
virchowiana. Estomat Cult. 1974;8:137–152.
15. Santos GG, Marcucci G, Marchese LM. Aspectos estomatológicos das
lesões especı́ficas e não-especı́ficas em pacientes portadores da moléstia
de Hansen. Pesqui Odontol Bras. 2000;14:268–272.
16. de Abreu MA, Alchorne MM, Michalany NS, et al. The oral mucosa in
paucibacillary leprosy: a clinical and histopathological study. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 2007;103:e48–e52.
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