A 23-year-old female who had recently immigrated from Micronesia presented with a one-week history of painful nodules on her lower legs. She noted areas of decreased sensation throughout her upper and lower extremities. Associated symptoms included intermittent fever and night sweats. Previous treatment consisted of cephalexin for possible cellulitis, which was prescribed by her infectious disease physician, as well as empiric treatment with an unknown medication for nine months beginning two years prior from a leprosy clinic in Micronesia. Since relocating to the United States, she had discontinued all medications. Past medical history was negative for any immunodeficiencies. Physical examination revealed edema and erythema of the bilateral lower limbs with painful subcutaneous nodules of varying sizes. Hypopigmented macules were present on the upper arms, legs, and trunk (Figure 1).
Laboratory evaluation was significant for leukocytosis and anemia. Quantiferon-TB Gold was negative. An 8 mm punch biopsy was performed along the lateral aspect of her left leg, which revealed noncaseating granulomatous inflammation with numerous bacilli highlighted by the Fite stain (Figure 2). The acid-fast bacilli smear was positive. Given the patient's clinical, laboratory, and histological findings, a diagnosis of lepromatous leprosy with a type 2 erythema nodosum leprosum reaction was established.
Therapeutic management was initiated with rifampin, dapsone, folic acid, minocycline, and a short course of prednisone, which provided symptomatic relief. A trial of clofazimine was then administered following approval from her ophthalmologist.