Leonine Facies: Lepromatous Leprosy
A 57-year-old man presented with a 7-year history of diffuse skin infiltration associated with sensory loss in his left hand. His face had multiple nodular lesions that coalesced into plaques, especially on the forehead, ears, nose, and lips (Panel A). He had weakness in the muscles on the left side of his face and loss of eyebrow hair and eyelashes. The ulnar and tibial posterior nerves were enlarged. A skin smear stained according to the Ziehl–Neelsen method revealed acid-fast bacilli in clumps. Screening for IgM antibodies to phenolic glycolipid I, which is specific for Mycobacterium leprae, was performed with the use of enzyme-linked immunosorbent assay. The highly positive results were consistent with a diagnosis of lepromatous leprosy. This anergic form of leprosy is characterized by an inefficient immune response. Nerve damage is slow to occur and is related to high levels of infection of the nerves. The patient underwent multidrug therapy, with the addition of prednisone, for 5 months. After 9 months of multidrug treatment, the skin infiltration and weakness in the left eyelid had diminished (Panel B). The treatment period for standard multibacillary leprosy is 12 months, but anergic polar forms, as occurred in this patient, usually require 24 months of treatment before cure.source: nejm.org
