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Case Reports

Abstract

An 81-year-old male with a history of prostate adenocarcinoma and Alzheimer’s disease presented with a persistent erythematous rash since November 2023. He had previously lived in Florida. The rash worsened following COVID-19 vaccination and oxycodone administration, which was switched to tramadol with no resolution. It later spread to involve the torso, upper arms, back, and legs and progressively worsened in severity. The rash was characterized by numerous scattered 4-6mm edematous pink erythematous smooth papules and plaques. The clinical differential diagnosis included a cutaneous drug eruption (including a dermal hypersensitivity reaction), urticarial phase of bullous pemphigoid, and COVID-vaccine reaction. Despite treatment with triamcinolone 0.1%, the rash persisted and spread to involve the legs. Additionally, the patient reported sporadic numbness in his hands twice in the last six months, along with hand swelling and arthralgias. Punch biopsies of skin showed dense interstitial histiocytic inflammatory infiltrates in the superficial dermis and extending into the reticular dermis along nerves, vessels, and adnexal structures. Kinyoun (AFB) and Fite stains highlighted numerous acid-fast bacilli within histiocytes and nerves. Considering these findings, biopsies were sent to the National Hansen’s Disease Program to confirm the diagnosis of lepromatous leprosy and to guide the patient’s management further.  The PCR returned positive for M. leprae. This case highlights an unusual and unexpected presentation of lepromatous leprosy and the importance of considering infectious etiologies in medically complex patients.