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Year : 2017  |  Volume : 60  |  Issue : 4  |  Page : 616-617
Lepromatous leprosy-negative images giving the diagnostic clue

Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

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Date of Web Publication12-Jan-2018

How to cite this article:
Singla S, Singla G, Gupta K, Arora R, Mandal AK. Lepromatous leprosy-negative images giving the diagnostic clue. Indian J Pathol Microbiol 2017;60:616-7

How to cite this URL:
Singla S, Singla G, Gupta K, Arora R, Mandal AK. Lepromatous leprosy-negative images giving the diagnostic clue. Indian J Pathol Microbiol [serial online] 2017 [cited 2022 Jan 20];60:616-7. Available from: https://www.ijpmonline.org/text.asp?2017/60/4/616/222973

Leprosy also known as Hansen's disease is one of the oldest diseases known to humanity. It is caused by Mycobacterium leprae.[1] The disease has a long incubation period of 3–5 years and is transmitted by nasal discharge and digital impregnation of skin as bacilli can be carried under nails and are inoculated under the skin by scratching. It is still considered as a social stigma and is common in population where poor living conditions, overcrowding, and malnutrition exist.[2] It affects the skin, peripheral nerves, the mucosa of the upper airways, and other tissues such as bone because it survives better at temperature close to 30°C than at 37°C. There are several forms of leprosy that range from the mildest indeterminate form to the most severe lepromatous type depending upon the immune response. The disease presents polar clinical forms (the “multibacillary” lepromatous leprosy and the “paucibacillary” tuberculoid leprosy) as well as other intermediate forms with hybrid characteristics.[1] Tuberculoid leprosy occurs in individuals with good cell-mediated immunity while lepromatous leprosy occurs in individuals with poor cell-mediated immunity. Borderline leprosy is an intermediate form between tuberculoid and lepromatous leprosy. Tuberculoid leprosy can present either as a hypopigmented macule or as an erythematous plaque with well-defined borders that are elevated. Lepromatous leprosy can present as plaques, macules, papules, and nodules affecting the face, ears, the trunk, and extremities.[3] The skin nodules can clinically mimic infective or soft-tissue nodules. Patients may present to different nondermatology clinics and are referred for fine-needle aspiration cytology (FNAC). Here, we present a similar case in which the patient presented as multiple skin nodules in the surgery department and was referred for FNAC.

A 27-year-old female presented in surgery outpatient department (OPD) with multiple tender nodules over both wrists and forearm. The lesion measured 1–1.5 cm. The clinical diagnosis of an inflammatory lesion was suggested. The patient was then referred for FNAC.

On aspiration, the nodule yielded pus-like material. Giemsa-stained FNA smears revealed inflammatory exudate consisting of macrophages, few lymphocytes, and neutrophils. Macrophage showed foamy cytoplasm with intracellular unstained clefts interpreted as negative images. Similar extracellular-negative images were also seen [Figure 1]. The smears were then destained and restained with Fite stain which showed alcohol fast M. leprae in globi and singly [Figure 2]. Based on negative images and M. leprae in globi on Fite stain, cytological diagnosis of lepromatous leprosy was rendered. The case was then referred to dermatology OPD, and the diagnosis of lepromatous leprosy was confirmed on biopsy.
Figure 1: Giemsa-stained smears showing intra- and extra-cellular-negative images (×400)

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Figure 2: Fite stain showing acid-fast bacilli (×1000)

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Demonstration of “negative images” in unsuspected cases raises the suspicion of leprosy and should prompt a cytologist to use special stains to demonstrate acid-fast bacilli (AFB). Negative images of mycobacteria are seen in leprosy and atypical Mycobacterium avium in AIDS. The negative staining is possibly due to high lipid content of the mycobacterial cell wall. Lepromatous leprosy should be distinguished from cutaneous leishmaniasis and xanthogranulomatous lesions which also present as dermal nodules and may show foamy histiocytes on microscopy.[3] However, cutaneous leishmaniasis will show LD bodies and xanthogranulomatous lesions will show Touton giant cells and both will be AFB negative.[3] FNAC is a simple and safe technique and has been described as a useful tool for the diagnosis of leprosy in skin lesions and nerves.[4]

Although the “gold standard” for the diagnosis and classification of leprosy to date is histological examination of skin biopsy in correlation with the bacteriological indices, however, studies have shown that FNAC can play an important role in the early diagnosis and management of leprosy.[4] Singh et al. in 1995 attempted the cytological diagnosis and classification of leprosy and found 100% cytohistological concordance. Rao et al. also evaluated the utility of FNAC in the classification of leprosy and found 90% concordance in cases of tuberculoid leprosy, and 93.75% concordance was observed in lepromatous leprosy.[5]

The importance of negative images should be realized by young budding cytopathologists who may mistake these negative images as artifacts in the smear and may misdiagnose the case. Negative images provide a very important diagnostic clue, and cytopathologist should be very careful in the diagnosis.

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There are no conflicts of interest.

   References Top

Chimenos Küstner E, Pascual Cruz M, Pinol Dansis C, Vinals Iglesias H, Rodríguez de Rivera Campillo ME, López López J, et al. Lepromatous leprosy: A review and case report. Med Oral Patol Oral Cir Bucal 2006;11:E474-9.  Back to cited text no. 1
Jain S. Lepromatous leprosy with palatal perforation: A rare presentation. Egypt Dermatol Online J 2014;10:8.  Back to cited text no. 2
Singh N, Arora VK, Ramam M. Nodular lepromatous leprosy: Report of a case diagnosed by FNA. Diagn Cytopathol 1994;11:373-5.  Back to cited text no. 3
Gulati A, Kaushik R, Kaushal V. Cytological diagnosis of lepromatous leprosy: A report of two cases with review of literature. J Cytol 2012;29:203-4.  Back to cited text no. 4
[PUBMED]  [Full text]  
Rao IS, Singh MK, Gupta SD, Pandhi RK, Kapila K. Utility of fine-needle aspiration cytology in the classification of leprosy. Diagn Cytopathol 2001;24:317-21.  Back to cited text no. 5

Correspondence Address:
Gaurav Singla
Department of Pathology, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPM.IJPM_363_16

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