“Itching” lepromatous leprosy in an elderly man: the importance of dermatologic and neurological examination and the diagnosis’ suspicion.

Abstract

Introduction: Polar lepromatous leprosy (LLp) is a clinical form which the diagnosis is very difficult in early stages, since nerve damage is not seen, and there are not visible plaques. We report a case with atypical symptoms in an elderly man: the  ruritus. Case report: Male, 81 years, caucasian, coming from Iti- Male, 81 years, caucasian, coming from Itirapina - SP, referred to the dermatological service with the diagnosis of “allergy”, reported that two years ago noted the presence of papules, plaques and nodules on the body, associated with intense pruritus, more pronounced on the lesions. Physical examination revealed diffuse livedo (which was not seen only on the area of the Michaelis polygon), as weel as acrocyanosis, madarosis, papules, plaques, and erythematous-violaceous nodules on the abdomen, perimamilar region, legs and buttocks. On neurological examination it was noted nerves thickening: both ulnars, radials, tibials, and left fibular. He had no ulnar claw and sensitivity test monofilaments showed no loss of tactile sensitivity on the hands, or even loss of protective sensitivity on the feet. Bacilloscopy of smear from index points ranged from 3-5+, with morphological index = 3%. The Mitsuda test was negative, and biopsy of the lesions showed LL. Discussion: The LLp is the most infectious form of leprosy, and it is the most difficult to make diagnosis, mainly when do not suspected. The virtual lack of immunity allows the bacilli proliferate in the nerve cell for nearly a decade, on average, without typical symptoms (lumps, “stains”, neuritis or deformities). Although atypical symptom, mucocutaneous xerosis can cause itching, and neurovascular involvement leads to livedo reticularis and acrocyanosis, signs that should alert the clinician to the diagnosis, especially if there is presence of spared areas of infiltration / livedo, like armpits, scalp and Michaelis polygon, very suggestive of LL. The neurological examination always shows diffuse thickening neural and skin smear is always very positive.