Leprosy in the Eastern United States
- William R. Levis, MD;
- Eduardo A. Vides, MD;
- Aloys Cabrera, RN
To the Editor: While leprosy is known to have been transmitted in Louisiana, Texas, Hawaii, and possibly California, it is not yet endemic in the eastern United States.1 Exogenous cases of leprosy have been found in the New York City area for some time,2 but before 1996 no secondary transmission of leprosy had been documented in this area. Since then, however, we have diagnosed 2 new cases of lepromatous leprosy in people living on the East coast, neither of whom had any obvious history of exposure to this disease.
Report of Cases
The first patient was a 74-year-old woman who had lived her entire life in New Jersey, where she had worked for 17 years as a nurse in an infectious disease unit. Her only overseas travel was a 1-week tour of China, where she stayed in tourist hotels and was not directly exposed to anyone with leprosy. The second patient was a 73-year-old retired chemist who had lived exclusively in New York City and Virginia and had no history of overseas travel. He had had a long history of hypogonadism and hypothyroidism, both of which were likely secondary, in retrospect, to lepromatous leprosy.
Both patients met the following diagnostic criteria: (1) a typical infiltrative skin lesion, (2) positive histology and Fite stains, (3) positive polymerase chain reaction for Mycobacterium leprae, and (4) erythema nodosum leprosum that responded to treatment with thalidomide.
Comment
Leprosy, or Hansen disease, is a chronic granulomatous disease. Transmission is thought to require repeated contact with the etiologic M leprae organisms. The typical skin lesion is an inflammatory dermatosis that is always without scales, which differentiates it from psoriasis, eczema, and other more common dermatoses. The diagnosis cannot be made without skin biopsy. Because the organisms may not appear with more common acid-fast staining, a Fite stain must be ordered,3 and the pathologist should be made aware of the clinical suspicion of leprosy. Other accompanying signs and symptoms may include peripheral neuropathy, autoimmune endocrinopathy, and arthralgias. Patients may have false-positive antinuclear antibody tests, leading to an incorrect diagnosis of lupus erythematosus. North American clinicians should suspect leprosy in patients who present with these findings, even if they have no obvious risk factors for the disease.
