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    Grouped crusted papules and plaques on the trunk of the patient on a background of infiltrated skin. This figure appears in color at www.ajtmh.org.

  • View in gallery

    Erythematous papules and nodules with overlying small crusts on palms and fingers of the patient. This figure appears in color at www.ajtmh.org.

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    Discrete erythematous papules may be seen on the face and neck, whereas they are coalescent and crusted on the ear helix. There is infiltration of the skin on the face and ears, with madarosis and depressed nasal bridge. Thickened greater auricular nerve is visible on the neck (red arrowheads). This figure appears in color at www.ajtmh.org.

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    Ziehl–Neelsen staining of slit-skin smear revealing the presence of acid-fact bacilli in groups and as globi (bacteriological index -6+; ×100). This figure appears in color at www.ajtmh.org.

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    Scabies mite on KOH mount (×40). This figure appears in color at www.ajtmh.org.

  • 1.

    Workowski KA, Bolan GA, 2015. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 64: 1137.

  • 2.

    Roberts LJ, Huffam SE, Walton SF, Currie BJ, 2005. Crusted scabies: clinical and immunological findings in seventy-eight patients and a review of the literature. J Infect 50: 375381.

    • Search Google Scholar
    • Export Citation
  • 3.

    Park H, Lee C, Park S, Kwon H, Kweon SS, 2016. Scabies among elderly Korean patients with histories of leprosy. Am J Trop Med Hyg 95: 7576.

 

 

 

Lepromatous Leprosy with Crusted Scabies

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  • 1 Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

A 36-year-old vegetable vendor presented with asymptomatic crusted lesions on the skin of 2-month duration. On examination, there were grouped crusted papules and plaques all over the body (Figure 1), including palms (Figure 2), soles, ear helix (Figure 3), and genitals, on the background of infiltrated skin. Nervous system examination revealed thickened peripheral nerves and a glove-and-stocking pattern of sensory loss without any motor weakness. Slit-skin smear from the papules on the trunk showed acid-fast bacilli (bacteriological index -6+; [Figure 4]), and potassium hydroxide mount of scrapings from hands and the trunk revealed scabies mite (Figure 5). The test for HIV was negative. A diagnosis of lepromatous leprosy with crusted scabies (CS) was rendered, and he was started on an anti-scabetic regimen for CS as per CDC guidelines1 (daily topical 5% permethrin application for 7 days followed by twice weekly for 2 weeks, with oral ivermectin 12 mg on days 1, 2, 8, 9, and 15) along with the WHO multidrug therapy–multibacillary regimen for leprosy (monthly supervised doses of rifampicin 600 mg, dapsone 100 mg, and clofazimine 300 mg, followed by daily dapsone 100 mg and clofazimine 50 mg, for 12 months) with improvement in symptoms. All close contacts were screened for leprosy and treated for scabies as well.

Figure 1.
Figure 1.

Grouped crusted papules and plaques on the trunk of the patient on a background of infiltrated skin. This figure appears in color at www.ajtmh.org.

Citation: The American Journal of Tropical Medicine and Hygiene 103, 6; 10.4269/ajtmh.20-0763

Figure 2.
Figure 2.

Erythematous papules and nodules with overlying small crusts on palms and fingers of the patient. This figure appears in color at www.ajtmh.org.

Citation: The American Journal of Tropical Medicine and Hygiene 103, 6; 10.4269/ajtmh.20-0763

Figure 3.
Figure 3.

Discrete erythematous papules may be seen on the face and neck, whereas they are coalescent and crusted on the ear helix. There is infiltration of the skin on the face and ears, with madarosis and depressed nasal bridge. Thickened greater auricular nerve is visible on the neck (red arrowheads). This figure appears in color at www.ajtmh.org.

Citation: The American Journal of Tropical Medicine and Hygiene 103, 6; 10.4269/ajtmh.20-0763

Figure 4.
Figure 4.

Ziehl–Neelsen staining of slit-skin smear revealing the presence of acid-fact bacilli in groups and as globi (bacteriological index -6+; ×100). This figure appears in color at www.ajtmh.org.

Citation: The American Journal of Tropical Medicine and Hygiene 103, 6; 10.4269/ajtmh.20-0763

Figure 5.
Figure 5.

Scabies mite on KOH mount (×40). This figure appears in color at www.ajtmh.org.

Citation: The American Journal of Tropical Medicine and Hygiene 103, 6; 10.4269/ajtmh.20-0763

Crusted scabies is a highly contagious variant of scabies wherein the host immune response fails to control the proliferation of the mites in the skin, resulting in hyper-infestation and an inflammatory reaction. It is seen mostly in immunocompromised elderly or physically incapacitated individuals. Leprosy has been among the diseases that predispose to CS, hypothesized to be due to a predominant T-helper-type of immune response, especially in lepromatous leprosy.2 In addition, overcrowding and poor socioeconomic conditions are predisposing factors for both diseases. In a study of scabies in elderly patients with a history of leprosy, 66% belong to the lepromatous spectrum.3 Another study of 78 patients with CS reported 17% of patients to have had leprosy.2

Both leprosy and scabies are neglected tropical diseases. Leprosy in addition is associated with significant stigma and discrimination. These patients are often poor and neglected by their own families and the society at large, predisposing them to other infections and infestations such as scabies, adding to their overall morbidity.

REFERENCES

  • 1.

    Workowski KA, Bolan GA, 2015. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 64: 1137.

  • 2.

    Roberts LJ, Huffam SE, Walton SF, Currie BJ, 2005. Crusted scabies: clinical and immunological findings in seventy-eight patients and a review of the literature. J Infect 50: 375381.

    • Search Google Scholar
    • Export Citation
  • 3.

    Park H, Lee C, Park S, Kwon H, Kweon SS, 2016. Scabies among elderly Korean patients with histories of leprosy. Am J Trop Med Hyg 95: 7576.

Author Notes

Address correspondence to Muthu Sendhil Kumaran, Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Nehru Hospital, Sector 12, Chandigarh, 160012, India. E-mail: drsen_2000@yahoo.com

Authors’ addresses: Raihan Ashraf, Tarun Narang, and Muthu Sendhil Kumaran, Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India, E-mails: raihanash91@gmail.com, narangtarun@yahoo.co.in, and drsen_2000@yahoo.com.

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