Lepromatous lymphadenitis masquerading as lymphoma.
ABSTRACT A 70-year-old male presented with multiple lymphadenopathy and a strong clinical suspicion of non-Hodgkin's lymphoma. Cervical and axillary nodes were excised and were sent for histopathological evaluation, which revealed aggregates of lepra cells loaded with lepra bacilli. Clinicians practising in leprosy endemic areas should keep lepromatous lymphadenitis in mind while investigating patients with lymphadenopathy.
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ABSTRACT: The question was raised as to why 'obvious' signs of leprosy, Hansen's disease (HD), are often missed by medical doctors working in a HD endemic area. This study describes a small sample of patients who were diagnosed with HD during their hospital admission and not before. The discussion is whether the typical early signs and symptoms of HD are just not recognized, or whether unusual presentations confuse the attending physician. A total of 23 HD patients were hospitalized during the study period, of which 6 (26%) were only diagnosed with HD during their admission. All were classified as lepromatous leprosy (LL) with a history of signs and symptoms of HD. In nearly all patients, a suspicion of HD might have been raised earlier if a careful history and dermato-neurological examination had been done. Multibacillary (MB) HD, especially close to the lepromatous end of the spectrum, may mimic other diseases, and the patient can not be diagnosed without a biopsy or a slit skin smear examination. Clinicians working in a HD endemic area (Rio de Janeiro) do not always include HD in their differential diagnosis, especially when the clinical presentation is unusual. HD should be considered in all patients with skin lesions not responding to treatment, especially when they have neurological deficits, and live or have lived in an HD endemic area. Due to the increase in global travel and immigration, doctors in low endemic areas need to consider HD as a possible diagnosis.Journal of the European Academy of Dermatology and Venereology 10/2008; 23(2):150-6. · 2.69 Impact Factor
Lepromatous lymphadenitis masquerading as
NIPIN BAGLA, MANDAKINI M. PATEL,
RAJNIKANT D. PATEL & MAYUR JARAG
Department of Pathology, Government Medical College, Majura
Gate, Surat-395001 (Gujarat), India
Accepted for publication 15 November 2004
strong clinical suspicion of non-Hodgkin’s lymphoma. Cervical and axillary nodes
were excised and were sent for histopathological evaluation, which revealed
aggregates of lepra cells loaded with lepra bacilli. Clinicians practising in leprosy
endemic areas should keep lepromatous lymphadenitis in mind while investigating
patients with lymphadenopathy.
A 70-year-old male presented with multiple lymphadenopathy and a
Leprosy, first described in ancient Indian texts from the 6th century B.C., is a non-fatal,
chronic infectious disease caused by Mycobacterium leprae, whose clinical manifestations
are largely confined to the skin, peripheral nervous system, upper respiratory tract, eyes and
testes.1Leprosy most commonly presents with both characteristic skin lesions and skin
histopathology. The disease should be suspected when a patient from an endemic area has
suggestive skin lesions or peripheral neuropathy.1However, this disease can even mimic
lymphoma clinically, as can be seen in the following case report.
Materials and methods
Supraclavicular and axillary lymph nodes were excised surgically and were transported in
10% formalin. Formalin-fixed and paraffin-embedded 5mm thick sections were made. These
sections were stained with haematoxylin and eosin (H&E) and modified Ziehl–Neelsen
techniques, and were examined by a light microscope.
A 70-year-old illiterate male presented with chest pain, fever, cough, right axillary swelling
and bilateral leg oedema. On examination, cervical, supraclavicular, axillary and inguinal
Correspondence to: N. Bagla, D-3 Staff Village, Royal Preston Hospital, Sharoe Green Lane, Preston PR2 9HT,
UK (e-mail: email@example.com)
Lepr Rev (2005) 76, 87–90
lymph nodes were enlarged. The average size of these lymph nodes was approximately
3 £ 3cm. Considering the age of the patient and the presence of generalized
lymphadenopathy, the clinicians strongly suspected a non-Hodgkin’s lymphoma (NHL).
The supraclavicular lymph node was excised and sent for histopathological evaluation.
We received a 3 £ 3cm lymph node, the cut surface of which was homogenous
gray-white. Microscopic evaluation of sections stainedby H&E revealedaggregates of foamy
histiocytes (Figure 1) surrounded by plasma cell infiltrate. These foamy histiocytes resembled
the lepra cells seen in skin biopsies of patients with lepromatous leprosy. Therefore, a
modified Ziehl–Neelsen stain was performed. The foamy histiocytes were packed with acid-
fast lepra bacilli (Figure 2). No evidence of a neoplastic process in the lymph node was found.
After the histopathology report of lepromatous leprosy, the patient was referred to the
dermatology department for further evaluation. Multiple skin lesions were found all over the
body, which were dry and icthyotic with loss of hair. There was sensory loss to touch and
painful stimuli over both the lower extremities. Left common peroneal and posterior tibial
nerves were thickened. A skin biopsy was done which revealed lepromatous leprosy with
lepra bacilli in the lepra cells. Slit skin smears were not performed. The patient did not have
any documentary evidence of his past medical history. On probing, he revealed that he had
been prescribed drugs for leprosy a few years ago, and he had been asked for a follow-up visit
after 1 month. However, he neither took the drugs regularly nor went for the follow-up.
The patient did not give any history of high-risk behaviour or exposure, and serological test
for HIV was not performed.
The surgeons, still suspecting a coexisting NHL, excised the axillary lymph node and sent
it for histopathology. Even this lymph node revealed the same morphology as the
supraclavicular lymph node.
Figure 1. Aggregates of lepra cells (arrows) in lymph node. Stain: haematoxylin & eosin. Magnification £ 400.
N. Bagla et al.88
Lymph node involvement in lepromatous leprosy has a very characteristic microscopic
appearance. The main change is the progressive accumulation of large, pale, rounded
histiocytes (‘lepra’ or ‘Virchow’ cells), without granuloma formation and with minimal or no
necrosis. Wade–Fite and File–Farasco stains (modified Ziehl–Neelsen reactions)
demonstrate packing of the cytoplasm by acid-fast organisms. Nevertheless, it is very
unusual to diagnose leprosy primarily by lymph node biopsy.2Although lymph nodes have
been reported to be moderately enlarged in leprosy, in the experience of W. H. Jopling and
A. C. McDougall, enlargement is confined to phases of lepra reaction and then there is
marked swelling and tenderness, especially of femoral and inguinal groups.3
In the present case, the morphology is clearly that of lepromatous leprosy. As in the
present case, if a surgeon encounters generalized lymphadenopathy in an elderly patient, with
no overt skin lesions or deformities, he is unlikely to suspect leprosy. A clinical suspicion for
lymphoma would be more likely. Leprosy is most prevalent in developing nations, and in
rural and poor societies with a high degree of illiteracy. A reliable detailed history is usually
not forthcoming in these patients. Moreover, if the clinician does not suspect leprosy, he is
unlikely to perform a detailed neurological examination. Only a detailed history and
examination can avoid misdiagnosis and mismanagement in such patients. Leprosy is a non-
fatal and treatable condition, while lymphoma is a malignancy.
M. leprae has not been shown to predispose patients to an increased risk of neoplasia,4
and Hodgkin’s lymphoma has rarely been reported in patients with leprosy.5In contrast,
several cases of leprosy have been reported in patients with T-cell non-Hodgkin’s
lymphoma.6In the present case, leprosy preceded the lymphadenopathy by many years.
Figure 2. Clustered lepra bacilli (globi) in lepra cells (arrows). Stain: modified Ziehl–Neelsen.
Magnification £ 1000.
Leprosy mimics lymphoma 89
Therefore, it is unlikely that leprosy could have developed in the background of an
To summarize, leprosy can manifest as generalized lymphadenopathy and clinicians
practicing in endemic areas should bear this fact in mind.
We are deeply indebted to Dr Viral Patel for collecting all the relevant clinical data. This case
report would have been incomplete without his contribution.
1Gelber RH. Leprosy (Hansen’s disease). In: Braunwald E, Fauci AS, Kasper DL et al. (eds). Harrison’s principles
of internal medicine, 15th edn. McGraw-Hill, New York, 2001, pp. 1035–1040.
2Rosai J. Lymph nodes. In: Rosai J (ed.) Ackerman’s surgical pathology, 8th edn. CV Mosby, St Louis, 1999,
3Jopling WH, McDougall AC. The disease. In: Jopling WH, McDougall AC (eds). Handbook of leprosy, 5th edn.
CBS Publishers, New Delhi, 2000, pp. 10–49.
4Miller RA. Leprosy (Hansen’s disease). In: Isselbacher KJ, Braunwald E, Wilson JD et al.(eds). Harrison’s
principles of internal medicine, 13th edn. McGraw-Hill, New York, 1994, pp. 718–722.
5Levy ML, Rosen T, Tschen JA et al. Hansen’s disease following lymphoma. J Am Acad Dermatol, 1986; 15:
6Grossman D, Rapini RP, Osborne B, Duvic M. Emergence of leprosy in a patient with mycosis fungoides.
J Am Acad Dermatol, 1994; 30: 313–315.
N. Bagla et al. 90