Medical mystery: Tingling, hair loss, and an ancient diagnosis

hs1mystery08
This handout image shows skin lesions on a 41-year-old man who went to the doctor complaining of tingling in his hands and feet.

A 41-year-old man noticed tingling in his hands and feet for a couple of years before deciding he ought to seek medical treatment.  He had emigrated from Costa Rica to Philadelphia 10 years prior, and had been working as a house painter. He feared that exposure to paint or other chemicals might be responsible, but put off seeing a doctor because he didn't have health insurance.

Doctors ordered tests to determine the tingling’s cause, but the results were all normal for common conditions such as diabetes. His doctors then began to notice some skin changes, mostly a scaly, thick spot on his right leg. His earlobes, fingertips, and toes looked a little red, too, though those changes were more subtle.

They sent him to our dermatology practice, and we noticed something else: the man had virtually no eyebrows or eyelashes. The patient did not seem particularly bothered by this hair loss, though — he was focused on the tingling in his hands and feet.

We performed biopsies on the leg lesion, and ordered more blood tests to figure out what happened to his brows and lashes. Was one diagnosis responsible for his odd array of symptoms, or did he have several unrelated problems?


Solution:

This patient’s skin biopsy findings revealed collections of cells, known as granulomas, around his skin’s blood vessels and nerves. A special red dye known as Fite staining highlighted bacterial organisms.  These findings confirmed a diagnosis of lepromatous leprosy, also known as Hansen’s disease.

Though often thought of as a historical disease, leprosy is still common in some regions.  According to the World Health Organization, there were more than 200,000 new cases reported in the world in 2014, especially in India and Brazil.

But in the United States, it is a rare condition. There were 175 new cases reported in 2014, with 62 percent of these occurring in immigrants. Cases are especially focused in southern states such as Florida, Texas, and Louisiana. Research suggests that the nine-banded armadillo, native to those areas, has transmitted the disease to humans. 

Despite its dread reputation throughout history, leprosy doesn't pose a public health threat today, especially in the U.S.  "Leper colonies" are a thing of the past, as leprosy patients do not need to be quarantined. The condition is rarely fatal, and difficult to transmit. It has a long incubation period — an average of 10 years. It can cause severe disability through loss of sensation, tingling, and loss of strength, all related to nerve damage. But as our patient's case illustrates, it is curable long before such serious damage takes place.

We referred him to the National Hansen’s Disease Clinical Center in Louisiana, where doctors put him on a triple antibiotic regimen (dapsone, rifampin, and clofazimine) and then sent him home to Philadelphia, where he is back at work. The medication regimen lasts two years; he travels to Louisiana every 6 months for checkups. His tingling sensations have improved, though his eyebrows and eyelashes have been slow to grow back.

Jules Lipoff, M.D.,  is an assistant professor of clinical dermatology in the Perelman School of Medicine at the University of Pennsylvania. Find him on Twitter @juleslipoff. This case was published this month in JAMA as a “Clinical Challenge,” and you can find a more detailed account on the journal’s website.

Continue Reading