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The diagnostic dilemma of erythema nodosum leprosum - a clinicohistological study

Abstract

Background: Erythema nodosum leprosum (ENL) is a common complication among leprosy patients. It is diagnosed based on clinical findings and biopsy is performed only in patients with atypical presentation or doubtful diagnosis. This study was undertaken to describe the key clinical and pathological features in doubtful and severe cases of ENL.
Materials and methods: Biopsies of all diagnosed ENL cases over the past 10 years (January 2005 to July 2014) were reviewed along with the related clinical features.
Results: A total of 1195 leprosy patients were registered in the leprosy clinic of our institute over this period, amongst whom 233 cases of ENL (19·5%) were diagnosed; a biopsy was performed in 37 cases (15·8%). Of these 37 cases, the diagnosis of ENL was doubtful in 32 cases with the absence of typical erythematous nodules. Frequent histological findings in doubtful cases included stromal neutrophilic infiltrate (31/32, 97%), panniculitis (81%) and vasculitis of varying degree (24/32, 75%). Neutrophilic infiltration within the granuloma and eosinophilic infiltrate (nine cases each, 27%) were relatively less common. Among five cases with severe presentation, four had suppurative ENL with neutrophilic abscess within the dermis and one presented with ulcers and epidermal necrosis.
Conclusion: Besides vasculitis, panniculitis and varying degrees of neutrophilic infiltrate, which are diagnostic features of ENL, eosinophilic infiltrate and stromal oedema are reliable early diagnostic clues for ENL on histopathology. As ENL can be the initial presentation of leprosy, an adequate biopsy including subcutaneous fat is required for a definite diagnosis, in the absence classical clinical features.

More information

Type
Journal Article
Author
Chatterjee D
Saikia UN
Narang T
Dogra S