Spontaneously occurring chronic non-healing cutaneous ulcers in an Indian male

A 45-year-old Indian male presented with multiple asymptomatic non-healing ulcers over both elbows and knees and dorsa of hands and feet (Figure 1). These ulcers started spontaneously 2 years ago and were slowly progressing since then. He was treated with multiple courses of antibiotics and wound care without any success. On cutaneous examination we noted four discrete, firm subcutaneous nodules present on the back; also noted were bilaterally thickened, non-tender, ulnar, superficial cutaneous branch of radial, common peroneal and posterior tibial nerves (Figure 2). There was also hypoesthesia in a glove and stocking distribution. Further systemic examination did not reveal any abnormality. His past and family history were not significant. All relevant laboratory tests were within references ranges and tests for coagulation panel, vasculitis and viral markers as well as arterial and venous studies were negative. Wound swab did not reveal growth of any organism. A nerve conduction study showed predominantly axonal sensorimotor polyneuropathy. A biopsy taken from a nodule on the back showed a thinned out epidermis with spindle-shaped histiocytes forming whorls in the dermis, suggestive of histoid leprosy (Figure 3). Slit skin smear showed abundant acid fast bacilli on Zeihl-Neelsen stain (Figure 4).