Borderline tuberculoid leprosy

Three cases which bear on the unsettled question of the transformation of tuberculoid leprosy to the lepromatous type are presented. Two of them have been for long periods in a peculiarly unstable, "borderline" condition, repeatedly suspected of becoming lepromatous. The third one presented, in the phase here dealt with, as at one time one of the others did to a less extent, lesions of peculiar, atypical morphology and histology that are designated as "relapse tuberculoid". The persistently borderline cases have long been characterized mainly by repeated reactions of more or less mild degree and repeated, at times continuous, eruptions of papular lesions, the earlier large leprids having subsided relatively early in the course of the disease. The papular elements have usually not been discrete, but diffused peripherally, and when acute they have ordinarily yielded numerous to abundant bacilli; yet they have regularly receded spontaneously or yielded promptly to local treatment in the way of papular leprids, while the new ones appeared coincidentally or in later eruptions. Histologically most of them have been indeterminate, neither tuberculoid nor frank lepromatous. Seldom have they shown any attempt to anlarge, but that development has been seen. At one time in Case 1 a few become miniature circinate leprids, of clear-cut tuberculoid. Nor have these cases become lepromatous, though the prognosis remains uncertain. Other lesions of highly atypical, suspicious character appeared during one period in Case 2, and in the third case such lesions were extensive and very striking. With their diffused outlines, abundant bacilli and peculiar histology, they might easily be taken for lepromata; and, with enclosed or adjoining unaffected areas that are know to have been sites of previous major tuberculoid lesions, against which the infiltration is sharply limited, they might seem to have arisen by lepromatous transformation of such earlier lesions; yet they later subsided in the way of leprids. The explanation of the obvious relationship of these "relapse tuberculoid" lesions to the apparently healed, previously tuberculoid areas is a matter of speculation. There is reason to believe that such lesions have at times been taken to be lepromata, thus confusing the picture of transformation of tuberculoid cases if that occurs, which remains to be established satisfactorily...

Bullous tuberculoid leprosy: report of a case, with a discussion of Lazarine leprosy

Our records of the case here reported cover the period from 1930 to the present time, during which period the course of the disease has shown startling developments. In one phase there suddenly appeared numerous bullae, followed by ulceration and finally leading to the formation of a mixture of pigmented, achromic and spotted scars. These phenomena, taken together, used to be regarded by some of the old writers as characteristic of the so-called "lazarine leprosy". The original rapidly spreading macular lesions in our case showed a typical tuberculoid picture both clinically and histologically, with numerous bacilli. The occurrence of bullae in the course of the different types of the disease is discussed. Perhaps because it is commonly known that blisters do sometimes occur in the "pure" neural and the lepromatous types, as well as in acute tuberculoid reaction, "lepra lazarina" is not at present looked upon as a separate type or subtype of the disease and is seldom mentioned. However, the article of Pardo-Castella and Caballero (1931), which described a peculiar monosymptomatic form of the sisease, accompanied by blister formation, which those authors called lazarine leprosy, has awakened anew considerable interest in this old term. Pending restudy of the histology of their cases in the light of current knowledge of tuberculoid leprosy, it is suggested the term lazarine leprosy be limited to this special Cuban form. We have tentatively designated our case as one of bullous tuberculoid leprosy.

Conversion of simple macular neural leprosy to the lepromatous type: a report of three cases

Our observations of these three cases, though incomplete, afford some information regarding the changes occurring when they underwent transformation from the neural to the lepromatous form of the disease. The first one was typically "neurmacular" when first seen, with characteristic lesions that were apparently quiescent and certainly not lepromatous, but during the course of a year they underwent slow, progressive activation, one after the other, and became bacteriologically positive; after that, with "reactional" disturbances of a sort, new ones of lepromatous nature appeared. The second one was almost as definitely neuro-macular when first seen, with a single anesthetic lesion that when biopsied more than a year later was diffusely erythematous (which we would now consider a suspicious condition) but still bacteriologically negative and histologically without suggestion of lepromatous transformation; after another period, somewhat longer, new lesions distinctly of that nature were found, and the patient is now doing far from well. The third case is the simplest up to a certain point, in that when he was first seen the only active lesion (there were two residual ones) was a small recent macule that slowly enlarged for nearly years, when new ones of apparently the same nature appeared; the patient was not seen for three years thereafter, and the events of that period are unknown, but the case has become rather extensively lepromatous...

The course of open cases of tuberculoid leprosy at the Cebu leprosarium

The clinical features and histological findings in eight tuberculoid neural-type cases in the Philippines, that were hospitalized because bacteriologically positive and observed from two to more than six years, are recorded. In seven cases the principal lesions were of major grade, moderate or very marked; but one case, though otherwise essentially similar, was never more than of minor grade. In three, if not four, other cases, after partial subsidence of the condition, some of the lesions progressed as of the minor tuberculoid variety, giving further evidence of lack of fundamental type differentiation of the ordinarily recognized(major) tuberculoid condition from the lesser forms of neuromacular leprosy. In two cases there was unilateral involvement of a nerve trunk of an extremity on which the first lesion appeared further indicating that in this form of the disease such affection may occur by extension through the cutaneous nerves, and not necessarily by metastasis. Onset of the disease was commonplace, in three instances with anesthesia preceding the appearance of macules, which in the group as a whole were usually of the simple form at first. Development of tthe condition that led to hospitalization usually, though apparently not invariably, resulted from reaction, whether mild or severe. Several cases experienced one or more relapses by reaction after they came under observation. A striking feature of the condition, hitherto not emphasized, is a secondary eruption, primarily papular or mixed papular and macular, often abundant, that can be ascribed only to metastatic dissemination of the infecting agent by may of the blood stream...

The status after five years of neural leprosy cases studied in Cebu

Although five years is much too short a time to determine the final outcome in cases of the neural type of leprosy, interesting changes have been observed in many of the 52 cases of the group that we began to study in 1933 and 1934. Of three cases with only anesthetic areas over normal-looking skin, one has shown no change whatever; in another the anesthetic area became a macule; and the last, whose neural manifestations were secondary to a macule that had disappeared four years previous to the initial examinations, now has progressive polyneuritic changes but no skin lesions. Thirteen patients exhibited residual macules, seven of them without atrophy of the involved skin. Four of the latter have become quite negative; one shows new suspicious lesions which, however, failed to show changes pathognomonic of leprosy; two others have developed polyneuritic manifestations. Among the six cases with residual macules that showed atrophy, none of the five that were fully followed up shows any evidence of activity. It seems that leprids which cause severe enough damage to the skin to cause atrophy (lesions that probably were clinically tuberculoid when most active) are of more favorable prognosis than those that do not produce such effects...

Development of major tuberculoid leprosy: a report of cases

In the first of the two cases here presented there were, as late as the fifth year of the disease, only two simple flat macules which at most had been very indolently progressive and which had shown only a very slight tuberculoid condition histologically. Suddenly they flared up in an obvious "reaction" process to become active major tuberculoid plaques, smears showing numerous bacilli, often in small globi. A few months after the patient was hospitalized an eruption of multitudinous small, papular lesions began to appear in crops, evidently as a further reaction condition the causative agent obviously distributed metastatically by the blood stream; they never attempted to expand to produce macules, but subsided. Histologically both the plaques and the papules consisted of a massive tuberculoid granuloma of "intermediate" or reaction type and the papules were of the same nature. From that point, in 1936, retrogression of the lesion was rapid, so that in 1937 they all seemed entirely quiescent if not residual, but until 1938 an occasional smear contained a few bacilli. The patient has now been paroled.