Title : A case of leprosy in North Florida
Abstract:
Introduction
The global prevalence of leprosy, also known as Hansen’s disease is <1/10 000, with the majority of new cases in India, Brazil and Indonesia. It can be broadly categorized as tuberculoid or lepromatous based on histopathological analysis. The USA continues to have approximately 200 new cases a year, concentrated in the southern states and data suggest that leprosy may be endemic to Florida. Human-to-human contact is a potential mode of transmission. However, exposure to armadillos and the Eurasian red squirrel have also been linked to zoonotic spread. We present a case of leprosy in North Florida without travel to an endemic area, contact with a known case or zoonotic exposures.
Case Presentation
A 55-year-old female, living in North Florida, presented with lesions on her arm that she noticed a year ago. Initial biopsy and clinical examination revealed probable granuloma annulare. Twelve months later, the patient was informed that the initial biopsy was positive for Hansen’s disease and she was recalled for follow up and additional biopsies, which confirmed this diagnosis.
Past history was negative for direct exposure to armadillos, gerbils or squirrels. She denied any international travel or exposure to known cases of Hansen’s disease. She had previously lived in central Florida where there was an infestation of tree rats in the attic of her house. She currently lives with two dogs, works in finance and denies participating in any outdoor occupational or recreational activities.
Physical examination revealed multiple itchy macules and patches with central clearance and erythematous borders on the right arm and shoulder. She reported right knee swelling and pain but denied hypoesthesias over the lesions, fever, chills or abdominal pain. Serum vitamin D levels were in the optimal range, and negative for hepatitis and TB. Patient was prescribed rifampin 600 mg, moxifloxacin 400 mg and minocycline 100 mg monthly.
One month later, new lesions were noted on the arms, forehead and right foot. Treatment plan remained unchanged. At the two-month follow-up visit, number and size of lesions remained unchanged, but she reported paresthesias in her hands. Adjunctive methotrexate and low dose prednisone were added to the patient’s regimen.
Discussion and Conclusion
Cases of leprosy in the USA have doubled since 2000, concentrated in the southeastern states. Our patient did not have any of the traditional risk factors, including travel to an endemic area, exposure to armadillos, squirrels, contact with someone who has been to an endemic area or a confirmed case of leprosy. This case adds to the body of literature that supports leprosy being endemic to Florida. Travel to Florida should be considered when investigating for leprosy within the USA, in addition to the typical risk factors. Given the slow progression of leprosy, the possibility of other undiscovered zoonotic reservoirs should also be considered.
Audience Take Away:
- Leprosy, also known as Hansen’s disease is an ancient chronic bacterial disease caused by Mycobacterium leprae or Mycobacterium lepramotosis. While the majority of new cases are in India, Brazil and Indonesia, the United States continues to have approximately 200 new cases a year concentrated in the southeastern states.
- We present a case of leprosy in North Florida without travel to an endemic area, contact with a known case or zoonotic exposures, providing further evidence that leprosy is now endemic to Florida.
