CASE PRESENTATION
We present a case of 20 years old female from the Hilly terrain of Dolakha presented to out -patient department ofDolakha Hospital, an outreach center of Dhulikhel Hospital on 15th May, 2021.She presented with chief complaints of acne like lesions (maculopapular lesions, pustules and later nodules) on face since 2 years which gradually progressed to back, and flexor surface of lower limbs bilaterally (FIGURE 1 ) (FIGURE 2 ) (FIGURE 3 ).The lesions first noted on her face were comedones, papules,pustules and gradually developed to nodules on face, back and
flexor surface of lower limbs. Her past medical history was uneventful and she had neither significant family history nor contact history with Tuberculosis patients, Leprosy or Sexually Transmitted Infections(STDs). There was no history of weight loss, loss of appetite, hair fall, loss of eyebrows, loss of sensation, hypo pigmented areas, thickening of nerves, loss of motor function, lethargy. She had been using Topical Retinoic Acid Gel 0.25% on face for acne, based on advice from friends along with topical application of Herbs from traditional healers for 2 years prior to consultation in our hospital. There was no use of antibiotics or any other medication.
On examination, her general condition was fair. There were multiple maculopapular lesions, pustules, nodules, face, lower back and lower part of lower extremities. Perineal lesions were absent. Lymphadenopathy was not present, patient was afebrile and there was no organomegaly. Routine tests CBC(complete blood count), LFT, RFT,UREME, total count, Culture of sputum, Mantoux tests were sent which all yielded normal results.However  ESR and TSH were raised and differential count showed lymphocyte predominance. Serology(HbSAg, HIV, VDRL) was non-reactive and chest radiograph was also within normal limits. Laboratory markers are presented in the table (TABLE 1 ).
On history taking retrospectively from the past 2 years,treatment with Topical Retinoic Acid Gel 0.25% with application of herbal pastes had shown no improvement and  there was gradual spread of lesions.The presenting findings were suggestive of Acne Vulgaris, Cutaneous Tuberculosis,Leprosy, Sarcoidosis, SLE, Granuloma Annulare, fungal infection.
Patient was offered Excisional biopsy of skin lesions for HPE which showed Lepromatous Leprosy.
Skin biopsy specimen consisted of single piece of skin covered tissue measuring 0.3 cm. Entire specimen was submitted in two sections. Sections showed orthokeratotic epidermis with basal layer with melanin pigmentation. Subepithelially, band of collagen fibres forming Grenz zone were seen(FIGURE 4 ). Underlying dermis showed lymphohistiocytotic clusters with dense perivascular and periadnexal lymphocytic infiltrations with neural tissue destruction (FIGURE 5 ). Granuloma was not seen. Stain for AFB Leprae was positive (FIGURE 6 ). Bacillary Index was 3 (1 to 10 per HPF)
Leprosy though eliminated is fairly common in this part of the world hence in view of this patient was referred to Anandaban Hospital which is a national center where state of the art treatment is provided free of cost to patients.
InAnandaban Hospital, detailed history was taken and examination was done. Contact and Family history were ruled out. Repeat biopsy was taken which showed features consistent with Lepromatous Leprosy. On examination multiple lesions were found on face, back, legs, however other telltale signs of Leprosy such as hypochromic anesthetic skin patches, thickening of nerve, loss of sensation, loss of motor function, amputation of limbs or nasal septum,loss of eyebrows, clawing, visible deformities were absent. A large number of acid-fast bacilli were present in the slit skin smears (BI: 3+)  taken from left lower limb .Patient was diagnosed and confirmed as a case of Lepromatous Leprosy with BI 3+ based on HPE report of skin.
She was given Multibacillary Multidrug therapy which consists of the following regimen:Rifampicin 600 mg PO once a month, Dapsone 100 mg PO once a day, Clofazimine 300 mg PO once a month and Clofazimine 50 mg PO once a day for 12 months. She is doing well and responding well to the treatment with visible decrement of nodules on face and limbs. There has been no intolerance to medications provided in course of the treatment.