Tuberculoid leprosy presenting as a “racket” lesion^*

Abstract

The "racket" lesion is a rare presentation of tuberculoid leprosy, which consists of a thickened nerve branch emerging from a tuberculoid plaque. It results from centripetal damage to cutaneous nerves caused by granuloma formation. We describe a typical case of tuberculoid leprosy presenting as a "racket" lesion. The lesion persisted after treatment with paucibacillary multidrug therapy.

Keywords:
Leprosy, paucibacillary; Leprosy, tuberculoid; Peripheral nerves

CASE REPORT

A 38-year-old man had a 2-year history of well-defined annular plaque in the medial dorsal region of his left hand. The plaque had erythematous borders consisting of grouped papules and its infiltration gradually decreased towards the normochronic, atrophic center. There was pronounced sensory loss at the site. We also observed a significant thickening of the dorsal branch of the radial nerve emerging from the plaque, which characterizes the "racket" lesion (Figures 1 and 2). The patient had undergone treatment with multidrug therapy paucibacillary in the past 6 months. Complementary tests revealed negative sputum smear microscopy and 11.5 mm Mitsuda reaction. Skin biopsy showed the formation of tuberculous granuloma and associated type 1 reaction (Figures 3 and 4).

FIGURE 1
“Racket” lesion: Circular plaque with papulous well-defi ned borders in the medial dorsal region of the left hand. Signifi cant thickening of the dorsal branch of the radial nerve (arrow)

FIGURE 2
“Racket” lesion, typical of tuberculoid leprosy

FIGURE 3
Pathological examination of a fragment of the border of the skin lesion: Superfi cial and deep tuberculoid granulomas along the neural pathway (HE, 40X)

FIGURE 4
Pathological examination of a fragment of the border of the skin lesion: A) Tuberculoid granuloma with epithelioid macrophages in the center and a large number of lymphocytes and monocytes in the periphery; B) Tuberculoid granuloma with central necrosis (HE, 400X)

DISCUSSION

The "tennis racket" lesion is a typical presentation of tuberculoid leprosy. It consists of a thickened nerve branch emerging from a tuberculoid plaque and results from centripetal damage to cutaneous nerves caused by granuloma formation.^1,2,3

In paucibacillary patients, the evolution of neural lesions is not always related to multidrug therapy, as in the case presented here, in which the lesion persisted after the treatment had been discontinued. Its persistence is justified because the amount of bacilli in tuberculoid forms of leprosy is minimal, and antimicrobial drugs only act on metabolically active bacilli. Thus, bacterial destruction is independent from the therapy used in the treatment of this group of patients. This explains the spontaneous healing observed in patients in the "pre-dapsone" era.^4,5,6

However, the authors emphasize that, despite the possibility of spontaneous regression of tuberculoid leprosy, all patients should be treated and have their contacts examined in order to identify new cases of leprosy.

• Financial Support: None.
• How to cite this article: Brandão LSG, Marques GF, Barreto JA, Coelho APCP, Serrano APP. Tuberculoid leprosy presenting as a “racket” lesion. An Bras Dermatol. 2015; 90(3):420-2.
• *
  Study conducted at the Lauro de Souza Lima Institute (ILSL) – Bauru (SP), Brazil.

Reference

• ¹
  Carneiro APS, Correia MMS, Cury Filho M, Marcos EVC, Souza FC, Nogueira MÊS, et al. Tuberculoid leprosy presenting as a racket lesion: report of a typical case. Hansen Int 2008;33:35-40.
• ²
  Sa N, Silva AK, Averbeck E, Guerini M. "Racket" lesion reaction in a dimorphic tuberculoid leprosy patient. J Am Acad Dermatol. 2011;64: AB99.
• ³
  Scollard DM, Adams LB, Gillis TP, Krahenbuhl JL, Truman RW, Williams DL. The continuing challenges of leprosy. Clin Microbiol Rev. 2006;19:338-81.
• ⁴
  Opromolla DVA. Ação terapêutica das drogas anti-hansênicas e evidências de persistência microbiana nos casos paucibacilares. Hansen Int. 2004;29:1-3.
• ⁵
  Araújo MG. Hanseníase no Brasil. Rev Soc Bras Med Trop. 2003;36:373-82.
• ⁶
  Opromolla DV, Tonello CJ.Antibiotics in leprosy, with special reference to rifampicin. Lepr Rev. 1975;46:141-5.

Publication Dates

• Publication in this collection
  June 2015

History

• Received
  26 Jan 2014
• Accepted
  14 May 2014