Back to Top Skip to main content Skip to sub-navigation

Case Report: Hansen’s Disease in an Active Duty Soldier Presenting with Type 1 Reversal Reaction

Image of Ulcer along the interspace between the patient’s right index and middle fingers. Photograph courtesy of Brooke Army Medical Center Medical Photography. Click to open a larger version of the image. Ulcer along the interspace between the patient’s right index and middle fingers. Photograph
courtesy of Brooke Army Medical Center Medical Photography.

Recommended Content:

Medical Surveillance Monthly Report

ABSTRACT

Leprosy, or Hansen’s disease (HD), is caused by the bacterium Mycobacterium leprae and is a significant cause of morbidity worldwide. Clinical manifestations range from isolated skin rash to severe peripheral neuropathy. Treatment involves a prolonged course of multiple antimicrobials. Although rare in the U.S., with only 168 new cases reported in 2016, HD remains a prevalent disease throughout the world, with 214,783 new cases worldwide that same year.1 It remains clinically relevant for service members born in and deployed to endemic regions. This report describes a case of HD diagnosed in an active duty soldier born and raised in Micronesia, a highly endemic region.

CASE REPORT

In May 2018, a 21-year-old male soldier presented with right hand swelling and ulcer formation along the interspace between his index and middle fingers while he was deployed to Eastern Europe (Figure 1). He first developed a blister at that site after washing a tank several days earlier, and it subsequently progressed to an ulcer. The ulcer was initially assessed as a third-degree burn, and he was transferred to Brooke Army Medical Center (Joint Base San Antonio-Fort Sam Houston, TX) for management on 11 May 2018. At that time, the patient denied any pain but described gradual loss of sensation to his right hand dating back to January 2018. The patient had been otherwise healthy except for a right hand burn injury during basic training in early 2017, which had completely healed without complications. He denied any close contacts with Hansen's disease (HD). The patient had enlisted in the Army in January 2017 from the Federated States of Micronesia and completed initial entry training in June 2017 at Fort Benning, GA. He completed advanced individual training at Fort Riley, KS, and then was deployed to Europe in November 2017.

In May 2018, the patient successfully underwent full-thickness skin graft of his ulceration but continued to experience edema and eventually lost intrinsic motor function of his right hand. He remained at Fort Sam Houston, where a nerve conduction study in July 2018 revealed severe median, ulnar, and radial neuropathies in the right forearm. Around that time, the patient noticed eruption of annular, hyperpigmented, erythematous plaques on his right medial arm, which spread to his bilateral limbs and trunk (Figures 2a, 2b). These symptoms coincided with new edema and numbness involving his left hand. In September 2018, magnetic resonance imaging revealed perineural edema involving nerve groups of his distal right arm (Figure 3a, 3b). The patient was referred to dermatology, where examination noted thickening of peripheral nerves, including the greater auricular nerve (Figure 4); a clinical diagnosis of HD was made. Skin biopsy showed tuberculoid granulomas extending along adnexal structures and nerves (Figure 5a, 5b). Fite staining was negative for acid-fast organisms. Polymerase chain reaction testing at the National Hansen’s Disease Program (NHDP) was also negative for Mycobacterium leprae. Given his histopathology, edema, and rapid progression of neurologic impairment, the patient was diagnosed with paucibacillary leprosy complicated by type 1 reversal reaction. In consultation with the NHDP, the patient was started on clarithromycin 500 mg daily and minocycline 100 mg daily in October 2018. Prednisone 60 mg daily was started for the patient’s type 1 reversal reaction and neuropathy. Steroids were tapered over the ensuing 6 months, while methotrexate 12.5 mg weekly was added as a steroid-sparing agent.

At follow-up in December 2018, the patient showed improvement in the appearance of his skin lesions and the edema in both hands, with some improvement in motor and sensory exam. At follow-up in May 2019, he remained on clarithromycin, minocycline, and methotrexate. He showed further improvement in the appearance of his skin lesions. However, he continued to have persistent right hand weakness and persistent left ulnar neuropathy. He was referred to the medical evaluation board and was discharged from the Army in August 2019.

EDITORIAL COMMENT

HD is caused by M. leprae. While the disease is endemic in the southern U.S., the majority of cases found here are diagnosed in individuals born outside of the U.S., where exposure is thought to have occurred.2 The Federated States of Micronesia has a high prevalence of HD, and immigrants from Oceanic countries have the highest rates of diagnosis in the U.S.2,3

Skin lesions and peripheral nerve damage are hallmarks of HD. The diagnosis can be made clinically, though histopathology is the gold standard.4 Complications of HD include type 1 reversal reactions, which are associated with increased cell-mediated immune response to M. leprae, leading to increased edema and swelling of peripheral nerves and increased erythema of existing skin lesions.4 This patient’s presenting symptoms of hand edema and ulceration (Figure 1) represented a type 1 reversal reaction that led to significant neurologic impairment.

The treatment of HD typically involves dapsone and rifampin, with or without clofazimine, based on the disease classification.5 Minocycline and clarithromycin are bactericidal against M. leprae6 and have been used as alternative treatments when first-line agents cannot be used because of drug intolerance or, as in this case, drug interactions between rifampin and prednisone.4 The treatment of type 1 reversal reaction typically involves corticosteroids, though the overall efficacy and duration of therapy remain uncertain.7,8

The military provides a unique environment for exposure, as soldiers are often deployed into endemic areas. However, reported cases of HD among U.S. military personnel are rare. The first such reported cases occurred in the Spanish-American War (1898) despite prior conflicts in endemic areas.9,10 Among the 323 reported cases of leprosy in veterans between 1920 and 1968, less than 80 were thought to be service related.9 Among those cases not involving infections after receiving tattoos, only 2 cases involved service members whose length of exposure was reported as less than 1 year.9,10 The Vietnam War brought U.S. soldiers into combat in endemic areas of Southeast Asia, but there are even fewer reported cases among veterans of this conflict, with at least 3 service-related cases.11–13 The low number of cases likely reflected decreased exposure time due to shorter deployments and the use of dapsone for malaria prophylaxis.14 Since the start of the current Global War on Terrorism, there have been at least 6 published cases of HD among active duty U.S. military members, the majority of which were not service related.15–18 Five of the 6 published cases involved service members from Micronesia. (Currently, there are 2 other active cases of HD being treated in service members in conjunction with the NHDP.) In a case series of 3 active duty soldiers from Micronesia with HD, the average time to diagnosis was 8 months.15 This observation illustrates that HD’s indolent course of skin lesions and neurologic deficits can lead to a delay in diagnosis.19 Given the potential morbidity associated with delayed diagnosis, providers should consider HD in a patient from an endemic region with rash and neuropathy.

There have been no published reports among U.S. troops of HD secondary to exposure to other infected service members. However, there have been reported cases of family members contracting HD from service members.9 Such examples indicate that prolonged, close exposure to an infected individual or prolonged travel to endemic countries is needed for infection with HD.

Before effective therapies were widely available, a diagnosis of HD resulted in discharge from the U.S. Army.9 However, currently, if the HD responds to treatment and does not lead to physical limitations, affected service members may be retained.20

In summary, HD is rare in the U.S. military and its veterans. However, because of the potential significant morbidity associated with delayed diagnosis and treatment of HD, this condition should be considered in patients presenting with skin lesions and peripheral neuropathy, especially if the patients are from HD-endemic regions.

Author affiliations: Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX (MAJ Jansen and Maj Lindholm); National Hansen’s Disease Program, Baton Rouge, LA (Dr. Stryjewska); Uniformed Services University of the Health Sciences, Bethesda, MD (Maj Lindholm); Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio-Lackland, TX (Maj Bandino and Capt Durso)

Disclaimer: The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views or policies of the Uniformed Services University of the Health Sciences, Brooke Army Medical Center, Wilford Hall Ambulatory Surgical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, the Department of Defense, or the U.S. Government. Mention of trade name, commercial products, or organizations does not imply endorsement by the U.S. Government. The authors are employees of the U.S. Government. This work was prepared as part of their official duties. Title 17 U.S.C. §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17 U.S.C. §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.

REFERENCES

1. World Health Organization. Global leprosy update, 2016: accelerating reduction of disease burden. Wkly Epidemiol Rec. 2017;92(35):501–519.

2. Nolen L, Haberling D, Scollard D, et al. Incidence of Hansen's disease—United States, 1994–2011. MMWR Morb Mortal Wkly Rep. 2014;63(43):969–972.

3. Woodall P, Scollard D, Rajan L. Hansen disease among Micronesian and Marshallese persons living in the United States. Emerg Infect Dis. 2011;17(7):1202–1208.

4. Britton WJ, Lockwood DN. Leprosy. Lancet. 2004;363(9416):1209–1219.

5. Moschella SL. An update on the diagnosis and treatment of leprosy. J Am Acad Dermatol. 2004;51(3):417–426.

6. Ji B, Jamet P, Perani EG, Bobin P, Grosset JH. Powerful bactericidal activities of clarithromycin and minocycline against Mycobacterium leprae in lepromatous leprosy. J Infect Dis. 1993;168(1):188–190.

7. Van Veen NH, Nicholls PG, Smith WC, Richardus JH. Corticosteroids for treating nerve damage in leprosy. Cochrane Database Syst Rev. 2016;(5):CD005491.

8. Walker SL, Lockwood DN. Leprosy type 1 (reversal) reactions and their management. Lepr Rev. 2008;79(4):372–386.

9. Brubaker ML, Binford CH, Trautman JR. Occurrence of leprosy in U.S. veterans after service in endemic areas abroad. Public Health Rep. 1969;84(12):1051–1058.

10. Aycock WL, Gordon JE. Leprosy in veterans of American wars. Am J Med Sci. 1947;214(3):329–339.

11. Medford FE. Leprosy in Vietnam veterans. Arch Intern Med. 1974;134(2):373.

12. Rose HD. Letter: Leprosy in Vietnam returnees. JAMA.1974;230(10):1388.

13. Kivirand AI, Price PH. Leprosy in Vietnam veteran. Arch Pathol Lab Med. 1979;103(7):367.

14. Enna CD, Trautman JR. Leprosy in the military services. Mil Med. 1969;134(12):1423–1426.

15. Hartzell JD, Zapor M, Peng S, Straight T. Leprosy: a case series and review. South Med J. 2004;97(12):1252–1256.

16. Berjohn CM, DuPlessis CA, Tieu K, Maves RC. Multibacillary leprosy in an active duty military member. Emerg Infect Dis. 2015;21(6):1077–1078.

17. Bossalini JP, Bandino JP, Miletta NR. Delayed diagnosis of leprosy in a Micronesian soldier—case report. Mil Med. 2019;184(9/10):561–564.

18. Wellington T, Schofield C. Late-onset ulnar neuritis following treatment of lepromatous leprosy infection. PLoS Negl Trop Dis. 2019;13(8):e0007684.

19. Chad DA, Hedley-Whyte ET. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 1-2004. A 49-year-old woman with asymmetric painful neuropathy. N Engl J Med. 2004;350(2):166–176.

20. Headquarters, Department of the Army. Army Regulation 40-501. Medical Services. Standards of Medical Fitness. 27 June 2019.

Ulcer along the interspace between the patient’s right index and middle fingers. Photograph courtesy of Brooke Army Medical Center Medical Photography

Multiple, large, irregular, welldemarcated, scaly, erythematous plaques on the left arm. These lesions were noted to have diminished sensation compared to surrounding normal skin. Photograph courtesy of Brooke Army Medical Center Medical Photography.

Multiple, large, well-demarcated, annular, hyperpigmented, scaly plaques with relative central clearing on the left leg. These lesions were noted to have diminished sensation compared to surrounding normal skin. Photograph courtesy of Brooke Army Medical Center Medical Photography.Magnetic resonance imaging of the distal right arm. Coronal short T1 inversion recovery (STIR) image showing diffuse ulnar nerve enlargement (red arrow).Magnetic resonace imaging of the distal right arm. Coronal short T1 inversion recovery (STIR) imaging showing diffuse median nerve enlargement (red arrow).Thickening of the left greater auricular nerve. Photograph courtesy of Brooke Army Medical Center Medical Photography.Photomicrograph of punch biopsy specimen demonstrating superficial and deep dermal, non-caseating, epithelioid cell granulomas (black arrow), some forming preferentially around adnexal structures and nerves (hematoxylin and eosin stain, original magnification x 4).Photomicrograph of punch biopsy specimen demonstrating discrete, non-caseating, epithelioid cell granulomas around adnexal structures (black arrow, eccrine glands) and nerves (red arrow) within the dermis (hematoxylin and eosin stain, original magnification x 10).

You also may be interested in...

Obesity prevalence among active component service members prior to and during the COVID-19 pandemic, January 2018–July 2021

Article
3/1/2022

This study examined monthly prevalence of obesity and exercise in active component U.S. military members prior to and during the COVID-19 pandemic. These results suggest that the COVID-19 pandemic had a small effect on the trend of obesity in the active component U.S. military and that obesity prevalence continues to increase.

Recommended Content:

Medical Surveillance Monthly Report

Update: Malaria, U.S. Armed Forces, 2021

Article
3/1/2022

Malaria infection remains an important health threat to U.S. service members who are located in endemic areas because of long-term duty assignments, participation in shorter-term contingency operations, or personal travel. In 2021, a total of 20 service members were diagnosed with or reported to have malaria.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Snapshot: Medical Separation from Service Among Incident Cases of Osteoarthritis and Spondylosis, Active Component, U.S. Armed Forces, 2016–2020

Article
3/1/2022
Marines hike to the next training location during Exercise Baccarat in Aveyron, Occitanie, France, Oct.16, 2021. Exercise Baccarat is a three-week joint exercise with Marines and the French Foreign Legion that challenges forces with physical and tactical training. Photo By: Marine Corps Lance Cpl. Jennifer Reyes

Osteoarthritis (OA) is the most common adult joint disease and predominantly involves the weight-bearing joints. This condition, including spondylosis (OA of the spine), results in significant disability and resource utilization and is a leading cause of medical separation from military service.

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Refractive Surgery Trends at Tri-Service Refractive Surgery Centers and the Impact of the COVID-19 Pandemic, Fiscal Years 2000–2020

Article
3/1/2022
Cadet Saverio Macrina, U.S. Military Academy West Point, receives corneal cross-linking procedure at Fort Belvoir Community Hospital, Va., Nov. 21, 2016. (DoD photo by Reese Brown)

Since the official introduction of laser refractive surgery into clinical practice throughout the Military Health System (MHS) in fiscal year 2000, these techniques have been heavily implemented in the tri-service community to better equip and improve the readiness of the U.S. military force.

Recommended Content:

Medical Surveillance Monthly Report

Brief report: Using syndromic surveillance to monitor MIS-C associated with COVID-19 in Military Health System beneficiaries

Article
3/1/2022
Air Force 1st Lt. Anthony Albina, a critical care nurse assigned to Joint Base Andrews, Md., checks a patient’s breathing and heart rate during an intubation procedure while supporting COVID-19 response operations in Cleveland, Jan. 20, 2022.

SARS CoV-2 and the illness it causes, COVID-19, have exacted a heavy toll on the global community. Most of the identified disease has been in the elderly and adults. The goal of this analysis was to ascertain if user-built ESSENCE queries applied to records of outpatient MHS health care encounters are capable of detecting MIS-C cases that have not been identified or reported by local public health departments.

Recommended Content:

Medical Surveillance Monthly Report

Diagnosis of hepatitis C infection and cascade of care in the active component, U.S. Armed Forces, 2020

Article
2/1/2022
Navy Petty Officer 2nd Class Cecil Dorse, left, and Navy Petty Officer 3rd Class Janet Rosas test blood samples aboard the Military Sealift Command hospital ship USNS Comfort while the ship is in New York City in support of the nation’s COVID-19 response, April 6, 2020. Photo By: Navy Petty Officer 2nd Class Sara Eshleman

Hepatitis C virus (HCV) infection rates are rising in the U.S. despite widely available tools to identify and effectively treat nearly all of these cases. This cross-sectional study aimed to use laboratory data to evaluate the prevalence of HCV diagnoses among active component U.S. military service members.

Recommended Content:

Medical Surveillance Monthly Report

A new approach to categorization of ocular injury among U.S. Armed Forces

Article
2/1/2022
Air Force and Space Force Surgeon General Lt. Gen. Dorothy Hogg receives an eye exam from Air Force Reserve Maj. Leslie Wilderson at Joint Base Anacostia-Bolling, Washington, D.C., March 26, 2021. Photo By: Air Force Staff Sgt. Kayla White

Ocular injuries present an ongoing threat to readiness and retention of service members. This report describes a new approach to categorizing ocular injury using Military Health System data, the application of an algorithm to a dataset, and the verification of the results using an audit of clinical data.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance snapshot: Health care burden attributable to osteoarthritis and spondylosis, active component, U.S. Armed Forces, 2016–2020

Article
2/1/2022
Air Force security forces trainees climb a hill during a 3-mile ruck march to commemorate National Police Week at Joint Base San Antonio, May 13, 2019. Photo By: Sarayuth Pinthong, Air Force

This snapshot summarizes the total numbers of inpatient and outpatient encounters with an OA or spondylosis diagnosis in the first diagnostic position and the total numbers of unique individuals affected by these conditions during the same 5-year surveillance period.

Recommended Content:

Medical Surveillance Monthly Report

Description of a COVID-19 Beta Variant Outbreak, Joint Base Lewis-McChord, WA, February–March 2021

Article
1/1/2022
U.S. Army Soldiers from 1-17th Infantry Battalion, 2nd Stryker Brigade, 2nd Infantry Division, clear an objective during the training exercise Bayonet Focus 19-02 at Yakima Training Center, Wash., May 6, 2019. Bayonet Focus is a training exercise designed to assess Soldiers’ ability to preform tasks and complete objectives under conditions experienced during combat situations. (U.S. Army photo by Spc. Angel Ruszkiewicz)

This report describes an outbreak of SARS-CoV-2, the causative agent of COVID-19, that peaked during 21–26 February 2021 and was tied to a single military training event. A total of 143 laboratory-confirmed cases were identified.

Recommended Content:

Medical Surveillance Monthly Report

COVID-19 and Depressive Symptoms Among Active Component U.S. Service Members, January 2019–July 2021

Article
1/1/2022
With the holiday season upon us, the cold, dark days that winter brings, and the social distancing and movement restrictions brought about by COVID-19, it’s not uncommon for people to feel depressed. (Photo by Erin Bolling)

This study examined the rates of depressive symptoms in active component U.S. service members prior to and during the COVID-19 pandemic and evaluated whether SARS-CoV-2 test results (positive or negative) were associated with self-reported depressive symptoms.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Snapshot: Lengths of Hospital Stays for Service Members Diagnosed with Sepsis, Active Component, U.S. Armed Forces, 2011–2020

Article
1/1/2022
The (left to right) Senior Airman Austin Shrewsbury, 88th Diagnostics and Therapeutic Squadron medical laboratory technician, works with student, Airman 1st Class Taylor Altman, 88th Diagnostics and Therapeutic Squadron medical laboratory technician, to identify bacteria of patient’s cultures inside the microbiology laboratory at Wright-Patterson Air Force Base medical center June 30, 2017.

Sepsis is a serious and life-threatening organ dysfunction caused by a dysregulated host response to infection. In the U.S., sepsis is a leading cause of in-hospital mortality and 1 of the most expensive conditions treated in U.S. hospitals.

Recommended Content:

Medical Surveillance Monthly Report

Incident COVID-19 Infections, Active and Reserve Components, Jan. 1, 2020–Aug. 31, 2021

Article
12/1/2021
U.S. Marines with Marine Rotational Force - Darwin receive a second COVID-19 test during quarantine on Royal Australian Air Force Base Darwin in Darwin, NT, Australia, June 12, 2020. The COVID-19 test was administered to each Marine after arriving from California. All Marines will be quarantined for 14 days and undergo an additional test before quarantine release. No Marines tested positive for COVID-19. The U.S. Marine Corps and Australian Defence Force service members are working together to ensure the safety of the local community. (U.S. Marine Corps photo by Lance Cpl. Natalie Greenwood)

Incident COVID-19 Infections, Active and Reserve Components, 1 January 2020–31 August 2021

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Snapshot: Donovanosis Among Active Component Service Members, U.S. Armed Forces, 2011–2020

Article
12/1/2021
This photomicrograph of a tissue sample extracted from a lesion in the inguinal region of the female granuloma inguinale, or Donovanosis patient, depicted in PHIL 6431, revealed a white blood cell (WBC) that contained the pathognomonic finding of Donovan bodies, which were encapsulated, Gram-negative rods, representing the responsible bacterium Klebsiella granulomatis, formerly known as Calymmatobacterium granulomatis. Photo credit: CDC/ Susan Lindsley

Recommended Content:

Medical Surveillance Monthly Report

Update: Osteoarthritis and Spondylosis, Active Component, U.S. Armed Forces, 2016–2020

Article
12/1/2021
Osteoarthritis (OA) knee . film x-ray AP ( anterior - posterior ) and lateral view of knee show narrow joint space, osteophyte ( spur ), subchondral sclerosis, knee joint inflammation. Photo by: iStockPhoto

Osteoarthritis (OA), the most com­mon adult joint disease, is primarily a degenerative disorder of the entire joint organ, including the subchondral bone, synovium, and periarticular structures (e.g., tendons, ligaments, bursae). Spondylosis, often referred to as OA of the spine, is characterized by degenerative changes in the vertebral discs, joints, and vertebral bodies.

Recommended Content:

Medical Surveillance Monthly Report

Update: Plant Dermatitis Among Active Component Service Members, U.S. Armed Forces, 2010–2020

Article
11/1/2021
Poison ivy (Toxicodendron radicans)

Plant dermatitis is an allergic inflammatory skin reaction in response to the oils of poisonous plants. In the U.S., the most common dermatitis-causing plant genus is the Toxicodendron (formerly Rhus). Approximately 50%–75% of the U.S. adult population are susceptible to skin reactions upon exposure to Toxicodendron oil or oleoresin, called urushiol.

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 16

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.