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

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

Disparities in COVID-19 Vaccine Initiation and Completion Among Active Component Service Members and Health Care Personnel, 11 December 2020–12 March 2021

Article
4/1/2021
Capt. Shamira Conerly, 149th Medical Group, gives Staff Sgt. Timmy Sanders, 149th Maintenance Squadron, his first does of COVID-19 vaccine on Joint Base San Antonio-Lackland, Texas, March 18, 2021. Members of the 149th Fighter Wing who have opted to receive their vaccine have been scheduled over the past two weeks by the 149th Medical Group. (US Air National Guard Photo by Senior Airman Ryan Mancuso)

Recommended Content:

Medical Surveillance Monthly Report

Update: Heat Illness, Active Component, U.S. Armed Forces, 2020

Article
4/1/2021
Fort Jackson, SC. A trainee with 2nd Battalion, 60th Infantry Regiment puts his arms in an arm immersion cooling tank during training. The tanks allow Soldiers to rapidly cool by putting their forearms into a tank of ice water. (Photo by Saskia Gabriel)

Recommended Content:

Medical Surveillance Monthly Report

Update: Exertional Rhabdomyolysis, Active Component, U.S. Armed Forces, 2016–2020

Article
4/1/2021
Marine Corps Recruit Depot, San Diego  Recruits with Bravo Company, 1st Recruit Training Battalion, hydrate after a physical training session at Marine Corps Recruit Depot San Diego, April 12, 2020. The recruits performed multiple exercises at different stations after completing a 400-meter dash. (U.S. Marine Corps photo by Cpl. Brooke C. Woods)

Recommended Content:

Medical Surveillance Monthly Report

Skin and Soft Tissue Infections, Active Component, U.S. Armed Forces, January 2016–September 2020

Article
4/1/2021
Detailed view of elbow with carbuncle or furuncle. iStock.com/andriano_cz

Recommended Content:

Medical Surveillance Monthly Report

Update: Exertional Hyponatremia, Active Component, U.S. Armed Forces, 2005–2020

Article
4/1/2021
Marine Corps Recruit Depot, San Diego  Recruits with Bravo Company, 1st Recruit Training Battalion, hydrate after a physical training session at Marine Corps Recruit Depot San Diego, April 12, 2020. The recruits performed multiple exercises at different stations after completing a 400-meter dash. (U.S. Marine Corps photo by Cpl. Brooke C. Woods)

Recommended Content:

Medical Surveillance Monthly Report

Influenza Outbreak During Exercise Talisman Sabre, Queensland, Australia, July 2019

Article
3/1/2021
Flight Lt. Michael Campion, an aviation medical officer from No. 3 Aeromedical Evacuation Squadron prepares a medical patient leaving Exercise Talisman Sabre to be transferred to a C-27J Spartan aircraft July 18, 2019 at Rockhampton Airport. No. 3 Aeromedical Evacuation Squadron is providing medical support to troops participating in Talisman Sabre 2019, a bilateral combined Australian and United States exercise designed to train respective military services in planning and conducting Combined and Joint Task Force operations, and improve the combat readiness and interoperability between Australian and US forces. (U.S. Army photo by Sgt. 1st Class John Etheridge)

Influenza Outbreak During Exercise Talisman Sabre, Queensland, Australia, July 2019

Recommended Content:

Medical Surveillance Monthly Report

Update: Sexually Transmitted Infections, Active Component, U.S. Armed Forces, 2012–2020

Article
3/1/2021
Under a magnification of 1150X, this photomicrograph of a Gram-stained urethral discharge specimen, demonstrated the presence of Gram-negative, intracellular diplococci, which is a finding indicative of the possible presence of Neisseria gonorrhoeae bacteria.  Credit: CDC/ Dr. Caldwell

Update: Sexually Transmitted Infections, Active Component, U.S. Armed Forces, 2012–2020

Recommended Content:

Medical Surveillance Monthly Report

Influenza Surveillance Trends and Influenza Vaccine Effectiveness Among Department of Defense Beneficiaries During the 2019–2020 Influenza Season

Article
3/1/2021
Captured in 2011, this transmission electron microscopic (TEM) image depicts some of the ultrastructural details displayed by H3N2 influenza virions, responsible for causing illness in Indiana and Pennsylvania in 2011. See PHIL 13469, for the diagrammatic representation of how this Swine Flu stain came to be, through the “reassortment” of two different Influenza viruses.  Credit: CDC/ Dr. Michael Shaw; Doug Jordan, M.A.

Influenza Surveillance Trends and Influenza Vaccine Effectiveness Among Department of Defense Beneficiaries During the 2019–2020 Influenza Season

Recommended Content:

Medical Surveillance Monthly Report

A Retrospective Cohort Study of Blood Lead Levels Among Special Operations Forces Soldiers Exposed to Lead at a Firing Range in Germany

Article
3/1/2021
A soldier assigned to the U. S. Army John F. Kennedy Special Warfare Center and School who is in the Special Forces Weapons Sergeant Course fires a pistol during small arms training at Fort Bragg, North Carolina November 4, 2019. The soldiers were trained to employ, maintain and engage targets with select U.S. and foreign pistols, rifles, shotguns, submachine and machine guns, grenade launchers and mortars and in the utilization of observed fire procedures. (U.S. Army photo illustration by K. Kassens)

Recommended Content:

Medical Surveillance Monthly Report

Surveillance for Vector-borne Diseases Among Active and Reserve Component Service Members, U.S. Armed Forces, 2016–2020

Article
2/1/2021
This image depicts a dorsal view of a female lone star tick, Amblyomma americanum, and is found in the Southeastern, and Mid-Atlantic United States. Females exhibit the star-like spot on their distal scutum. This tick is a vector of several zoonotic diseases, including human monocytic ehrlichiosis, and Rocky Mountain spotted fever (RMSF).  CDC/Michael L. Levin, PhD

Recommended Content:

Medical Surveillance Monthly Report

Update: Malaria, U.S. Armed Forces, 2020

Article
2/1/2021
Spc. Joshua Jones, left, and Pfc. Richard Bower, both preventive medicine specialists, 227th Preventive Medicine Detachment, 62nd Medical Brigade, check an insect trap during a field training exercise on Joint Base Lewis-McChord, June 20. The 227th PMD notionally deployed to Guiria, Venezuela, where a tropical storm caused floods and presented a real world concern for mosquitos, which are known to spawn in stagnant water and cause widespread vector borne illnesses such as malaria, yellow fever and dengue fever.  Photo by Sgt. Sarah Enos 5th Mobile Public Affairs Detachment

Recommended Content:

Medical Surveillance Monthly Report

Historical Perspective: The Evolution of Post-exposure Prophylaxis for Vivax Malaria Since the Korean War

Article
2/1/2021
An Aedes aegypti mosquito can transmit the viruses that cause dengue fever.  CDC/Prof. Frank Hadley Collins, Cntr. for Global Health and Infectious Diseases, Univ. of Notre Dame

Recommended Content:

Medical Surveillance Monthly Report

Attrition Rates and Incidence of Mental Health Disorders in an Attention-Deficit/Hyperactivity Disorder (ADHD) Cohort, Active Component, U.S. Armed Forces, 2014–2018

Article
1/1/2021
Capt. Michelle Tsai, the behavioral health officer for the 4th Brigade, 2nd Infantry Division, reviews medical information in her office at the Joint Readiness Training Center June 17. Tsai, an Alexandria, Va., native, is here with the Raider Brigade in support of training operations for the unit's upcoming deployment to Iraq. (Photo by Pfc. Luke Rollins)

Recommended Content:

Medical Surveillance Monthly Report

Exertional Rhabdomyolysis and Sickle Cell Trait Status in the U.S. Air Force, January 2009–December 2018

Article
1/1/2021
JOINT BASE SAN ANTONIO, Texas - Master Sgt. Daniel Bedford, Air Force Recruiting Service National Events program manager, prepares to pump up a gold medal lift in the bench press during the USPA (United State Powerlifting Association) 2020 Texas State Bench Press Championship. Senior Master Sgt. Michael Lear, AFRS Strategic Marketing Division superintendent, prepares to spot Bedford. Lear and Bedford are Total Force recruiting partners who train together and motivate one another at work and in the gym. (Courtesy photo) (Photo By: babin.)

Recommended Content:

Medical Surveillance Monthly Report

The Prevalence of Attention-Deficit/Hyperactivity Disorder (ADHD) and ADHD Medication Treatment in Active Component Service Members, U.S. Armed Forces, 2014–2018

Article
1/1/2021
New Recruits with Golf Company, 2nd Recruit Training Battalion, are screened after arriving at Marine Corps Recruit Depot, San Diego, Dec. 28, 2020. As recruits arrive to the depot in the future, they will enter a staging period of 14 days during which they will be medically screened, monitored, and provided classes to prepare and orient them to begin recruit training. All of this will occur before they step onto our iconic yellow footprints and make that memorable move toward earning the title Marine. Current planning and execution remain fluid as the situation continues to evolve. The health and well-being of our recruits, recruiting and training personnel, and their families remain our primary concerns. All recruits will be screened and tested for COVID-19 prior to beginning recruit training. (U.S. Marine Corps photo by Lance Cpl. Grace J. Kindred)

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 9

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.