Tuberculoid leprosy with and ulnar nerve involvement: JAMA c
A previously healthy, 25-year-old woman presented with a hyperpigmented macule on the medial side of her right palm. She reported hypoesthesia over the lesion. Two years ago, she immigrated to the United States from Bangladesh. Five months ago, she visited Bangladesh to get married. A biopsy of the lesion obtained there showed multiple perineural granulomas with inflammatory cells.

Gram stain and acid-fast bacillary and fungal stains of the biopsy specimen were negative. The patient was prescribed 1 dose each of doxycycline, ofloxacin, and rifampin and experienced no improvement.

On physical examination there was a mildly erythematous macule located over the medial aspect of the right palm, with loss of touch and temperature sensation over the involved area (Figure). A thickened, nontender ulnar nerve was palpated on the ipsilateral side in the olecranon fossa.

The key to the correct diagnosis is the presence of a hypoesthetic macule and peripheral nerve enlargement in a patient from a region where tuberculoid leprosy is endemic. The diagnosis of tuberculoid leprosy is often based on clinical presentation, because skin biopsies, nerve biopsies, or both frequently do not reveal the pathogen.

Diagnosis: Tuberculoid leprosy with a single lesion and ulnar nerve involvement

The patient was given a 12-month course of dapsone combined with rifampin. During 3 months of follow-up, the patient experienced improved sensation over the palm. No family members were identified with similar skin lesions. The National Hansen’s Disease Program provided the patient with a 12-month supply of dapsone and rifampin.

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