An unusual presentation of Hansen’s disease: A case report

Leprosy is a chronic granulomatous infection caused by Mycobacterium leprae, which gives rise to a wide spectrum of clinical manifestations depending on the host’s cell-mediated immunity. Although classical features include hypopigmented or erythematous anaesthetic patches and peripheral neuropathy, atypical presentations may occur, delaying the diagnosis. Ichthyosiform changes are uncommon and usually associated with multibacillary disease. 
We present a 69-year-old male who presented with progressive generalized scaling for one year, without prior dermatological illness. Detailed evaluation revealed associated glove-and-stocking sensory neuropathy, which was neglected for years, associated with left-sided partial foot drop. Cutaneous examination showed diffuse ichthyosis with large scales over the extremities and finer scaling over the trunk, without classical hypopigmented lesions, and madarosis with thickening of peripheral nerves. Slit-skin smears demonstrated a high bacillary index (5+ to 6+). Histopathology revealed diffuse dermal infiltration and focal aggregates of foamy macrophages with a Grenz zone, consistent with borderline lepromatous leprosy.
This case highlights acquired generalized ichthyosis as an unusual presenting feature of leprosy, which requires a high degree of clinical suspicion. Autonomic nerve dysfunction leading to anhidrosis and xerosis likely contributes to the ichthyosiform appearance. Recognition of subtle clinical clues such as madarosis and peripheral sensory neuropathy is essential for early diagnosis. Slit skin smear and skin biopsy are simple but important tools in the diagnosis of unusual cases of leprosy. Prompt initiation of multidrug therapy can prevent progression and long-term disability.