Case for diagnosis.

Hansen's disease is a chronic infecto-contagious disease caused by Mycobacterium leprae. The bacillus prefers low-temperature areas and the nose is usually the initial site of lesions. Transmission of the bacilli occurs by nasal and oropharyngeal secretions, and through solutions of continuity of the skin and/or mucosae. Nasal manifestations are found in the later stages of the disease.

CASE REPORT

A 70-year-old male patient, native of Ibitiara-BA but resident in Guarulhos for 42 years complained about discomfort, nasal obstruction, rhinorrhea and pruritus. He was referred to dermatology 3 months after his first visit to the primary health care center. Personal history: systemic arterial hypertension. Dermatological examination of the nose and nasal cavity revealed the presence of confluent papulonodular lesions. Some of the lesions were crusty (Figures 1 and 2). Smear was positive for Mycobacterium leprae. Serology for leishmaniasis, paracoccidioidomycosis and culture for fungi were negative. Anatomopathological examination showed: pseudoepitheliomatous hyperplasia, absence of granulomas, macrophages with wide vacuolated cytoplasm. Search for acid-alcohol resistant bacilli using Ziehl-Nielsen staining was positive (Figure 3).

FIGURE 1

Nasal leprosy. Tumoral lesion with crusty surface within the nasal cavity

FIGURE 2

Nasal leprosy. Collapse of the nasal septum. Tumoral lesion with crusty surface at the end of the nasal dorsum

FIGURE 3

HE-1000x. Clumps of acid-fast bacilli within macrophages

DISCUSSION

Hansen's bacillus has tropism for cooler parts of the body, such as the nasal septum, ear lobes, skin of extremities and testes, where temperature is ideal for its development.[1] Multibacillary forms of leprosy are associated with nasal lesions. Dermatological examination shows infiltration, hansenomas, ulceration and perforation or suggestive and nonspecific changes, such as pallor of mucous membrane, congestion, vasculitis, crusting, atrophy and dryness.[2]-[4] Nasal obstruction in lepromatous leprosy reflects granulomatous infiltration of the mucosa.[5] In leishmaniasis, perforation and collapse of the nasal septum may occur as a result of the edematous infiltration of the supporting structures of the nose.[6] Facial lesions in chronic forms of paracoccidioidomycosis originate by contiguity to mucosa, lymph node, and bone lesions or by hematogenous spread of primary pulmonary disease. This disease may also compromise the nasal pyramid and nasal septum.[7,8] Other differential diagnoses of the condition in question are tuberculosis (a highly prevalent infection in Brazil), as well as sinus lymphoma and autoimmune diseases like Wegener's granulomatosis (which are more rare).[9] Faced with this evidence, we made the diagnosis of lepromatous leprosy with exuberant nasal lesions. The patient remains in outpatient follow-up and is being treated with multibacillary multidrug therapy (MB-MDT), as established by the World Health Organization (WHO). He shows gradual improvement of mucocutaneous lesions. We emphasize the importance of the clinical picture of the nose for the clinical diagnosis of the disease.