- Volume 67 , Number 4
- Page: 471–3
Leprosy at the age of 141 years: a case report
This department is for the publication of informal communications that are of interest because they are informative and stimulating, and for the discussion of controversial matters. The mandate of this JOURNAL is to disseminate information relating to leprosy in particular and also other mycobacterial diseases. Dissident comment or interpretation on published research is of course valid, but personality attacks on individuals would seem unnecessary. Political comments, valid or not, also are unwelcome. They might result in interference with the distribution of the JOURNAL and thus interfere with its prime purpose.
To the Editor:
A 141-year old male, the oldest living human being in Nepal, presented with asymptomatic, multiple, erythematous plaques all over his body for the last 2 months. The lesions appeared suddenly on his face and progressed to involve the upper and lower limbs and trunk. There was a history of redness of the eyes and lacrimation for the previous 20 days. Fever, arthralgia, epistaxis, testicular swelling and pain in eyes were absent. The patient had never suffered from any major illness in his entire life. He was the documented oldest citizen of Nepal, according to the records of the Nepal Land Survey. He was a much revered figure and a lot of people used to visit his home to have audience with him daily. The patient had been living a simple life. He was married and had five children and three great-grandchildren. There was no history of leprosy in the family.
Fig . 1. Erythematous plaques ou right lower limb.
Fig . 2. Erythematous plaques and nodules over the chin and right cheek.
Examination revealed a frail old man alert and conscious but unable to respond to queries because of impaired hearing. His conjunctivae were congested and there was a scanty purulent discharge. There was no pallor, icterus, lymphadenopathy, pedal edema, trophic ulceration or plantar Assuring. There was an atrophic, 2 cm × 1 cm, depigmented scar on the depressed bridge of the nose. The systemic examination was within normal limits. Cutaneous examination showed well-defined, erythematous, indurated plaques on both eyebrows without any madarosis. Multiple, erythematous, illto well-defined plaques varying in size from 1 cm to 10 cm were present bilaterally in an asymmetrical pattern over bald areas of the scalp, the nape of the neck, the chin, cheeks, nose, trunk, buttocks and upper and lower extremities (Figs. 1 and 2). Multiple, nontender, erythematous nodules were present over the cheeks and chin. The left ulnar nerve was thickened and mildly tender. There were no deformities. Sensation over the lesions, hands and feet could not be tested because of his advanced age and inability to communicate.
A clinical diagnosis of borderline lepromatous (BL) Hansen's disease was made. Slit-skin smears for acid-fast bacilli (AFB) were positive from the lesions and earlobes (BI 1+). A skin biopsy from a lesion on the left forearm showed atrophy of the epidermis and multiple epithelioid cell granulomas in the upper and deep dermis. The granulomas were composed of epithelioid cells, lymphocytes, and a few giant cells. Nerve destruction was seen in places. The biopsy was negative for AFB. The histological diagnosis of borderline tuberculoid (BT) Hansen's disease was made. All hematological and biochemical investigations were normal. The patient was started on the World Health Organization multibacillary multidrug therapy (WHO/MDT) regimen. The patient expired 2 weeks later of an unknown cause at home.
Leprosy is a chronic infectious disease, caused by Mycobacterium leprae, affecting the peripheral nerves, skin and certain other tissues (2). It is transmitted from one person to another, probably by contact with untreated patients hosting contagious forms of the disease. In highly endemic regions, a very large percentage of the population is exposed to the infection but only 5% develop the disease, depending on the cellmediated immunity of the individual. The prevalence of leprosy is highest among young adults (1). It has been reported in all age groups but the prevalence is only 0.09% for those over 80 years of age. In an article by Monteiro, et al. from Brazil on ocular changes in leprosy patients, it is mentioned that their oldest patient was aged 89 years (3). There were no reports of any patient older than this, to the best of our knowledge.
We report here a case of borderline lepromatous Hansen's disease in a 141-yearold person. Our patient was unique not because of his advanced age alone but because the onset of disease was at the age of 141 years. This case highlights the long incubation period of leprosy. We believe that the patient must have acquired the infection at an early age, as is true for most of the people living in endemic areas. The late onset of the disease in our patient may be because of decreased immunity in old age (4). However, the possibility of his acquiring infection even later in life from the people who had started visiting him from far and wide, after recognition as the oldest living person of Nepal, cannot be discounted.
- Sudha Agrawal, M.D.
Assistant Professor
- Arun Joshi, M.D.
Senior Resident
- Mary Jacob, M.N.A.M.S.
Professor and Head
Department of Dermatology and Venereology
- Shatrughan P. Sah, M.D.
Assistan t Professor
Department of Pathology
- Arun Agarwalla, M.D.
Senior Resident
- Vijay Kumar Garg, M.D.
Associate Professor
Department of Dermatology and Venereology
B. P. Koirala Institute of Health Science
Dharan, Nepal
REFERENCES
1. Ali, P. M. The age at onset of leprosy. Lepr. Rev. 35(1964)193-197
2. Jopling, W. H. and McDougall, A. C. Delinition, epidemiology and world distribution. In: Handbook of Leprosy . 4th edn. Oxford: Heinemann Medical Books, 1988, pp. 1-9.
3. Monteiro, L. G., Campos, W. R., Orefice, F. and Grossi, M. A. F. Study of ocular changes in leprosy patients. Indian J. Lepr. 70(1998)197-202.
4. Noordeen, S. K. The epidemiology of leprosy. In: Leprosy. 2nd edn. Hastings, R. C, ed. London: Churchill Livingstone, 1992, pp. 29-45.
Reprint requests to Dr. S. Agrawal at the above address or FAX 977-25-20251; e-mail: sudha92@hotmail.com.