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Hansen's Reaction Presenting as Acute Generalized Exanthematous Pustulosis-A New Facet to an Old Disease

Shreya K1*, Amulya M Lakshman1, Dinesh P Asati1, Garima Goel2

Hansen’s disease presents with a spectrum of clinical manifestations ranging from lepromatous leprosy to tuberculoid leprosy. The course of the disease may be superseded by the leprosy reactions which are of two types, Type 1 and Type 2 reactions. A 61-year-old male initially diagnosed with scrofuloderma after Fine Needle Aspiration Cytology (FNAC) of the discharge from the swelling over the axilla and inguinal region which tested positive for Ziehl- Neelsen (ZN) stain. He was started on Anti-Tubercular Treatment (ATT). Five days after starting the ATT, the patient developed fever, edema of the bilateral lower limb, and generalized arthralgia. It was followed by the development of multiple tiny pustules over bilateral legs. A provisional diagnosis of acute generalized exanthematous pustulosis was considered and a skin biopsy was taken from the lesion. Histopathological examination revealed epidermis with pustule filled with neutrophils, superficial and deep dermis showed granulomatous inflammation. On further clinical examination, patient had thickening of bilateral ulnar nerve, right common peroneal nerve with no neuritis. On sensory examination, hypoesthesia noted over bilateral soles. On reviewing, the biopsy specimen showed edematous superficial and deep dermis with interstitial, perivascular and periappendageal inflammatory infiltrate comprising foamy macrophages, lymphocytes and polymorphs. The fite stain for Acid fast bacilli was positive and Bacterial Index (BI) was 5+. Acute Generalized Exanthematous Pustulosis (AGEP) is a severe cutaneous eruption with nonfollicular, sterile, pustules on an erythematous background associated with fever and leukocytosis. In the vast majority of cases medications are implicated, few theories of infectious etiologies are also suspected. Previous case reports of infectious etiology such as coccidioidomycosis, chlamydia, cytomegalovirus, and parvovirus have been described. This may implicate AGEP-like eruptions is also a rare presentation of Hansen’s reaction. The pustular lesion in Erythema Nodosum Leprosum (ENL) is an uncommon form of ENL and is a criterion for severe ENL. This case highlights the need for thorough clinical examination and histopathological correlation for diagnosing the new facets of Hansen’s disease.