P027 A case of cutaneous nodules in a migrant man

Abstract A 32-year-old Haitian man presented with a 6-month history of asymptomatic, widespread, erythematous nodules. Systems review revealed joint pain affecting his elbows and wrists, and symptoms of median nerve entrapment. He was otherwise systemically well. He was originally from Haiti and had lived in Brazil prior to moving to Ireland 18 months ago. There was family history of sarcoidosis in a second-degree relative. The patient’s full blood count, renal and liver profiles and C-reactive protein were normal. The following investigations were negative: HIV, hepatitis B, hepatitis C and Treponema palladium serology. The serum angiotensin-converting enzyme level was slightly elevated at 61 U L−1 (normal range 0–56). QuantiFERON was reported to be in the grey zone. Excision of a nodule from his left upper arm revealed a dense histiocytic infiltrate and non-necrotizing granulomas throughout the superficial and deep dermis. Lymphocytes were present. No fungal, mycobacterial or leishmania DNA was identified. Periodic acid–Schiff stain and direct immunofluorescence were negative. Acid-fast bacilli were positive on skin swab. Nerve conduction studies showed moderate median nerve compression at the right wrist, and severe ulnar neuropathy with conduction block at the right elbow. Magnetic resonance imaging of the right wrist and elbow revealed diffuse thickening over a long length of ulnar nerve and some thickening of the median nerve. Multiple subcutaneous nodules were also identified on imaging. Our key differentials included sarcoidosis, Mycobacterium or fungal infection. Repeat biopsy was performed and Mycobacterium leprae was confirmed on polymerase chain reaction. Repeat QuantiFERON was positive. The infectious disease team treated him for multibacillary leprosy with dapsone, rifampicin, clofazimine and steroids. Leprosy is a neglected tropical disease that is under-recognized in Europe, resulting in treatment delay. This is a unique case of leprosy in Ireland, which demonstrates the utility of cutaneous findings and skin biopsy in attaining a diagnosis.