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A previously healthy, 25-year-old woman presented with a hyperpigmented macule on the medial side of her right palm. She reported hypoesthesia over the lesion. Two years ago, she immigrated to the United States from Bangladesh. Five months ago, she visited Bangladesh to get married. A biopsy of the lesion obtained there showed multiple perineural granulomas with inflammatory cells. Gram stain and acid-fast bacillary and fungal stains of the biopsy specimen were negative. The patient was prescribed 1 dose each of doxycycline, ofloxacin, and rifampin and experienced no improvement.
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Tuberculoid leprosy with a single lesion and ulnar nerve involvement
D. Prescribe a 12-month course of dapsone combined with rifampin
The key to the correct diagnosis is the presence of a hypoesthetic macule and peripheral nerve enlargement in a patient from a region where tuberculoid leprosy is endemic. The diagnosis of tuberculoid leprosy is often based on clinical presentation, because skin biopsies, nerve biopsies, or both frequently do not reveal the pathogen. Single-dose therapy is inappropriate for patients with paucibacillary leprosy and peripheral nerve enlargement. A repeat biopsy is unlikely to be of benefit because of the low number of organisms in the tuberculoid form of leprosy. The presentation of a hypoesthetic macular patch with nerve enlargement is not consistent with a diagnosis of tuberculosis, so antituberculosis therapy would not be appropriate.
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Published Online: October 8, 2018. doi:10.1001/jama.2018.14701
Correction: This article was corrected online on December 7, 2018, to correct the letter for the answer in the What to Do Next section.
Corresponding Author: Pranatharthi H. Chandrasekar, MD, Harper University Hospital, 3990 John R St, 5 Hudson, Room 5929, Detroit, MI 48201 (firstname.lastname@example.org).
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Additional Contributions: We thank the patient for providing permission to share her information.
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