[Skip to Content]
[Skip to Content Landing]

Hyperpigmented Macule on the Palm and Diminished Sensation

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

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.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

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 (pchandrasekar@med.wayne.edu).

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.

References
1.
World Health Organization (WHO). What is leprosy? http://www.who.int/lep/disease/en/. Accessed January 20, 2018.
2.
 Global leprosy update, 2014: need for early case detection.  Wkly Epidemiol Rec. 2015;90(36):461-474.PubMedGoogle Scholar
3.
Smith  DS. Leprosy. https://emedicine.medscape.com/article/220455-overview. August 24, 2018. Accessed September 21, 2018.
4.
Walker  SL, Lockwood  DN.  The clinical and immunological features of leprosy.  Br Med Bull. 2006;77-78:103-121. doi:10.1093/bmb/ldl010PubMedGoogle ScholarCrossref
5.
Gaschignard  J, Grant  AV, Thuc  NV,  et al.  Pauci- and multibacillary leprosy.  PLoS Negl Trop Dis. 2016;10(5):e0004345. doi:10.1371/journal.pntd.0004345PubMedGoogle ScholarCrossref
6.
Kitajima  S, En  J, Kitajima  S, Barua  S, Goto  M.  Review of WHO Expert Committee on Leprosy 8th report—comparison to 7th report  [in Japanese].  Nihon Hansenbyo Gakkai Zasshi. 2014;83(1):14-19. doi:10.5025/hansen.83.14PubMedGoogle ScholarCrossref
7.
World Health Organization (WHO). WHO model prescribing information: drugs used in leprosy. http://apps.who.int/medicinedocs/en/d/Jh2988e/5.html#Jh2988e.5. Published 1998. Accessed January 21, 2018.
8.
Fischer  M.  Leprosy—an overview of clinical features, diagnosis, and treatment.  J Dtsch Dermatol Ges. 2017;15(8):801-827.Google Scholar
9.
Centers for Disease Control and Prevention (CDC). Hansen's disease (leprosy): diagnosis and treatment. https://www.cdc.gov/leprosy/treatment/index.html. Updated January 30, 2017. Accessed January 24, 2018.
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close