Lepromatous leprosy in a heart transplant recipient

Northern Louisiana is not an area for indigenous cases of leprosy. Limited data are available on the occurrence of leprosy in organ transplant recipients. No cases have been reported in heart transplant recipients. Mr J.R. is a 68-year-old man from Shreveport, Louisiana. He underwent orthotopic heart transplantation in March 1996. He presented in March 2000 with a maculopapular skin rash and intermittent hand swelling for 5 months. He also complained of intermittent burning of his feet for a year. The skin lesions were of two types - a fine red migratory, intermittent maculopapular rash over the upper torso and a raised, larger, violaceaous lesion on his hands. Neurological examination revealed complete loss of protective sensation in the right foot by filamentous test and some loss in the left foot. Punch skin biopsies from his right arm and right chest lesion revealed abundant acid-fast bacilli (AFB). Histopathologic examination revealed perivascular, interstitial and perineural granulomatous inflammation and a large number of AFB organisms within histiocytes. Culture of the skin biopsy specimen was negative for Mycobacterium tuberculosis or atypical mycobacterium. Polymerase chain reaction (PCR) performed for Mycobacterium leprae was positive. The patient was treated with a modified regimen consisting of dapsone 100 mg qd, ethionamide 250 mg qd, and minocycline 100 mg qd. His skin rash and neurological symptoms have resolved.