Bilateral ptosis/blepharitis due to lepromatous leprosy

Abstract

Purpose: To underscore the importance of histopathological evaluation in cases presenting with a constellation of unusual ocular inflammation and physical findings.

Observation: A 51-year-old male, presented with a chief complaint of worsening visual field loss due to droopy eyelids two months post excision of a right upper eyelid squamous cell carcinoma. His past medical history included chronic edematous facial features, chronic sinusitis, unexplained peripheral neuropathy, and worsening fatigue. Pre-blepharoplasty work-up revealed mechanical ptosis from lid edema, madarosis, a concave nasal bridge, pancytopenia, and numerous burn marks due to inadvertent injuries. Bilateral blepharoplasty was performed, and the excised tissue submitted for histopathological evaluation that revealed non-caseating granulomatous perineural inflammation with numerous acid-fast bacilli in dermal layers and nerves. These findings prompted a diagnosis of lepromatous leprosy with suspected bone marrow involvement. The source of the infection was unknown. The blepharoplasty restored his visual fields and multi-drug therapy (MDT) improved his general health and wellbeing with concomitant reductions of pancytopenia, fatigue, and facial edema.

Conclusions and importance: Biopsy histopathology, in patients with longstanding ocular adnexal inflammation, can facilitate diagnosis and treatment. To the authors' knowledge, this is an unusual ocular leprosy presentation and represents the first leprosy case diagnosed via blepharoplasty.

Keywords: Acid-fast bacillus; Eye; Hansen's disease; Mycobacterium leprae; Neuropathy; Pancytopenia.

Fig. 1

Clinical presentations pre and post blepharoplasty. (A) Photo of patient in mid-twenties. (B) Coarse facial features, bilateral ptosis, excessive and redundant eyelid skin, loss of eyelashes and eyebrows, and wide nasal bridge. (C) Side facial view showing his concave nasal bridge, excessive/redundant eyelid skin, and loss of eyelashes. (D) Thickened/edematous features of his hands with scars/burn marks. (E) Five days post surgery. (F) Six-months post surgery/MDT.

Fig. 2

Biopsy histopathology. (A) Hematoxylin-stained eyelid skin section showing numerous non-caseating granulomas (arrows). (B) Granulomatous inflammatory cells surrounding nerve fibers (arrows). (C) Numerous acid-fast bacilli seen in groups and singly dispersed within the dermis. Note the acid-fast bacilli in the nerve (arrow).