Lepromatous Leprosy with nasal myiasis presenting as epistaxis in postleprosy elimination era

Dear Editor,

Leprosy is a chronic mycobacterial infection caused by Mycobacterium leprae. India achieved elimination of Leprosy in 2005, defined as less than one case per 10,000 population. Nevertheless, India has the highest number of Leprosy cases globally, despite being eliminated, and thousands of new cases are detected every year.¹ Lepromatous Leprosy patients remain asymptomatic for years, and harbor bacteria in the nasal cavity, and these patients are responsible for the transmission of the disease in the community. Many recent studies conducted in the postelimination era in our country have concluded a higher percentage of multibacillary cases and child Leprosy cases, suggesting active transmission of disease.^2,3 We present a case of Lepromatous Leprosy that presented with epistaxis. Patient consent was obtained for disclosure of data and images.

A 38-year-old male patient presented to the otorhinolaryngology outpatient department with complaints of epistaxis of 2 days duration. Evaluation of epistaxis using nasal endoscopy showed nasal myiasis. He was referred to the dermatology outpatient department for loss of sensation involving hands and feet. Dermatological examination revealed superciliary madarosis, infiltration of face and ears, resulting in leonine facies [Fig. 1a]. There was a patchy glove and stocking hypoesthesia with ichthyosis involving upper and lower limbs. Bilateral greater auricular [Fig. 1b], ulnar nerve, common peroneal, and sural nerve were thickened and nontender. Right ulnar claw hand with trophic ulcer was present on the ulnar aspect of right hand [Fig. 1c]. Investigations revealed normocytic, normochromic anemia with hemoglobin of 9 gm%, erythrocyte sedimentation rate of 40 mm/h, rest of the hematological and biochemical parameters were within normal limits. Slit skin smear from ear lobe revealed acid-fast bacilli in globi. Histopathological examination showed the presence of atrophic epidermis, uninvolved Grenz zone, and macrophage granulomas [Fig. 2a]. Fite-Faraco stain showed the presence of acid-fast bacilli [Fig. 2b]. Diagnosis of Lepromatous Leprosy with the right ulnar claw hand and nasal myiasis was made. Maggots were removed using nasal endoscopy, and the patient was started on multibacillary multidrug therapy (MB- MDT) [Fig. 2c].

Fig. 1.

a – Infiltration of face, ears, superciliary madarosis giving rise to leonine facies. b –Thickened and elongated ear lobes and thickened greater auricular nerve. c –Right ulnar claw hand and the presence of trophic ulcer on the ulnar aspect of the right hand.

Fig. 2.

a – Histopathological examination of skin biopsy shows atrophic epidermis, the presence of Grenz zone, and macrophage granuloma (H&E stain, 10 ×). b – Fite-Faraco stain shows the presence of acid-fast bacilli. c – Nasal endoscopy shows nasal myiasis.

Leprosy is a chronic disease with a long incubation period ranging from two months to six years, affecting the skin and peripheral nerves. It is caused by Mycobacterium leprae that is an acid-fast, obligate intracellular organism. It can also affect the mucous membranes, eye, nose, joints, lymph nodes, internal organs, and bone marrow.⁴ Leprosy is transmitted mainly to the people living in close contact with patients through aerosols and direct contact. Humans are the main natural reservoirs of the bacillus, especially patients suffering from Lepromatous Leprosy.⁵ Host cellular immune response decides the clinical manifestations of Leprosy. The indeterminate form that is defined by hypopigmented lesions with ill-defined borders is thought to be the early presentation of Leprosy. Tuberculoid pole of Leprosy occurs in a patient with good immune response and presents early due to hypoaesthetic or anesthetic numb patch and early nerve involvement. The lepromatous pole of Leprosy presents late due to ill-defined normoaesthetic lesions and late nerve damage. The average duration for diagnosis of Lepromatous Leprosy before the definitive diagnosis is almost 10 years. The irony is that these patients are unaware of the disease, transmit it more effectively, and are detected late in the illness resulting in a barrier to its eradication. Lepromatous Leprosy in the advanced stage is characterized by disfiguring mutilation with infiltration of face and ears, superciliary madarosis, nasal septal collapse collectively known as leonine facies.^6,7

Nasal involvement is common in Lepromatous Leprosy, and respiratory droplets are responsible for the transmission of Leprosy. The nose acts as a reservoir and a conduit for M. leprae to enter inside the body. Nasal obstruction, stuffiness, crusting, epistaxis, and hyposmia are early symptoms and may occur before the development of skin or nerve involvement. The degree of hyposmia correlates with the severity of the disease. Epistaxis is generally mild and results from crusting of the nasal mucosa. The obstruction is secondary to granulomatous infiltration of the nasal mucosa.^8,9

Myiasis is a rare complication of Lepromatous Leprosy. It (Myia; Greek-fly) is an infestation of skin by larvae (maggots) of various fly species. Common species causing cutaneous myiasis are dermatobia hominis, cordylobia anthropophaga, cochliomyia hominivorax, chrysomia bezziana, hypoderma bovis, gasterophilus intestinalis and oesterus ovis.¹⁰ It can be classified as wound myiasis, furuncular myiasis, migratory, cavitary, and orbital myiasis. Cutaneous and wound myiasis is the commonest presentation. Myiasis is more common in the tropics and subtropics, and it causes local tissue damage. Nasal myiasis is the infestation of the nasal cavity by larvae. The patient presents with epistaxis, foul-smelling and blood-tinged nasal discharge, nasal obstruction, and facial pain. Orbital cellulitis, meningitis, and cavernous sinus thrombosis are rare but potentially fatal complications.¹¹ Tissue destruction at times can lead to nasal perforation and deformities. The commonest underlying disease is primary atrophic rhinitis; it has also been reported in Leprosy, tuberculosis, and rhinoscleroma. The long-standing damage to the nasal mucosa, hyposmia, and loss of sensation predispose Lepromatous Leprosy patients to develop nasal myiasis.¹² Topical application of turpentine in swabs with manual extraction has been used as a treatment. Endoscopic removal of maggots under direct vision is preferable as it allows removal from inaccessible areas of the nose and sinus.¹³

Even in the postelimination era, Leprosy is not uncommon and still remains a public health problem. A high index of suspicion is required to diagnose Lepromatous Leprosy cases early to prevent the spread of the disease in the community. Awareness of both general public and treating physicians to the nasal signs may help in the early detection of Lepromatous Leprosy.