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Mycobacteria: Tuberculosis and Leprosy. Rick Lin, DO MPH. Tuberculosis. Epidemiology Estimated 1.7 billion infected persons 1/3 of world’s population 10 million people in US 12 million new cases per year w/ 3 million deaths 4 million co-infected with HIV ¾ live in sub-Saharan Africa

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  • Estimated 1.7 billion infected persons
    • 1/3 of world’s population
    • 10 million people in US
  • 12 million new cases per year w/ 3 million deaths
  • 4 million co-infected with HIV
    • ¾ live in sub-Saharan Africa
  • Incidence tied to poverty, unemployment, homelessness, AIDS and drug resistance
  • Multi-drug resistant disease (MDRTB) major problem


  • Mycobacterium tuberculosis (Tubercle bacillus, MTB), M. bovis, M. africanum and BCG
  • Immune response contains infection in majority
    • 5-10% of immunocompetent develop clinical disease
  • Rarely eradicated due to resistance to macrophage destruction, dormancy within granulomas
  • Dormant bacilli resistant to antimycobacterials
  • Immunosuppression often leads to clinical sx


  • MTB Surface Coat
    • Mycolic acid
    • Highly inflammatory
    • Stimulates Macrophages and T lymphs


  • Pulmonary:
    • SOB
    • Sputum production
  • Systemic:
    • Fatigue
    • Malaise
    • Fever (in ddx for FUO)
    • Lethargy
    • Weight loss


  • Disseminated Disease:
    • Miliary pattern on CXR
    • Pancytopenia
    • Other Sites:
      • Bones, GI, brain, meninges
      • Almost any organ
  • Asymptomatic in large number of persons
    • 90%
the tuberculin reaction
The Tuberculin Reaction
  • The Koch Phenomenon
  • Most likely due to a Delayed T-cell Hypersensitivy (DTH) rxn
    • Mediated by sensitized T lymphs when injected into a nonsensitized individual
  • In sensitized individual rxn varies depending on test dose and route of administration
  • Local intradermal inject. leads to the local TB rxn
  • Reaches max intensity after 48 hrs
  • Consists of a sharply circumscribed area of erythema and induration
the tuberculin reaction9
The Tuberculin Reaction
  • Purified Protein Derivative (PPD) is currently used
  • Read 48-72 hours after intradermal injection
  • Becomes positive between 2 and 10 weeks and remains positive for many years

ppd evaluation
PPD evaluation
  • 0.1ml of PPD (5U) placed intradermally to form a wheal
  • Measure true induration (not erythema) 48-72 hrs
    • >5mm Induration is positive in following hosts:
      • patients with recent close contact with a person with active TB
      • patients with fibrotic lesions on chest radiograph
      • patients with known or suspected HIV infection
    • >10mm Induration is positive in:
      • Patients with high risk comorbid conditions
      • Persons from endemic areas
      • Residents of long-term (chronic) care facilities
    • >15mm required for positivity in normal hosts
tb histopathology
TB Histopathology
  • Tubercle is the hallmark
    • Accumulation of epithelioid histiocytes with Langerhans giant cells
    • Caseation necrosis in the center
    • Rim of lymphs & monos
  • The tuberculioid granuloma is characteristic but NOT pathognomonic

This is a higher magnification of the tuberculous process illustrating specifically the multinuclear giant cells (g) or Langerhans cells with numerous adjacent histiocytes (h) or epithelioid cells. The epithelioid cells are the fat histiocytes which bear some resemblance to epithelial cells. The Langerhans giant cells possibly result from a coalescing of multiple histiocytes or perhaps even by incomplete mitotic division of reproducing histiocytes.


This frame shows caseation necrosis (c). There is none of the residual framework of the pre-existing tissue and the blue dots represent the nuclear debris from necrotic cells. The peripheral cells in the field are histiocytes (h).

bcg vaccination
BCG Vaccination
  • Bacillus Calmette-Guerin (BCG) is a living attenuated bovine tubercle bacillus to enhance immunity to tuberculosis
  • Only given to TB (-) persons
  • Reduces childhood TB up to 75%
  • Normal course of BCG vaccination
    • 2 wks: infiltrated papule develops
    • 6-12 wks: size of 10mm, ulcerates, and then slowly heals leaving a scar
primary inoculation tb
Primary Inoculation TB
  • 2-4 wks after inoculation painless brown-red ulcer with hemorrhagic base
  • 3-8 wks regional lymphadenopathy - painless
  • Face, hands, and legs
  • Histopathology
    • Typical tubercles
      • Langerhan’s cells w/ epithelioid cells surrounded by monocytes
primary inoculation tb17
Primary Inoculation TB
  • Course:
    • W/o tx may last up to 12 mo
    • Lesions heal by scaring
  • Primary TB complex usually yields immunity but reactivation my occur
primary cutaneous tb
Primary Cutaneous TB

tuberculosis verrucosa cutis
Tuberculosis Verrucosa Cutis
  • Exogenous reinfection of MTB in a person previously sensitized
  • Minor wound often site of entry
    • many cases in pathologists/ postmortem attendants - hence the expression “prosector’s warts”
  • PPD highly (+)

tuberculosis verrucosa cutis20
Tuberculosis Verrucosa Cutis
  • Usually a single slow-growing plaque or nodule m/c on hands
    • Small papule that becomes hyperkeratotic
    • Peripheral expansion w/ wo central clearing
  • Clefts and fissures discharging pus extend into the underlying base which is brownish-red to purplish
  • TB involvement of the skin by direct extension
  • Usually underlying TB lymphadenitis
    • Cervial Lymph nodes MC
  • Develops as firm subcutaneous bluish-red nodules
    • Break down and perforate leaving undermined ulcers and discharging sinuses
    • Bilateral

  • Histopathology:
    • Massive necrosis and abscess formation in the center
    • The periphery of the abscess or the margins of the sinuses contain tuberculoid granulomas and true tubercles
      • Acid-fast bacilli
    • MTB can be found
tuberculosis orificialis
Tuberculosis Orificialis
  • TB of mucous membranes and skin surrounding orifices
    • Usually by autoinoculation
  • Seen in pts with TB of internal organs
    • GI Tract or Lungs
  • Mouth most commonly affected site
    • Tongue and palate
  • Prognosis poor – advanced internal disease
  • Presents as painful yellow or red nodule that ulcerates to form punched-out ulcer
tuberculosis orificialis25
Tuberculosis Orificialis
  • Histopath:
    • Massive nonspecific inflammatory infiltrate and necrosis
    • Tubercles with caseation may be found deep in the dermis
    • Numerous bacilli
lupus vulgaris
Lupus Vulgaris
  • Cutaneous TB from hematogenous spread
    • Chronic and progressive
    • 50% have TB elsewhere
  • Single plaque of grouped red-brown papules that blanch with diascopic pressure
    • “Apple-jelly” nodules = pale brown/yellow
    • Spreads peripherally
    • Risk of BCC/SCC with mets
  • 90% occur head/neck

lupus vulgaris28
Lupus Vulgaris
  • Histopath
    • Hallmark: Classic Tubercles
metastatic tuberculous abscess
Metastatic Tuberculous Abscess
  • Tuberculous Gumma
    • Hematogenous dissemination from primary focus during a period of lowered resistance leading to distant abscess/ulcer
      • SubQ abcesses
      • Nontender
      • Fluctuant
      • Singly or as multiples on the trunk, ext, or head
      • Usually occurs in undernourished children or the immunodeficient or immuosuppressed
metastatic tuberculous abscess31
Metastatic Tuberculous Abscess
  • Histo:
    • Similar to scrofuloderma
    • Massive necrosis and abcess formation
    • Acid fast stains = copious amounts of myocbacteria
miliary tb miliaris disseminata
Miliary TB (Miliaris Disseminata)
  • Hematogenous dissemination of MTB
  • Infants / young children
  • Focus of infection typically meningeal/pulmonary
  • May follow infections such as measles and HIV
  • Presentation:
    • Minute erythematous macules or papules and purpuric lesions
    • Sometimes umbilicated vesicles or a central necrosis and crust develop in severely ill patients
miliary tb miliaris disseminata33
Miliary TB (Miliaris Disseminata)
  • Histopath:
    • Initially:
      • Necrosis and nonspecific inflam infiltrates and abcesses
      • Occasionally signs of vasculitis
      • MTB are present in and around vessels
    • Later stages (if the pt. develops immunity):
      • Lymphocytic cuffing of vessels and even tubercles

Miliary TB of the Liver

Multinucleated Giant Cell

  • Cutaneous immunologic rxn to TB elsewhere
  • By definition stains negative
  • Most likely the result of hematogenous dissemination in pts with high degree of immunity
    • With PCR, mycobacterial DNA demonstrated in both papulonecrotic tuberculid and erythema induratum of Bazin
  • All demonstrate rapid response to antiTB tx
  • Strongly positive PPD
  • Most exhibit tuberculois features histologically
  • Lichen Scrofulosorum
    • Rare eruption of asymptomatic, minute, flat-topped yellow to pink follicular or parafollicular papules
    • May have a minute horny spine or fine scales
    • Occurs m/c on trunk of children and adolescents with TB in lymph nodes/bone
    • PPD (+)
    • Persist for months but spontaneous involution ensues
    • AntiTB tx results in resolution w/in weeks
  • Lichen Scrofulosorum
  • Histopath:
    • Superficial noncaseating tuberculoid granulomas develop around hair follicles
  • Mycobacterium are not seen and can't be cultured

Papulonecrotic Tuberculid

  • Symmetric, necrotic papules that occur in crops over the extremities and healby scarring
  • Dusky red, symptomless, pea-sized papules
  • Usually seen in children or young adults
  • MTB DNA has been detected in about 50% of pts

Papulonecrotic Tuberculid

  • Histopath:
    • Wedge-shaped necrosis of the upper dermis extending into the epidermis
    • Involvement of blood vessels is a cardinal feature
      • Consists of an obliterative and sometimes granulomatous vasculitis leading to thrombosis and complete occlusion
papulonecrotic tuberculid
Papulonecrotic Tuberculid

Dusky red, pea sized papules that

are symmetric and become necrotic


Erythema Induratum (Bazin’s Disease)

  • Dusky-red 1-2 cm tender nodules usually occurring on the lower legs in middle-aged women
  • Resolve spontaneously w or wo ulceration
  • The vessels of these pts react abnormally to changes in ambient temp
    • The eruptions assoc w/ exposure to cold
  • Active TB is found only rarely
erythema induratum
Erythema Induratum

Evidence of panniculitis exhibiting lobular, granulomatous, and lymphohistiocytic inflammation

Nodules after

resolving with


atypical mycobacteria
Atypical Mycobacteria

Mycobacterium marinum

  • “Swimming pool/fish tank” granuloma
  • Ulcerating lesions in skin at site of abrasions incurred in swimming pools about 2-3 wks. after inoculation
  • Single nodules, typically on hands, may ulcerate and suppurate with sporotricoid ascending spread
  • Fresh and salt water
  • Tx with Minocycline 100 mg bid
  • Heals spont. 1-2 yrs. w/residual scarring

Mycobacterium marinum

Localized Necrosis

Intracellular bacilli

Acid fast bacilli stain of tissue infected with M. marinum

atypical mycobacteria45
Atypical Mycobacteria

Mycobacterium ulcerans infection

  • Buruli ulcer, Bairnsdale ulcer, Searl ulcer
  • Subequatorial regions of Africa, wet, marshy, swampy areas
  • Never found outside the human body
  • Incubation period of ~3 mo
  • Painless subq swelling which enlarges to a nodule that ulcerates
  • Ulcer is deeply undermined and necrotic fat is exposed exposing muscle and tendon
atypical mycobacteria46
Atypical Mycobacteria

Mycobacterium ulcerans infection

  • Histo- Central necrosis in the interlobular septa of the subcut. fat, surrounded by granulation tissue w/giant cells but no typical caseation necrosis or tubercles. AF orgs. can always be demonstrated.
  • TX- Excision of early lesion. Local heat, hyperbaric oxygen and chemo w/RIF and Bactrim.
m ulcerans
M. ulcerans

In A, arrows indicate necrosis of adipose tissue distant from the location of AFB, and in B, the arrow indicates predominance of extracellular bacilli and microcolonies

atypical mycobacteria48
Atypical Mycobacteria

Mycobacterium kansasaii

  • Unusual skin pathogen more commonly associated with pulmonary disease in middle-aged men
    • Infections localized to Midwestern states and Texas
  • Acquired from the environment
  • Variable skin presentations:
    • Nodules
    • Plaques
    • Crusted ulcers m/c in immuno-suppressed
  • Responsive to anti-TB tx: Streptomycin, Rif, Emb
  • Atypical mycobacterium most closely related to MTB
atypical mycobacteria49
Atypical Mycobacteria
  • Mycobacterium avium complex (MAI/MAC)
  • M. avium and M. intracellulare infects lungs and lymph nodes but occasionally causes cutaneous lesions with dissemination
  • Single or multiple painless, scaling, yellowish plaques w/ a tendency to ulcerate
  • Common in AIDS
  • Highly resistant to anti-TB drugs requiring several in combination:
    • Azithromycin, Rifampin, Ethambutol
  • Where feasible surgical tx is advisable
  • Rifampin used for prophylaxis

Mycobacterium avium

Mycobacterium intracellulare

atypical mycobacteria51
Atypical Mycobacteria

Mycobacterium szulgai

  • Associated with:
    • Cervical lymphadenitis
    • Cellulitis
    • Draining nodules and plaques
  • Can also cause bursitis and pneumonia
  • More susceptible to antiTB drugs than most other atypical mycobacterium
atypical mycobacteria52
Atypical Mycobacteria

Mycobacterium haemophilum

  • SubQ granulomatous eruptions
    • Immunosuppressed - HIV
  • Histo:
    • mixed polymorphonuclear and granulomatous inflam
    • “Dimorphic inflammatory response”
      • No caseation necrosis
  • May be sensitive to p-aminosaliclyic acid and Rifampin
atypical mycobacteria53
Atypical Mycobacteria

Mycobacterium genavese

  • Little is known about this organism
  • Causes disseminated dz
    • Similar to M. avium intracellulare in HIV infected pts
atypical mycobacteria54
Atypical Mycobacteria

Mycobacterium fortuitum complex

  • Three similar species:
    • M. fortuitum
    • M. chelonei
    • M. abscessus
  • Saprophytes, found chiefly in soil and water
  • Rarely cause human disease
    • Immunocompromised
    • Prosthetic heart valves and joints
  • Usually follows puncture wound or surgery
atypical mycobacteria55
Atypical Mycobacteria

Mycobacterium fortuitum complex



  • Dreaded, chronic, poorly-transmissible granulomatous disease of the skin and nerves caused by acid-fast M. leprae
  • Probably least infectious of all diseases:
    • Strong cell-mediated immunity keeps organism at bay in most people
    • Humans only natural host but reservoirs:
      • 9-banded armadillo (Texas)
      • 3 species of monkey


  • Pregnancy is a precipitating factor in 10-25% of female patients
    • Due to altered immunity
  • Approx 1/3 of newly dx'ed pts w/leprosy will eventually have some chronic disability
    • Secondary to irreversible nerve injury
    • M/C hands or feet
  • Lepromin skin test
    • Analogous to the tuberculin test
    • Positive at 48 hours = Fernandez reaction
    • Positive again at 3-4 weeks = Mitusda reaction
  • Late reaction indicative of immune status of patient
  • Clinical presentation complex
  • Little is known about why different people respond differently to leprosy bacillus


  • 5 million persons worldwide
  • 7 thousand active cases in USA
  • 250 new cases /year
  • 620,000 new cases worldwide/year.
  • 80% in 6 countries: Bangladesh, Brazil, India, Indonesia, Myanmar, Nigeria
  • Endemic in SE Asia, Far East, Africa, South/Central America
  • Cases in Puerto Rico, Cuba, USA

Biological behavior and transmission

  • Cell-mediated immune response
    • Low antigenicity
  • Obligate intracellular parasite
  • Grows only in colder areas:
    • skin, cutaneous nerves, testes, hands, feet
  • Multiplies in neurons in macrophages and keratinocytes causing nerve damage/disability

Biological behavior and transmission

  • Strips away myelin from nerve fibers
    • Directly harms nerve cells with involving the inflammatory system
  • Does not have to enter the schwann cells to cause degeneration of myelin
nerve examination sites
Nerve Examination Sites

1) Ulnar Nerve

Muscle wasting in hand with contracture 4th and 5th fingers with anaesthesia. Enlarged at or above Olecranon groove at elbow - may be confused with an enlarged Trochlear lymph gland adjacent to the nerve.

2) Median Nerve

Muscle wasting and contractures of thumb and 2nd and 3rd fingers. Enlarged at anterior wrist but difficult to distinguish from adjacent tendons.

3) Radial Nerve

Wrist drop - not common. An enlarged radial cutaneous nerve may be palpated at the lateral border of the radius proximal to the wrist. This nerve passes to the dorsum of the hand.

4) Lateral or External Popliteal Nerve

Foot drop. May be palpated crossing the neck of the fibula. Can often be palpated in a normal muscular person.

5) Posterior Tibial Nerve

Posterior and inferior to the medial malleolus.

6) Great Auricular Nerve

A sensory skin nerve which crosses the sternomastoid muscle in the neck. It is usually not palpable in a normal person.

7) Skin Sensory Nerves near skin lesions may be enlarged.

8) 7th Cranial Nerve

It is not palpable but damage to the nerve leads to facial paralysis and lagophthalmos.

9) 5th Cranial Nerve Sensory Fibers

If it is damaged, it leads to anaesthesia of cornea.


Biological behavior and transmission

  • Transmission similar to TB
    • Nasal mucosa
    • Typically requires extensive contact
  • Incubation for Tuberculoid leprosy is up to 5 yrs and may be > 20 yrs


  • 2 of 3 clinical criteria
    • Anesthesia of the skin
    • Thickened peripheral nerves
    • Typical skin lesions
  • Slit-skin smear (Abroad)
    • Tissue fluid exudate examined with Fitestain to determine bacterial index
  • Punch bx of skin lesion (USA)
    • Fite stain reveals intracellular bacilli
    • PCR


  • Histologic changes helpful but are not diagnostic
    • One exception to this rule:
      • Presence of epitheloid cell granulomas w/in nerves = Tuberculoid leprosy or a severe reversal reaction.

Identification and Quantification of Bacilli

  • AFB in tissue are best shown by carbolfuschin staining using modifications of the Ziehl-Neelson method collectively called Fite-Farraco stains
  • M. leprae are weekly acid fast
  • Rod shaped bacilli
    • Found in macrophages and nerves
    • Quantified logarithmically by the bacillary index (BI): the numbers of bacilli per oil-immersion field or the numbers of OIFs sought to find 1 bacilli
tuberculoid leprosy
Tuberculoid Leprosy
  • TT = Polar Tuberculoid
    • Features:
      • Single to few anesthetic macules or plaques
      • Hypopigmented
      • Borderswell defined
      • Peripheral nerve involvement common
      • Localized & asymmetrical
      • May contact epidermisand do more damage to nerves than LL
    • Lepromin Rxn: very strong
    • Bacillary density: None
tuberculoid leprosy70
Tuberculoid Leprosy






tuberculoid leprosy histology
Tuberculoid Leprosy Histology

Linear granuloma following the course of a nerve

Higher power view of granuloma surrounding the nerve

borderline tuberculoid leprosy
Borderline Tuberculoid Leprosy
  • Lesions similar to TT
    • Borders less distinct
    • Multiple (>5)
  • Satellite lesions sometimes seen around larger lesions
  • Peripheral nerves involved earlier
  • Lepromin Rxn: Mild
  • Bacillary Density: Scant
borderline leprosy
Borderline Leprosy
  • Still more lesions that BT
  • Borders more vague
  • Asymmetric
  • Bizarre punched-outlesions
  • Hair loss
  • Anhydrosis
  • Most common type
  • Lepromin Rxn: Weak
  • Bacillary Density: Moderate
borderline lepromatous leprosy
Borderline Lepromatous Leprosy
  • Multiple macular/papular/plaques
  • Symmetric lesions
  • Vague borders
  • Neuritis late then neural lesions
  • Surface smooth and shiny with ill-defined border
  • Mixed granulomas
  • Leprae in neurons = enlargement
  • Lepromin Rxn: None
  • Bacillary Density: Heavy
borderline lepromatous leprosy75
Borderline Lepromatous Leprosy



Plaques with

Vague border

lepromatous leprosy
Lepromatous Leprosy
  • Multiple, non-anesthetic, macular and papular lesions
  • No neural lesions until very late
  • Late complications:
    • Madarosis
    • Leoninefacies
    • Testicular damage
  • Lepromin Rxn: None
  • Bacillary Density: Heavy
lepromatous leprosy77
Lepromatous Leprosy

Note the diffuse infiltration of the face with leonine facies and madarosis

lepromatous leprosy78
Lepromatous Leprosy
  • Pts have masses of histiocytes
    • Do not form good granulomas
    • Lepra cells = foamymacrophages packed with bacilli
    • Globi = masses of bacilli
    • Grenz Zone = seperates epidermis from dermis
lepromatous leprosy79
Lepromatous Leprosy

Grenz Zone

Seperates dermis from epidermis

Lepra Cells

Foamy histiocytes (macrophages) in the dermis

indeterminate leprosy
Indeterminate Leprosy
  • Vaguely defined hypopigmented or red macules
  • With or without sensory deficit
  • Lepromin Rxn: Weak
  • Bacillary Density: Rare
lucio leprosy
Lucio Leprosy
  • Scleroderma-like with hair loss and telangiectasias
  • Diffusely seen in Mexican/LA patients
  • May give rise to obstructive vasculitis
    • Aka Lucio phenomenon
sequelae of leprosy
Sequelae of Leprosy
  • Madarosis
  • Saddle nose
  • Blindness in the left eye
reactional states
Reactional States
  • 50% of patients after initiation of therapy
  • Causes considerable morbidity
  • Immune response-destructive, inflammatory process
reactional states84
Reactional States

Type 1 Lepra Reactions (upgrade)

  • Jopling's type 1 Reaction
  • Affects individuals with borderline disease
  • Type IV hypersensitivity – Cell-mediated change
  • Major Complication: Nerve swelling, pain and damage
  • Cutaneous lesions become tender, erythematous
  • Accelerated destruction of bacilli
  • Treat promptly with prednisone 40–60 mg/daily
  • Note downgrading reactions occur before the initiation of tx and represent shift to LL
reactional states85
Reactional States

Erythema Nodosum Leprosum (Type II lepra rxn)

  • Josling's type 2 reaction
  • Occurs in 50% of patients with LL and BL
  • Immune complex reaction (type III) between M. leprae antigens and host Ig
  • Widely distributed dermal nodules
    • Do not occur at previous skin lesions
  • IC precipitate in skin, endothelium, nerves, eyes
  • Systemic Sx’s: Fever, malaise, ulceration, neuritis, uveitis, glaucoma, acute inflammation
  • Tx with Thalidomide 400 mg daily
reactional states86
Reactional States

Lucio Phenomenon (Type III Lepra Reaction)

  • Latin Americans - Mexicans
  • Pts have La bonita's form of leprosy
    • Diffuse Lepromatosis
  • Lucio reaction results in large bullous lesions that ulcerate usually below knees
    • Due to deep cutaneous vasculitis (hemorrhagic infarcts)
    • Complications: sepsis and death
    • Tx:
      • Unresponsive to steroids or thalidomide
      • Antimicrobial chemo for leprosy
      • Wound care of ulcers
treatment of leprosy
Treatment of Leprosy

Medications of choice

  • Dapsone:
    • 100mg/d in adults
    • 1mg/kg/d in children
  • Clofazimine (Lamprene):
    • 50-100mg/d in adults
    • unestablished in children
  • Rifampin:
    • 600mg/mo in adults
treatment of leprosy88
Treatment of Leprosy

Type of Leprosy Monthly Daily Duration


(I, TT, BT) Rifampin 600mg Dapsone 100mg 6 months


(LL,BL,BB) Rifampin 600mg Clofazimine 50mg 24 months

Clofazimine 300mg Dapsone 100mg

treatment of leprosy89
Treatment of Leprosy

Effective 2nd-line drugs

  • Ofloxacin
  • Minocycline
  • Clarithromycin
treatment of leprosy90
Treatment of Leprosy


  • Dapsone:
    • Baseline G6PD and Hgb
  • Rifampin:
    • Baseline LFTs and platelets
  • Baseline and q 2 week PE of sensation and motor nerve function first months of therapy
  • Opthalmology baseline and periodic exam
  • Repeat slit-skin, Bx, PCR for response to tx
high resistance tuberculoid leprosy
High Resistance Tuberculoid Leprosy
  • Characterized by:
    • Few lesions
    • Rare organisms
    • Epitheloid cell granulomas w/ tendency to self-cure
    • Plaques w/ sharp margins are the inscription of anti-M. leprae DTH on the skin
    • Nerve trunk palsies are its inscription on the peripheral nerves
low resistance lepromatous leprosy
Low Resistance Lepromatous Leprosy
  • Characterized by:
    • Wide dissemination
    • Abundant orgs
    • Foamy macrophages
    • Untreated relentless progression