Figure 2: Clinical presentation showing nasal tip necrosis
Then the patient presented to emergency department (ER) with the same complaint. The ENT team were contacted. Then, she was admitted for further investigation. In ER, three biopsies were taken, mid nasal dorsum, left and right nasal dorsum. All showed acute inflammatory cells with no malignant cells. Also, culture was taken in ER and showed normal skin flora moderate growth. Blood culture was negative. Hepatitis A, B, and C negative. The patient was started on empirical antibiotic, Tazocin. At that time, by the clinical judgement of the nasal examination, our differential was either midline NK T cell lymphoma, granulomatosis with polyangiitis, leprosy, or vasculitis.
During her stay, Infectious diseases (ID) team were consulted, their recommendation was to discontinue Tazocin and start ceftriaxone 500mg once daily and metronidazole every 8 hours, amphotericin B 300mg intravenously. They also requested for acid fast bacilli, and culture. All came with negative results. Rheumatology team were also consulted, they requested for C-ANCA, P-ANCA, ANA, SSA, and SSB. All were negative except for ANA it came with positive result. Also, a chest x-ray was ordered and showed no cavities.
Next day the patient was taken to ENT operating room (OR). Endoscopic examination was normal, and no abnormality was seen except the nasal tip. Twelve biopsies were taken under general anesthesia. From right and left middle nasal turbinate, nasal septum. The result of the biopsies showed granulation tissue formation with dense acute inflammatory cells and no malignancy. Biopsies from the skin of right nostril, skin of left nostril were also taken, it showed chronic inflammation, no histopathological evidence of vasculitis, and no malignancy. Culture from wound and tissue came with a negative result, no organisms were seen.
Dermatology team were contacted, they took two punch biopsies from healthy tissues (cheeks) and requested for Hematoxylin and Eosin stain (H&E). Fungal, bacterial, mycobacterial swabs were also requested. Fungal culture and acid-fast bacilli were both negative. LDH normal 136. The biopsy was reported as a granuloma in deep dermis mainly around peripheral nerve. For a better visualization of Mycobacterium leprae, Wade-Fite acid fast stain (modified Ziehl-Neelsen stain) was used. It revealed scanty acid-fast bacilli-like organisms around the nerve suggestive of leprosy. Grocott’s Methenamine Silver (GMS) and Periodic Acid Schiff (PAS) stains were both negative.
After the biopsy result, ID were contacted, and they advised to start the patient on a triple antibiotic regimen which is dapsone 100mg orally once daily, rifampicin 600mg orally once monthly, clofazimine 50mg orally once daily, and follow up in their clinic. No surgical intervention other than the biopsies was done. Finally, the case was referred to plastic surgery for reconstruction and based on their recommendation, the reconstruction will be done after one year of starting the treatment, and if the disease is stable at that time. (Figure 3) Shows the presentation after 6 months of treatment initiation.