Lepromatous leprosy, melanoma, and basal cell carcinoma: clinical-histopathologic association

AnBrasDermatol.2019;94(5):586---589

Anais

Brasileiros

de

Dermatologia

CASE

REPORT

Lepromatous

leprosy,

melanoma,

and

basal

cell

carcinoma:

clinical-histopathologic

association

夽,夽夽

Cintia

Santos

Braghiroli

_,

_Maria

_Rita

_{Parise-Fortes}

_,

Mariângela

Esther

Alencar

Marques

_,

_Joel

_Carlos

_Lastória

a_{DepartmentofDermatologyandRadiotherapy,FaculdadedeMedicinadeBotucatu,UniversidadeEstadualPaulista,Botucatu,}

SP,Brazil

b_{DepartmentofPathology,FaculdadedeMedicinadeBotucatu,UniversidadeEstadualPaulista,Botucatu,SP,Brazil}

Received28June2018;accepted1September2018

KEYWORDS

Carcinoma,basal cell;

Leprosy; Melanoma

Abstract Cutaneousneoplasmsfrequentlyoccurinleprosy,buttherearefewreportsofthe

coexistence ofleprosyandbasal cellcarcinomainthesamelesion.This casereportsa

49-year-oldmalewithanulceratedplaqueontherightlateralnasalwall,brightpapulesonthe

sternalregion,andablackenedplaqueontherighttemporalregion.Thenasalandtemporal

lesionswerediagnosedbyhistopathologyasbasalcellcarcinomaandmelanoma,respectively.

The sternal lesions wereexcised with therepair ofthe‘‘dogear’’ which histopathological

examinationshowedmacrophagesinthedermisparasitizedwithacid-fastbacilli,confirming

thediagnosisoflepromatousleprosywithFite-Faracostaining.Thiscasereporthighlightsthe

importanceofreferringthedog-earspecimenforhistopathologicanalysis.

©2019PublishedbyElsevierEspa˜na,S.L.U.onbehalfofSociedadeBrasileiradeDermatologia.

ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/

by/4.0/).

夽 _{Howtocitethisarticle:BraghiroliCS, Parise-FortesMR,MarquesME,LastoriaJC. Lepromatousleprosy, melanoma,andbasalcell} carcinoma:clinical-histopathologicassociation.AnBrasDermatol.2019;94:586---9.

夽夽_{StudyconductedattheFaculdadedeMedicinadeBotucatu,UniversidadeEstadualPaulista,Botucatu,SP,Brazil.} ∗_{Correspondingauthor.}

E-mail:lastoria@fmb.unesp.br(J.C.Lastória). https://doi.org/10.1016/j.abd.2019.09.008

0365-0596/©2019PublishedbyElsevierEspa˜na,S.L.U.onbehalfofSociedadeBrasileiradeDermatologia.Thisisanopenaccessarticle undertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Lepromatousleprosy,melanoma,andbasalcellcarcinoma 587

Introduction

Basal cell carcinoma (BCC) is one of the most common malignantskintumors,accountingforabout75%ofallskin cancers, most commonly manifested on sun-exposed skin suchastheheadandneckofolderindividuals.1,2_Melanoma

isthemostaggressivecutaneousmalignancyandrepresents 10%ofallskincancerdiagnosed.3_{Melanomaislesscommon}

butmoreaggressivethanBCC.4

Leprosy is a chronic infectious disease caused by

Mycobacteriumleprae,anintracellularparasitethatmainly

affects skin and peripheral nerves, with tropism for macrophages and Schwann cells. The disease is transmit-tedthroughprolongedcontactwithuntreatedlepromatous leprosypatients.5,6_{The coexistenceof BCCandleprosyin}

the same lesion is uncommon, but it has been previously documented.7

Inthepresentreport,thediagnosisofleprosywasmade throughahistopathologicalfindinginthedog-earfragment excisedduringthesurgicalremovalofaBCC.The authors describethetripleassociationofBCC,lepromatousleprosy, andmelanomainamalepatientwithnoknown immunode-ficiency.

Case

report

The patientwasa 49-year-oldmalegardenerwithalarge ulcerated lesion on the right lateral nasal wall for three

yearsandonthesternalregionforfiveyears.Thesternal lesion showederythematous papules and a shinysurface, whilethenasallesionwasascar-like plaquewithpapules on the surface, meliceric crusts, and ulcerations. There wasalso a blackish plaque on the right temporal region, measuring approximately 4cm. Dermoscopy revealed a blue-white veil, chrysalis, globules, and irregular streaks on the periphery. Incisional biopsies were performed on the nasal and right temporal lesions, confirming ulcer-ated nodular BCC and melanoma, respectively (Fig. 1). The sternal lesion was completely resected by elliptical excision, withthe need tocorrect the ‘‘dog ear,’’ which wasalsoreferred forhistopathologicanalysis(Fig.2).The lesionwasconsistentwithBCC,andthefragmentfromthe ‘‘dogear’’ showedsome alterations thatled tothe need for acid-fast bacillus (AFB) staining, which revealed the presence of numerous intact granular bacilli with globus formation,resultinginthe diagnosisof multibacillary lep-rosy (Fig. 3). The patient presented ciliary madarosis, rarefaction of the terminal eyebrows, thickening of the skin on the frontal region and ears, and bilateral thick-ening of the ulnar nerve. The patient was treated for lepromatous leprosy with multidrug therapy (MDT: dap-sone,rifampicin,andclofazimine)andtotalexcisionofthe nasalandtemporallesionswasperformed.Histologic anal-ysis of the melanoma demonstrated the vertical growth phase, with Breslow thickness of 1.2mm and Clark level IV.

Figure1 (A)Basalcellcarcinoma(BCC)---nasal;melanoma---righttemporalregion.(B)BCC---clustersofbasaloidcells

(Hema-toxylin&eosin,×10).(C)Peripheralpalisadingofcells(Hematoxylin&eosin,×100).(D)Melanoma---nestsofatypicalmelanocytes

andpagetoidspread(Hematoxylin&eosin,×200).

588 BraghiroliCSetal.

Figure3 Histopathologyofthe‘‘dogear’’:(A)inflammatoryinfiltrateinperi-adnexalsuperficialanddeepdermis,lymphocytes

andmacrophageswithvacuolatedcytoplasm(Hematoxylin&eosin,×400).(B)Perineuriumdelaminationandinfiltrationby

lympho-cytesandmacrophages(Hematoxylin&eosin,_×400).(C)Acid-fastbacilluspositivewithintactgranularbacilliandglobusformation

(Fite-Faraco,×1000).

Discussion

The authors describe the co-occurrence of BCC and melanoma in a patient with lepromatous leprosy, whose diagnosiswasmadethroughhistopathologicanalysisofthe skinfragment fromthe ‘‘dogear’’ excisedduringsurgical removaloftheBCC.

BCC is one of the most prevalent tumors, and expo-sure to UV radiation is the main risk of factor for the developmentof thesetumors.The immunesystem is fun-damentalinthepreventionandcontrolofskintumors,and thedevelopmentappearstobedirectlylinkedto immuno-suppressioncausedbythecumulativeeffectofUVradiation, which acts to suppress the local and systemic immune response.8

Malignancydevelopingintrophiculcersinpatientswith lepromatous leprosy (e.g., squamous cell carcinoma and nodularmelanoma)isextremelyrare,withonlyafewcases reportedintheliterature.9,10

There is no report on whether immunosuppression in patientswithlepromatousleprosyfavorsamoreaggressive spreadofmalignantlesions.Astheimmuneresponseis

spe-cific toM. leprae, it is suggested that this factor cannot

beassociatedwiththedevelopmentofmalignanttumorsor susceptibilitytootherpathogens.

ThepresentcasesuggeststhatthecoexistenceofM. lep-raeandskintumorsinthesamelesionisprobablysecondary tolargenumbersofbacilli,althoughnobacilliwerefound inthemarginalanalysisofthefragmentsfromtheexcised lesionsonthenasalandtemporalregions.

The patient presented clinical signs of lepromatous leprosy, such as ciliary madarosis and terminal rarefac-tion of the eyebrows, infiltration of the frontal region and ears, and bilateral thickening of the ulnar nerve. Theseclinical signs of leprosy shouldhave been observed before the skin tumors, since the diagnosis of the dis-ease is based on clinical symptoms. Early diagnosis and specific treatment are essential to interrupt disease transmission.

Thiscasereportshowstheimportanceofcomplete der-matological examination and also reports the association betweenleprosyandcutaneousmalignancies,whichisstill poorlyunderstood.

Funding

Nonedeclared.

Author’s

contribution

Cintia Santos Braghiroli: Iintellectual participation in propaedeuticand/ortherapeuticconductofthecases stud-ied.

MariaRitaParise-Fortes:Obtaining,analyzingand inter-pretingthedata.

MariângelaEstherAlencarMarques:Obtaining,analyzing andinterpretingthedata.

Joel Carlos Lastória: Intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied.

Conflicts

of

interest

Nonedeclared.

Acknowledgments

TheauthorswishtothankDr.HamiltonOmettoStolfforhis collaborationwiththesurgeryandElieteCorreaSoaresfor hercollaborationwiththephotography.

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