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Volume 23, Number 11—November 2017
Research Letter

Autochthonous Leprosy without Armadillo Exposure, Eastern United States

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Tina Rendini and William LevisComments to Author 
Author affiliations: Bellevue Hospital Center, New York, New York, USA

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Abstract

Autochthonous leprosy has been reported in New York City, where there are no wild armadillos. Recent autochthonous cases also have been reported in Georgia and Florida and blamed on armadillos, including cases with no known armadillo exposure. International migration needs to be considered as a cause of autochthonous leprosy.

In 1982, we reported that leprosy in New York City occurred exclusively among foreign-born persons (1). In 1991, Mastro et al. reported that leprosy was an epidemic phenomenon without secondary transmission (2). In 2000, however, the first autochthonous cases of leprosy in New York City were reported (3), and 2 additional autochthonous cases subsequently were reported (4,5). Autochthonous leprosy has been reported in the eastern United States in Georgia (6) and central Florida (7); transmission was blamed on armadillos, even though most of these case-patients had no history of exposure to armadillos, and armadillos east of the Mississippi River rarely have leprosy (8).

Although the transmission of leprosy is poorly understood, international migration of persons with leprosy is a more likely scenario for autochthonous transmission than contact with armadillos, especially if a case-patient has no history of armadillo exposure. Ramos et al. linked an increase in autochthonous leprosy in Spain to a 5-fold increase in migration from countries where leprosy is prevalent (9). There are no wild armadillos in New York City. Autochthonous cases of leprosy reported from the eastern United States should not be assumed to be from armadillos. Physicians throughout the United States need to be aware that leprosy can occur in native-born Americans and that delayed diagnosis, which occurs frequently, can result in unacceptable deformities.

Leprosy most commonly is characterized by an infiltrative dermopathy, which dermatologists and many physicians know is an indication for skin biopsy. Many otherwise highly trained physicians are not aware of this indication for a skin biopsy, which is required to diagnose leprosy. This indication is routinely taught in dermatology clinics, but leprosy is common enough in the United States that it should be incorporated into the core curricula of medical schools. Leprosy also can be characterized by fever and arthritis simulating lupus erythematosus, rheumatoid arthritis, or antiphospholipid syndrome because autoantibodies occur in type II reaction known as erythema nodosum leprosum. Physicians should order a Fite stain on the skin biopsy specimen because Mycobacterium leprae is sensitive to the alcohol decolorizing step; if only a routine acid-fast stain (Ziehl-Neelsen) is ordered, the diagnosis is often missed (10).

Ms. Rendini is an RN training to be a nurse practitioner and works in the New York Hansen’s Disease Program, Bellevue Hospital, New York, NY. She has expertise in leprosy and HIV.

Dr. Levis is a physician scientist member of the American Society of Clinical Investigation and attending physician of the New York Hansen’s Disease Program, Bellevue Hospital. His research interests include leprosy, cancer, HIV, and autoimmunity.

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References

  1. Levis  WR, Schuman  JS, Friedman  SM, Newfield  SA. An epidemiologic evaluation of leprosy in New York City. JAMA. 1982;247:32216. DOIPubMed
  2. Mastro  TD, Redd  SC, Breiman  RF. Imported leprosy in the United States, 1978 through 1988: an epidemic without secondary transmission. Am J Public Health. 1992;82:112730. DOIPubMed
  3. Levis  WR, Vides  EA, Cabrera  A. Leprosy in the eastern United States. JAMA. 2000;283:10045. DOIPubMed
  4. Keo  T, Martiniuk  F, Latkowski  J, Cabrera  A, Rom  W, Levis  WR. Molecular origin of endemic leprosy in New York City. Clin Infect Dis. 2008;46:899901. DOIPubMed
  5. Levis  WR, Paraskevas  LR, Jacobson  M, Spencer  J, Spencer  T, Martiniuk  F. Endemic leprosy in New York City. Arch Dermatol. 2011;147:6246. DOIPubMed
  6. Lane  JE, Walsh  DS, Meyers  WM, Klassen-Fischer  MK, Kent  DE, Cohen  DJ. Borderline tuberculoid leprosy in a woman from the state of Georgia with armadillo exposure. J Am Acad Dermatol. 2006;55:7146. DOIPubMed
  7. Domozych  R, Kim  E, Hart  S, Greenwald  J. Increasing incidence of leprosy and transmission from armadillos in Central Florida: A case series. JAAD Case Rep. 2016;2:18992. DOIPubMed
  8. Sharma  R, Singh  P, Loughry  WJ, Lockhart  JM, Inman  WB, Duthie  MS, et al. Zoonotic leprosy in the southeastern United States. Emerg Infect Dis. 2015;21:212734. DOIPubMed
  9. Ramos  JM, Romero  D, Belinchón  I. Epidemiology of leprosy in Spain: the role of the international migration. PLoS Negl Trop Dis. 2016;10:e0004321. DOIPubMed
  10. Zhu  TH, Kamangar  F, Silverstein  M, Fung  MA. Borderline tuberculoid leprosy masquerading as granuloma annulare: a clinical and histological pitfall. Am J Dermatopathol. 2017;39:2969. DOIPubMed

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Cite This Article

DOI: 10.3201/eid2311.171145

Table of Contents – Volume 23, Number 11—November 2017

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William Levis, Bellevue Hospital Center—Dermatology, 462 1st Ave, 17N7, New York, NY 10016-9198, USA

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Page created: October 17, 2017
Page updated: October 17, 2017
Page reviewed: October 17, 2017
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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