[Bone complications in a patient with lepromatous leprosy].

To the Editor: Leprosy (Hansen disease) is a slowly progressive, infectious, chronic granulomatous disease caused by Mycobacterium leprae; it can be complicated by the appearance of lepra reactions.1 The skin and superficial peripheral nerves are most frequently affected.1 Although its worldwide prevalence has fallen,1 leprosy continues to be a health problem due to its ability to cause permanent deformities. Bone disease is one of the principal prognostic factors2 and occurs in 15% to 29% of patients.3 Higher percentages (40%-95%) have been reported in the literature,2,4 in part because such data come from subjects in leper colonies and are therefore selected cases.5 We present the case of a 34-year-old Nigerian man diagnosed with lepromatous leprosy (multibacillary) in August 2004 after clinical and histological study of multiple hypopigmented lesions on the trunk and limbs (Figure 1). The patient then did not return to the outpatient clinic until January 2006, when he was admitted for a type 2 lepra reaction, which resolved after treatment with oral corticosteroids. During the admission, a sensorymotor neuropathy of the cubital, median, and common peroneal nerves was detected, and areas of bone damage (acroosteolysis and bone cysts) in the distal phalanges of several fingers. Specific treatment was started with multidrug therapy for multibacillary leprosy (rifampicin, dapsone, clofazimine) and also with daily doses of vitamin D, oral calcium, and intramuscular calcitonin in order to halt the bone disease. After discharge, the disease remained well controlled until June 2008, when he was seen in urgent outpatient consultation for a history of several days of swelling of right foot and fever up to 38°C. Physical examination revealed marked edema on the dorsum of the foot, with no crepitation on palpation. The peripheral pulses were present, but the third toe was a violaceous-black color and, on the sole, there was an ulcer with a dirty, exudative appearance under the head of the third metatarsal. An x-ray of the foot was requested, which showed signs of osteomyelitis and dislocation of the metatarsophalangeal joint of the third toe (Figure 2). In view of these findings, the orthopedic department considered it necessary to perform complete amputation of that toe (metatarsus and phalanges), together with systemic antibiotic treatment to be adjusted according to the results of the bone culture (positive for Escherichia coli and Klebsiella species). Histological study of the surgical specimen showed signs of osteomyelitis, but without granulomas and with no M leprae on Ziehl-Neelsen stain. The clinical course has been very satisfactory, and the use of a vacuum-assisted wound care system has achieved complete closure of the amputated region by second intention (Figure 3). Leprous bone lesions mainly affect the hands and feet and, in more advanced cases, the bones of the cranium