A 34-year-old woman in a stable relationship, born and living in Maceió-AL, smoker (1 pack/day), had been treated for Virchow's Leprosy in 2017–2018, with retreatment in 2018/2019. She reported chronic ulcers of the left lower limb (LLL) for over three years, with progressive worsening. On exam, she had bilateral ulnar nerve thickening without signs of neuritis, saddle nose, and pallor. Household contacts (stepfather and partner) had no signs of leprosy. The lesion measured 17 × 17 cm and was located on the anterior, lateral, and posterior aspects of the left leg, heel, and medial aspect of the left foot, with exuberant granulation tissue and areas of necrosis, irregular fibrotic borders, serous exudate, peri-lesional ocher dermatitis, exposed Achilles tendon, and impaired dorsiflexion of the foot. MRI (23.08.23) showed near-complete rupture of the flexor hallucis longus tendon at the metatarsophalangeal joint and marked Achilles tendon degeneration. Past treatments included multibacillary leprosy therapy plus prednisone, thalidomide, daily clofazimine, amitriptyline, pentoxifylline, topical papain, acetylsalicylic acid, albendazole, daily dressings, local debridement, and hyperbaric oxygen therapy, with poor response. Serologies for HIV, HTLV, hepatitis B and C, and syphilis were negative. Doppler ultrasound of the LLL veins showed no abnormalities in evaluated segments but revealed multiple inguinal lymph nodes up to 4.9 × 1.4 cm. She was admitted to the university hospital and initially treated with ciprofloxacin for about two weeks. Differential diagnoses included neoplasia, deep mycosis, Marjolin ulcer, leprosy sequelae, venous ulcer, among others. Rapid molecular test for Tuberculosis (TRM-TB) of biopsy material was positive for Mycobacterium tuberculosis susceptible to rifampicin. After one month of standard anti-TB treatment (rifampicin, isoniazid, pyrazinamide, and ethambutol), she showed favorable clinical response and remains on therapy with outpatient follow-up. Tuberculosis may have diverse clinical presentations and should be considered in the differential diagnosis of chronic cutaneous lesions, even in atypical cases.
Carvalho et al. (2026) studied this question.