This is a 28-year-old man, born in Codazzi (Cesar), from Santa Rosa do Sul (Bolivar).
At 22 years of age, the patient presented an anesthetic spot on the left flank, followed by months after numbness of hands and feet, drop of eyebrows, new spots on the trunk and extremities, congestion.
He could not handle the machete skillfully in his agricultural work.
The community action promoter referred him to the health service, where he was diagnosed with lepromatous leprosy, confirmed with bacilloscopy.
Triconjugate polychemotherapy was initiated with rifampicin, diamino-diphenylisolate and cloimine.
Three months after starting polychemotherapy, the patient developed foot ulcers, generalized myalgias and arthralgias, fever, asthenia and numerous skin nodules that lasted a few days and returned.
He was admitted to hospital due to erythema nodosum leprosum and prescribed 30 100 mg thalidomide tablets once every 12 hours with little improvement.
The patient was admitted to the emergency room with alopecia, numerous maculae and erythematous anesthetics on the trunk and limbs, cutaneous nodules, mild thickening with pain in the neck, neck pain and neck pain.
The patient was treated with thalidomide 300 mg daily and continued on polychemotherapy with supervision.
He improved, but three months later he presented a new episode of fever, malaise, painful cutaneous nodules and bilateral testicular pain, more noticeable in the left testicle, which appeared edematous, indurated and painful.
He stated that left testicular pain had been present for a month.
The patient continued with polychemotherapy and thalidomide with slight improvement.
One month later, the patient presented another acute febrile episode, with left testicular pain, elbow and knee joint pain, painful cutaneous nodules and greater thickening of the ulnar nerves, painful to the stomach.
Predictnisolone is weekly prescribed for treatment (50 mg daily), with a decrease of 5 mg.
Symptoms improved but episodes reappeared every two to three months, with decreased doses of prednisolone and thalidomide.
During one of them, one year after the disease began, she had bilateral pain and redness of the eye with blurred vision.
A year and a half after the onset of the disease, episodes of recurrence were not only manifested with numerous cutaneous nodules, but testicular pain was predominant and continuous, up to four days of evolution, becoming an urgent need for analgesics.
The left testicle showed edema and the patient did not resist fixation.
Over time, it became smaller, of firm consistency and more painful to fixation.
Twenty-six months after polychemotherapy, sputum smear microscopy was negative, but episodes persisted.
Ultrasound showed left testicle and right edema.
Left orchidectomy was recommended, which was performed three years after the onset of the disease.
After that, he presented pain and edema in the right testicle, but although he did not take thalidomide or prednisolone, his episodes were not recurrent.
Five years after the onset of the disease, the patient was in good general condition, cured of lepromatous leprosy, with negative bacilloscopy, bilateral hair loss with a tenuous eminence and alopecia of the eyebrows.
He was illiterate, but during his stay in San Agua de Dios teaching in primary education and today he is a competent worker with commercial skill that includes skills in computer management.
It receives a state subsidy, according to a national law that covers leprosy patients (2.7).
Laboratory tests performed during several type 2 reaction episodes showed leukocytosis from 11,000 to 13,000 leukocytes/ml with neutrophilia from 80 to 83 % and a slight increase in erythrocyte sedimentation rate (SGV).
Hemoglobin was 12 to 13.5 g/dl.
Laboratory tests recently performed six years after the onset of the disease, when the patient is suffering from erythema nodosum leprosum, showed: testosterone lunormal at 1.7 pg/ml; follicle-free hormone at 17 ml/ml.
Spermogram reported volume of 1.5 ml, pH of 9, no spermatozoa were detected and 15 to 20 leukocytes were seen per field of 100 increases.
Pathological anatomy.
The removed testicle measured 3 x 1.5 x 1.5 cm, had a firm consistency and atrophic aspect.
At the cut, the color was homogeneous.
The histological study was performed in multiple sections stained with hematoxylin and eosin, Fite-Faraco, orcein, trichrome and immunohistochemistry for S100 protein.
A noticeable granulomatous inflammatory process that also compromised the rete testis and epididymis was demonstrated.
Inflammation extensively replaced the parenchyma and consisted of foamy macrophages, leukocytes and few lymphocytes, with notorious fibrosis.
The testicle was barely histologically recognizable by focal persistence after multiple cuts of small remnants of atrophic seminiferous tubules surrounded by large focal conglomerates hyper-prominent basal membranes.
In the rete testis and epididymis some tubules persisted separated by notorious inflammatory infiltrate of the characteristics described above, with significant fibrosis.
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The arterial vessels of diverse caliber, both of the testicle and the epididymis, showed notorious thickening of their layer, with narrow inflammatory infiltrate in the interstitial walls of their ductile fibers or granulomatosmu.
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The nerves, most apparent in the mediastinum testis, showed speciation of fibers and non-endodontic lymphotiocytic.
In this same area, perineural and intraneural Leydig cell clusters were observed.
Fite-Faraco staining showed no bacilli or granulocyte-resistant forms in any of the sections performed.
Some groups of foamy macrophages contained mild ochre pigment which was interpreted as remnants of cloimine (2).
Only one testicular focus with neutrophil persistence was demonstrated, which was interpreted as mild erythema nodosum leprosum (2).
