case_images: PMC7273538_01
case_images: Image of the anterior forearms. Multiple nodules on anterior forearms,
  hypotrichosis, and areas of hyperpigmentation. Some lesions had inflammatory
  appearance, which are typical for active lesions in the setting of erythema
  nodosum leprosum.
case_images: 10.1177_2324709620927884-fig1.jpg
case_images: PMC7273538_01_10.1177_2324709620927884-fig1.jpg
case_images: fig1-2324709620927884
case_images: On physical examination, she had extensive erythematous subcutaneous papules and nodules with a background of gray hyperpigmentation on her arms and legs (Figure 1), and few scattered tender superficial erythematous nodules on the face and abdomen.
case_images: (A) Hematoxylin and eosin stain of punch biopsy of forearms. Foamy
  macrophages (red arrow) in the dermis with an intense neutrophilic
  infiltrate (black arrow) forming abscesses (40x). (B) Fite stain of punch
  biopsy of the forearms. It shows acid-fast organisms (1000x) with beaded,
  granular and degenerated appearance within histiocytes (red arrow). Tissue
  polymerase chain reaction (PCR) was positive for Mycobacterium
  leprae DNA. A positive PCR result does not mean viable bacteria
  are present.
case_images: 10.1177_2324709620927884-fig2.jpg
case_images: PMC7273538_01_10.1177_2324709620927884-fig2.jpg
case_images: fig2-2324709620927884
case_images: A 4-mm punch biopsy taken from the right forearm revealed foamy macrophages in the dermis with an intense neutrophilic infiltrate extending into the subcutaneous fat (Figure 2A). Fite stain showed beaded and granular acid-fast bacilli within the histiocytes and focally within cutaneous nerve twigs (Figure 2B).
case_images: Image of the anterior forearms post-treatment. Decreased nodularity and
  hyperpigmentation of the skin after 6 months of treatment with
  thalidomide.
case_images: 10.1177_2324709620927884-fig3.jpg
case_images: PMC7273538_01_10.1177_2324709620927884-fig3.jpg
case_images: fig3-2324709620927884
case_images: Treatment with thalidomide 100 mg daily was initiated with improvement in the appearance of the skin lesions (Figure 3).