19. Multiple nodules

A 67-year-old man presented with multiple asymptomatic nodules on his face, scalp, neck and upper trunk which began to appear at the age of 20 and increased in size and number. The patient suffered from hypertension, hearing problems, chronic bronchitis and glaucoma. His daughter has similar but less obvious skin lesions. He was a chronic smoker (>15 cigarettes/day) and alcohol drinker (>4 glasses of wine/meal).

Extra-oral examination revealed numerous skin-coloured nodules, particularly on his face and neck, together with well-defined hyperpigmented macules (Figure 1). There was neither cervical lymphadenopathy nor cranial nerve dysfunction.

Oral examination revealed no abnormalities apart from a fissured tongue with hyperplastic papillae.

(a) Lepromatous leprosy (LL) is a chronic bacterial infection with the acid fast bacillus (Mycobacterium leprae), rare in the developed world, but still seen. It is characterized by a variety of skin lesions, such as macules, papules and nodules, which are associated with increased facial skin thickness (leonine face) but not with pigmented café au lait lesions, as seen in our patient. Early cranial nerve involvement, such as thickening the greater auricular nerves and eye problems, are characteristic findings in leprosy, but were not seen in our patient, apart from his glaucoma diagnosed at 65 years of age.