In an Orlando dermatology clinic, Dr. Rajiv Nathoo encountered a 54-year-old landscaper suffering from a splotchy and painful rash. Despite previous doctors being baffled by the cause of the rash, Dr. Nathoo’s intuition led him to perform five or six biopsies. His suspicion proved accurate as the biopsy results confirmed an unexpected diagnosis: leprosy, a condition rarely seen in the region.
Surprisingly, the man did not exhibit the typical risk factors associated with this hard-to-catch infection. After observing a cluster of similar cases in the area, Dr. Nathoo, a dermatologist and complex clinic director for Advanced Dermatology and Cosmetic Surgery Clinics in Orlando, began to suspect that Central Florida might be an emerging hotspot for leprosy.
As a result, Dr. Nathoo’s team is now urging other healthcare providers in the area to remain vigilant and watch out for similar cases.
According to a research letter published in the journal Emerging Infectious Diseases by Dr. Nathoo and his colleagues, Central Florida has reported some of the highest rates of leprosy in the United States. In 2020, the nationwide reported cases were 159, a small number when compared to the global count of 200,000 new cases each year, as stated by the World Health Organization. Nevertheless, the new letter reveals that Central Florida accounted for a staggering 81% of cases in Florida and nearly 1 out of 5 leprosy cases nationwide.
Leprosy, also known as Hansen’s disease, is caused by the bacteria Mycobacterium leprae, which affects nerves under the skin. The exact mode of transmission remains uncertain, but most scientists believe it is through droplets when an infected person coughs or sneezes. The disease is characterized by lesions and rashes that lack sensation due to nerve involvement.
Nine-banded armadillos in the Southeastern United States are also carriers of the bacteria, and studies show that human infections can be linked to the leprosy strains found in armadillos. However, it is not always clear how humans come into contact with the bacteria carried by these animals, as many patients do not recall any such contact.
It is essential to note that leprosy is not transmitted through casual contact, such as shaking hands or sitting next to an infected person. The spread of the disease requires prolonged close contact with an untreated leprosy patient over several months, according to the US Centers for Disease Control and Prevention (CDC). Fortunately, roughly 95% of people are genetically resistant to the infection due to their immune systems being programmed to resist it.
In the United States, leprosy is considered a rare disease. Historically, most cases were associated with people who traveled to countries with high leprosy rates or had contact with armadillos carrying the disease. However, there are instances where doctors are unable to determine how a person was exposed to the bacteria.
Dr. Linda Adams, chief of the laboratory research branch at the National Hansen’s Disease Program, which coordinates treatment for Americans diagnosed with leprosy, noted that certain states have more cases than others, with Florida being one of them. She added that in these areas, cases occasionally emerge with no apparent explanation, such as foreign travel or contact with armadillos.
In a recent report, a 54-year-old man from Florida presented with leprosy but had not left the state, had no exposure to armadillos, and had no extended interaction with people from countries with high leprosy rates, despite spending considerable time outdoors.
According to a research letter, about 34% of new leprosy cases between 2015 and 2020 lacked traditional risk factors, suggesting local infections and indicating that leprosy may be becoming endemic in Florida.
Experts agree that leprosy is becoming endemic in the region. However, Dr. Nicole Iovine, chief hospital epidemiologist at the University of Florida Health Shands Hospital, emphasized that “endemic” doesn’t imply a rise in rates, merely that the disease occurs regularly in the region.
Dr. Rajiv Nathoo, who has tracked clinical records of 15 biopsy-proven leprosy cases in eastern Orlando and Volusia County over five years, highlighted the rarity of the disease in the area, with relatively low numbers not causing significant concern.
Despite a “strong geographic predilection” for leprosy in central Florida, there’s a misconception among doctors that the disease only affects foreign-born individuals or those exposed to nine-banded armadillos, according to Dr. Charles Dunn, a study author and chief resident at Advanced Dermatology and Cosmetic Surgery Clinics.
Dunn believes it’s essential to dispel assumptions since their patients lacked the traditional risk factors associated with leprosy. Although armadillos are considered the “textbook example,” there is no definitive vector for leprosy that the medical community can pinpoint. Prolonged contact with nine-banded armadillos is uncommon for most people, further complicating the source of infection.
Nathoo emphasized that their paper aimed to draw attention to the aggregated cases in Florida and raise awareness among healthcare providers. The cluster of potentially endemic cases in Central Florida is a cause for concern, as untreated leprosy can lead to paralysis, blindness, and the shortening of fingers and toes. While the infection is curable, treatment involves a combination of antibiotics taken over a few years. However, delayed diagnosis can result in lasting nerve and skin damage, which is a common occurrence in the US, where doctors are not accustomed to encountering the disease.
One of the challenges with leprosy is the slow growth of the bacteria, which can take up to 20 years to manifest symptoms like pale numb blotches, rashes, ulcers, and lesions, according to the CDC. This delay makes it difficult to trace the source and spread of a leprosy infection, leading to initial misdiagnosis, particularly since most doctors rarely encounter leprosy cases.
Dr. Iovine expressed concern that patients might go for months without a correct diagnosis, highlighting that this is more common than not.
In the case report of the new study, the patient exhibited clinical signs of leprosy for five years before seeking help from Nathoo and undergoing screening for Hansen’s disease. Prior to that, several healthcare providers had been uncertain about his condition.
When healthcare providers identify leprosy, they are obligated to report it to the state health department within 24 hours. After the report, the National Hansen’s Disease Program dispatches specialized antibiotics to the provider’s office and initiates a contact-tracing process.