BRIEF REPORT Type 2 leprosy reaction resembling Sweet syndrome: Review of new and published cases Sonia Chavez-Alvarez | Maira Herz-Ruelas | Jorge Ocampo-Candiani | Minerva Gomez-Flores Universidad Autonoma de Nuevo Le on- School of Medicine - Dermatology Department Hospital Universitario “Dr. Jose Eleuterio Gonzalez”, Monterrey, Mexico ABSTRACT A leprosy reaction resembling Sweet syndrome was first described in 1987. This cutaneous manifestation can be classified as the type 2 reaction which arises from antigen–antibody interaction. It can occur in patients with diagnosed or undiagnosed leprosy, and men with borderline leprosy tend to exhibit this type of reaction. Triggering factors may include WHO multibacillary treatment or prescription antibiotics. Several reports of this clinical phenomenon have been published, making physicians consider it as part of this spectrum of the disease. Treatment regime can include systemic steroids and thalidomide. Key words: Hansen disease, leprostatic agents, leprosy, sweet syndrome. INTRODUCTION Leprosy may manifest two types of reactions which include the type 1 and 2 reactions. 1 Type 1 (reversal leprosy reac- tion) represents a hypersensitivity type IV Gell and Coombs reaction which is cell-mediated. 2 Pre-existing lepromatous lesions develop erythema, oedema and enlargement. Some of these may ulcerate. 3 There is also nerve inflammation, arthralgias and acral oedema. 3 This type of reaction, usu- ally, does not have systemic symptoms. 4 Type 2 (erythema nodosum leprosum) represents a hypersensitivity type III Gel and Coombs reaction. 2 Patients develop erythematous- painful ulcer-prone nodules. All tissues can develop inflam- mation, including nerves, lymph nodes, eyes, joints and gonads. This is accompanied by fever and leukocytosis. 3 We discuss a patient with a leprosy reaction whose clini- cal manifestations resemble Sweet syndrome, as well as other cases found in the literature. CASE REPORT A 61-year-old Mexican male farmer, with a personal history of prostatitis and a family history of leprosy, presented to the emergency department with intermittent fever, dysuria, vesi- cal tenesmus, malaise, night sweats and non-quantified weight loss within the last 3 months. A week earlier, a primary care physician had prescribed ciprofloxacin for the treatment of presumptive prostatitis. Despite this, the fever persisted and disseminated bright-red papules, plaques and nodules appeared. Some lesions developed pustules, coalesced into plaques and were painful. These were located on his left flank, anterior and posterior upper trunk, and limbs. (Figure 1). He was admitted with hyperthermia (38.5°C). CBC showed a normocytic–normochromic anaemia with leuko- cytosis (20,800 K/mcL) predominantly due to neutrophils (78%) and an elevated erythrocyte sedimentation rate (33 mm/Hr). Blood cultures, coccidiodin and tuberculin skin tests were negative. Skin biopsies showed interstitial oedema, a diffuse and perivascular inflammatory infiltrate, with neutrophils, lymphocytes, plasma and mast cells. Fite- Faraco stain demonstrated multiple intracellular acid-fast bacilli (Figure 2). Lepromatous leprosy and type 2 leprosy reaction resembling Sweet syndrome was diagnosed. WHO multibacillary regimen (daily dapsone 100 mg and clofazimine 50 mg plus rifampin 600 mg and clofazimine 300 mg monthly) was started along with prednisone 50 mg and thalidomide 200 mg daily. Skin lesions and systemic symptoms improved within 4 weeks. Prednisone and thalidomide were gradually tapered until resolution. Lepromatous leprosy may present with ill-defined hypopigmented or erythematous lesions, with papules and/ Correspondence: Minerva Gomez Flores, Universidad Autonoma de Nuevo Le on- School of Medicine - Dermatology Department Hospital Universitario “Dr. Jose Eleuterio Gonzalez”, Av. Francisco I. Madero S/N, Mitras Centro, 64460 Monterrey, NL, Mexico. Email: minervagomezmx@yahoo.com.mx Conflict of interest: The authors have no conflict of interest to declare. Funding: None. Sonia Chavez-Alvarez, MD. Maira Herz-Ruelas, MD, PhD. Jorge Ocampo-Candiani, MD, PhD. Minerva Gomez-Flores, MD, PhD. Submitted 30 August 2019; revised 29 October 2019; accepted 10 November 2019. Australasian Journal of Dermatology (2019) , – doi: 10.1111/ajd.13224 © 2020 The Australasian College of Dermatologists