Case report Multiple giant nerve abscesses presenting like lipoma in a treated patient of Hansen’s disease Sumit Kar 1 , MD, Ajay Krishnan 1 , MD, Nitin Gangane 2 , MD, Sonia Jain 1 , MD, Bupendra Mehra 3 , MD, and Sushil Kale 4 , MD 1 Departments of Dermatology, Venereology and Leprosy, 2 Departments of Pathology, 3 Departments of Surgery, and 4 Departments of Radiodiagnosis, MGIMS, Sewagram, Wardha, Maharashtra, India Correspondence Dr. Sumit Kar, MD Department of Dermatology Venereology and Leprosy MGIMS, Sewagram Wardha Maharashtra 442012 India E-mail: karmgims@gmail.com Conflicts of interest: None. A 50-year-old man from a leprosy endemic area of central India presented with asymptomatic slowly enlarging nod- ules near his elbow and wrist joints on the left side and near the knee joint on the right side for the past year. The patient also had swelling on the palmar aspect of the left hand and total clawing of the hand on the same side. Clawing of the hand was noticed for the past eight months. He had occasional bouts of fever. The patient was diagnosed with leprosy 15 years ago in a government hospital in central India and was treated with multidrug therapy, as recommended by the World Health Organiza- tion (WHO) for multibacillary leprosy, for a period of two years. He was asymptomatic after that until he devel- oped the present condition. Initially, nodules were noticed on the palmar aspect of the left hand, then lesions started appearing over the wrist, then elbow, and finally over the knee joint over a period of eight months. He was treated conservatively in a leprosy rehabilitation center with no significant improvement in the condition. There was no other significant family or medical history. On examination, the patient’s vitals were normal. Nod- ules measuring 6 · 4 cm in the largest diameter were seen just below the left olecranon process, in addition to a 4 · 4 cm lesion near the anatomical snuff box, a 4 · 3 cm lesion just below the ulnar head (Fig. 1), and a 7 · 5 cm lesion just below the fibular head on the right side. There was also diffuse swelling of the index fin- ger on the left side. Overlying skin appeared stretched, and the lesion was attached to it in some areas. The lesion was mobile in one direction and was lobulated. Fluctuation was positive. Clawing of the fingers on the left hand was also observed. There were no other sig- nificant clinical findings or any other active lesions of leprosy. Routine investigations were normal. Fine needle aspira- tion yielded sticky, turbid, pale brown fluid. Cytological examination revealed acute suppurative necrosis and the presence of epithelioid granulomas. Staining for acid-fast bacilli (AFB) was negative, and considering the location of the lesion, a nerve abscess with tuberculoid granuloma was made by the pathologist (Fig. 2). Ultrasonography of the lesions showed multiple thick-walled oval cystic lesions along the course of the various nerves associated with the swelling. Histopathological examination revealed tubercular granuloma with large areas of necrosis and extreme foamy change involving the nerve and the soft 835 ª 2012 The International Society of Dermatology International Journal of Dermatology 2012, 51, 835–837