state of Georgia with armadillo exposure. J Am Acad Dermatol 2006;55:714-6. 2. Truman R. Leprosy in wild armadillos. Lepr Rev 2005;76: 198-208. 3. Levis WR, Ernst JD. Mycobacterium leprae (leprosy, Hansen’s disease). In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas and Bennett’s principles and practice of infectious diseases, 6th ed, vol 2. New York: Elsevier/Churchill Livingstone; 2005. pp. 2886-96. 4. Levis WR, Schuman JS, Friedman SM, et al. An epidemiologic evaluation of leprosy in New York City. JAMA 1982;247: 3221-6. 5. Lu PD, Patel MJ, Yosipovitch G, Martiniuk F, Cabrera A, Levis WR. HIV and leprosy in the Eastern United States. J Infect Dis 2005;192:1673-4. doi:10.1016/j.jaad.2007.03.040 Reply To the Editor: We appreciate the interest shown by Levis et al in our article. 1 The letter will be informa- tive for the medical community regarding leprosy in native-born Americans in the United States. We agree with Levis et al that for many new leprosy patients in the United States, the source of the infection cannot be established. We concur that armadillos are a most unlikely source of leprosy infection in New York City. In our article we ob- served, however, that in the southern and southeast- ern United States, armadillos are an important reservoir for Mycobacterium leprae. As we noted, most studies on leprosy in wild armadillos have been conducted on populations from the TexaseLouisiana area; however, as early as 1984, it was reported that this population of armadillos had migrated into western Florida, and could import leprosy-infected armadillos. 2 Therefore it is reasonable to assume that contiguous areas of Georgia could be similarly invaded. Based on this knowledge, we applied Occam’s razor, in which speculations on the explanation of phenomena of unknown origin should be sought first in terms of known quantities. In this case, our patient had leprosy, she had no known contact with human cases, she had close association with wild armadillos in southern Georgia, and some of the armadillos could be reasonably suspected of carry- ing M leprae. To our knowledge, only a few armadillos in southern Georgia have been surveyed, and only by methods with low sensitivity for M leprae. Those armadillos were negative for M leprae infection. More extensive surveys using highly sensitive tech- niques would seem to be indicated. Finally, for clarity, we suggest that Levis et al could have indicated that leprosy had not been found in armadillos east of the state of Mississippi. Their statement as it stands may be misconstrued to mean the Mississippi River. The large river is viewed by some as a natural barrier. The reported M lepraee infected armadillo found east of the Mississippi River, thus, is relevant to our hypothesis. Joshua E. Lane, MD, a Douglas S. Walsh, MD, b Mary K. Klassen-Fischer, MD, c and Wayne M. Meyers, MD, PhD c Departments of Internal Medicine (Dermatology), and Surgery, Mercer University School of Medi- cine, Macon, Georgia, a and the United States Army Medical Research UniteKenya, Kisumu, Kenya, b and the Department of Environmental and Infectious Disease Sciences, Armed Forces Institute of Pathology, Washington, DC c Funding sources: None. Conflicts of interest: None declared. Correspondence to: Joshua E. Lane, MD, Division of Dermatology, Department of Internal Medicine, Mercer University School of Medicine, 707 Pine St, Macon, GA, 31201 E-mail: jlanemd@gmail.com REFERENCES 1. Lane JE, Walsh DS, Meyers WM, Klassen-Fischer MK, Kent DE, Cohen DJ. Borderline tuberculoid leprosy in a woman from the state of Georgia with armadillo exposure. J Am Acad Dermatol 2006;55:714-6. 2. Storrs EE, Burchfield HP. Epidemiology of leprosy in wild armadillos. Int J Lepr 1984;52(Suppl):734. doi:10.1016/j.jaad.2007.04.014 Chronic urticaria: One step forward and two steps back To the Editor: In their article Guerra et al 1 suggest that contact sensitization to chemicals, metals, or additives (often without clinical symptoms of eczema) may play a role in the pathogenesis of chronic urticaria (CU) and that routine patch tests and patch testedriven avoidance measures should be considered in patients with CU. However, several perplexities arise from a careful evaluation of the study design and the results obtained. Patch tests proved positive in 50 of 121 patients with CU (41%), a percentage similar to that found in the general population (40%) in another large study. 2 Avoidance measures were considered effective if remission occurred within 10 to 30 days. However, the duration of the remission was not specified; a control group with CU and showing contact sensitization but not submitted to avoidance measures was not included; only 4% of patients showed autologous serum skin test (ASST) positivity JAM ACAD DERMATOL AUGUST 2007 368 Letters