Volume 48, Number 3Printed in the U.S.A.

IN Ii RN I IONA' if )1:RN Al Or IA. PROs''

The Histopathology of the Spleen from a Patientwith Lepromatous Leprosy!•"

Thomas H. Rea, Lynn Bevans, and Clive R. Taylor 2

Study of the histopathology of leprosyhas been fundamental to the present under-standing of the disease. Of particular im-portance has been the work of Ridley andcoworkers ("• Their correlative clinicaland histological study of skin lesions notonly provided substantial evidence thathost resistance to Mycobacterium lepracwas crucial in determining the diverseexpressions of leprosy but also establisheda system of classification basic to manytypes of studies, including immunologicalinvestigation. Anatomical pathology hasalso provided important clues to under-standing the immunopathology of leprosy,as exemplified by the study of Turk andWaters (''), in which the observation of re-placement of paracortical areas (T-cellzones) by histiocytes provided an anatom-ical framework for understanding the gen-eralized impairment of cell-mediated im-mune (CMI) responsivity sometimesobserved in lepromatous leprosy.

The present paper is a report of the his-topathology of a spleen from a young manwith lepromatous leprosy, splenectomybeing occasioned by traumatic rupture.Earlier work by Bullock, et al. showingdepletion of T lymphocyte suhpopulationsin the spleen in murine leprosy (') togetherwith recent demonstrations of suppressor

' Received for publication on 2 January 1980; ac-cepted for publication in revised form on 24 March1980.

' T. H. Rea, M.D., Section of Dermatology, De-partment of Medicine, University of Southern Cali-fornia School of Medicine and Department of Der-matology, Los Angeles County-University of SouthernCalifornia Medical Center; L. Bevans, NI.D. (de-ceased); C. R. Taylor, M.B., Ch.B., D.Phil., Depart-ment of Pathology, University of Southern CaliforniaSchool of Medicine and Department of Pathology, LosAngeles County-University of Southern CaliforniaMedical Center, Los Angeles, California 90033,U.S.A. All correspondence to Dr. Rea.

'This material was presented in part by Dr. Bevansbefore the annual meeting of the California Society ofPathologists on 8 Decemher 1977 in San Diego, Cali-fornia. U.S.A.

cell activity in patients with lepromatousleprosy ( 2 . 8 ), suppressor cells of splenic or-igin in murine leprosy (I), and periarteriolarinfiltration by lepra cells in the spleen of apatient with lepromatous leprosy ( 3 ) em-phasize the importance of the histopathol-ogy of the spleen in leprosy.

CASE REPORT AND RESULTSThe patient, a 22 year old Mexican man,

presented in late April 1977 because of legulcers. At age 14 he had developed alopeciaof the eyebrows and eyelids, and at age 15a diagnosis of Hansen's disease was made.Sulfones were taken irregularly from age 15to 21, but not at all in the year precedinghis initial presentation to our clinic.

Pertinent physical findings included alo-pecia of the eyebrows and eyelashes, per-foration of the nasal septum, seven leg ul-cers measuring from one to three cm indiameter, approximately a dozen barelypalpable, irregular hemorrhagic lesions onthe legs and thighs, and the absence of anynodular lesions. Acral, distal symmetricalanesthia was present on the hands, butmuscle atrophy and trophic change in theskin were not evident.

The histological changes in a hemorrhag-ic lesion were characteristic of lepromatousleprosy and Fucioss reaction, i.e., perivas-cular accumulations of foamy histiocytes,ischemic necrosis of the epidermis, endo-thelial proliferation in some mid-dermalvessels, and numerous acid-fast bacilli(AFB) both in histiocytes and in some nor-mal or proliferating endothelial cells (").

Tuberculin testing with five units of PPDelicited 40 mm of intense induration at 48hr, but chest X-ray and urinalysis were nor-mal, and cultures of sputum and urine werenegative for mycohacterial species. At-tempted dinitrochlorohenzene sensitiza-tion, using a 2 mg sensitizing dose and achallenge of 0.1 mg at 21 days, failed. Se-rum IgA was 600 mg/I (normal upper limit400 mg), but IgG and IgM were normal: se-

285

286^ infernatioutd ./ourried of Leprosy^ 1980

FIG. I. Section of spleen showing sparsely distrib-

uted small lymphocytes in the periarteriolarareas (small arrows). A focus of II-cell proliferation is

represented by a small germinal center (large arrow).The white pulp is considerably reduced in extent by

comparison to What might be expected in normal men

of this age. (II^E, x32)

rum total hemolytic complement (CHSO)was 160 units (normal 480-1280)': serumcyroglobulins were 29 mg/I00 ml (normal<3 mg). Lysozyme was 13.8 ng/ml (nor-mal 7.7 ± S.D. 1.5), and angiotensin-con-veiling enzyme was 33.2 units/ml (normal22.6 S. D. 6).

The patient was begun on dapsone, 50mg daily. New hemorrhagic lesions ceasedwithin one week of beginning dapsone, andhis ulcers began to show good granulationtissue.

After four weeks of observation the pa-tient was lost to follow up for two months.In late July 1977 he was admitted to thesurgical service because of two stabwounds in the left side of the chest. Pneu-monia was a complication of this injury.While convalescing from pneumonia, pain-ful and tender, red, subcutaneous and der-mal nodules errupted in association with

* Editor's Note: Method used in authors' labora-tory.

FIG. 2. Aggregates of lepra cells about an arteriole

(large arrow) and in the red pulp (small arrows). (II &E, x135)

fever and malaise. Biopsy supported theclinical impression of erythema nodosumleprosum (ENL), and this syndrome remit-ted in association with thalidomide therapy.His leg ulcers had healed. Serum hemolyticcomplement was 240 units at that time. Inlate August 1977 the patient was once againadmitted to the surgical service, on this oc-casion because of a ruptured spleen, sus-tained when beaten severely with a metalpipe. Splenectomy was performed withoutincident. The patient was seen in the clinictwo weeks later, taking only dapsone andhaving no lesions of EN L. He was lost tofollow up thereafter.

The spleen weighed 294 g and measuredIS x 9 x 6 cm. Hemorrhagic material waspresent on the hilar surface. The surfacewas slightly wrinkled and grey to purple incolor. Three lacerations, 3, 6, and I() cmlong, were identified. On section, focalareas of hemorrhage were present. Grossly,changes attributable to leprosy were notevident.

Histopathologically, fresh hemorrhagewas apparent in many areas hut did not ap-

48, 3^Rea, et al.: Spleen Ili.slopathology in LL^ 287

3. An aggregate of lepra cells in a cord con-taining many plasma cells (II^E, x540)

pear to have any influence upon the othermicroscopic changes reported herein.

Germinal centers were numerous hutwere not large. They were distributedthroughout the white pulp, which was,however, markedly reduced in total amount.In particular, periarteriolar lymphocytes, inthe cell zone, were reduced in numberalthough small collections were still presentabout some vessels (Fig. I).

Lepra cells (Virchow cells or large vac-uolated histiocytes), containing large num-bers of acid-fast bacilli (AFR) and elobi,were abundant. They were found as aggre-gates in the cords of the red pulp, withoutdiscernible relationship to the arteriolartree (Figs. 2 and 3), as periarteriolar aggre-gates in the white pulp (Figs. 2 and 4), andas evidently nonaggregated cells in germin-al centers (Fig. 5). In general, lepra cellswere most abundant in the red pulp, com-paratively less common about arterioles,and sparse in germinal centers.

In the red pulp, collections of lepra cellsfrequently contained large numbers of plas-ma cells (see Fig. 3) showing a polyclonalpattern of immunoglobulin by immunope-roxidase methods. Plasma cells, eosino-

FRi. 4.^Lepra cells in a perithelial distributionabout an arteriole. Bacilli appear as dark cytoplasmicgranules. IFite-Farraco, >:250)

FIG. 5. Large vacuolated histiocytes containingbacilli are present in this field from a germinal center.The bacilli in this particular field, ideal for illustration.are present in greater numbers than found in most oth-er germinal centers. iFite-Farraco. x800)

288^ haernatitnia/ Journal of Leprosy^ 1980

phils, and neutrophils were present in thered pulp in larger numbers than normal.

In the white pulp the aggregated lepracells localized to the perithelium (Figs. 2and 4). When well developed, the lepracells formed a periarteriolar cuff. Oftenonly an incomplete arc was involved. Inarterioles sectioned horizontally only oneside might he infiltrated by lepra cells.

In germinal centers a few large vacuo-lated histiocytes (perhaps lepra cells) con-taining AFB were identified (Fig. 5). It wasdifficult to determine if these cells were tru-ly not aggregated or were so few in numberas to give that appearance. The number ofbacilli in these cells was usually smallerthan those seen in the periarteriolar or redpulp lepra cells.

Many lepra cells contained a hemosider-in-like pigment and stained positively foriron. Also these cells stained positively foroil-red 0. With immunoperoxidase stain-ing, the lepra cells of the spleen stainedpositively (one plus on a scale of four) forlysozyme, showing the same saccular mor-phology previously demonstrated in lepracells in lepromatous lesions of the (fermis( 13). Congo red staining for amyloid wasnegative as judged by light and fluores-cence microscopy.

DISCUSSIONThe present case appears to represent a

comparatively early phase in the normallyprotracted course of lepromatous leprosy.Although our patient was not untreated, histherapy had been intermittent. He had hadLucio's phenomenon, a syndrome associ-ated with active lepromatous leprosy ("),four months preceding splenectomy. Amy-loid, a usual finding in the spleen post-mor-tem of patients with long-standing leproma-tons leprosy ( 1 .".".'"), was not found in thepresent case.

Prior reports of the histopathology of thespleen in leprosy, autopsy cases or series,indicate that some of the changes observedherein are representative of the spleen inlepromatous leprosy. In his paper on thelepra cell, Mitsuda describes "Ieproticfoci'' as being numerous "in the region ofthe splenic arteries'' and that lepra cells"are seen . . . in the perithelium of the ar-teries'' ("). Red pulp and germinal centerinvolvement were also found. Furthermore,

the earliest change in the spleen was saidto he the perithelial lepra cells.

Powell and Swan ( 1 1 found "miliary lep-romas, — consisting of "vacuolated histio-cytes . . . located in every part of theparenchyma in both the red and white pulp,often around blood vessels.'' Likewise, De-sikan and Job (") found "discrete leproma-tons granulomata, scattered in both the redand white pulp — ; their photomicrographclearly shows a periarteriolar localizationof histiocytes.

Sifuentes Guerrero, et al. (' 7 ) reported apatient in whom the diagnosis of leproma-tous leprosy was not established prior toher terminal illness, renal failure. In thispatient's spleen large histiocytes containingAFI3 were noted (and pictured) about thesplenic arterioles. Sifuentes and Gomez ('")reported the necropsy of a patient who diedof pulmonary emboli a few months after thediagnosis of Lucio's reaction and diffusenon-nodular lepromatous leprosy was made.They found the spleen to contain focal in-filtrations of histiocytes. (Dr. Sifuenteskindly sent hematoxylin and eosin stainedsections of this spleen to us for review.There were no germinal centers, and therewas marked depletion of lymphocytes inthe periarteriolar areas. Aggregates of largevacuolated histiocytes were present in thered pulp and about arterioles, as in the pres-ent case.) Bullock recently published an il-lustration of periarteriolar histiocytic infil-tration but reported no details ( 3 ).

Another report of splenic involvement inleprosy did not comment critically upon thepresence or absence of periarteriolar histio-cytic infiltration ('). The photomicrographsof Powell and Swan ( 1 ") and of Bernard andVazquez (') show amyloid in a periarterio-lar pattern.

Germinal centers containing large vacu-olated histiocytes with AFB were previ-ously seen by Mitsuda ("), who describesreticulum cells of the spleen follicles turn-ing into lepra cells. Other reports make nomention of germinal centers, suggestingthat they are an early change in leprosy,disappearing with progression of the dis-ease or effaced by terminal illnesses. Mit-suda (") regarded the follicular lepra cells asmultiplying, finally causing atrophy of thefollicles. There is no evidence to associatethe AFB ladened histiocytes with the large

48, 3^ Rca, et al.: .S.p/cerf //istopatliolo,y in LL^ 289

dendritic reticulum cells of the germinalcenters. However, the absence of aggregra-tion and the fewer numbers of bacilli dosuggest that the AFB-containing cell of thegerminal center may differ in Origin orphysiologic activity from the periarteriolaror red pulp lepra cell.

Periarteriolar infiltration by histiocytes isnot restricted to lepromatous leprosy.Lukes states that in Letterer-Siwe's diseasethe white pulp is replaced by "nodules ofhistiocytes that circumscribe the central ar-tery — ( 7 ). Furthermore, we have noted peri-arteriolar large vacuolated histiocytes intwo of seven spleens in necropsy materialfrom patients with disseminated coccidioi-domycosis (r2 ). More generally well rec-ognized types of granulomas may involvethe white pulp or red pulp, with any of theircharacteristic features ( 7 ).

Using the term lepromatous leprosy toinclude only the polar and subpolar typesas delineated by Ridley (".''), the preva-lence of splenic involvement in leproma-tous leprosy is not known. Earlier necropsyseries probably employed the term "lep-romatous — in a broader sense and may wellhave included patients who today would heclassified as borderline with lepromatousfeatures. The cases reported by Sifuentesand Gomez ( 1 "), and Sifuentes Guerrero, etal. (' 7 ), as well as the present case, werelepromatous by Ridley's criteria, suggest-ing that splenic involvement is usual in lep-romatous disease, as defined by Ridley.

Histiocytes containing AFB were dem-onstrated in germinal centers, foci of B-cellproliferation about arterioles, sites of T-cell"homing": and in the red pulp, where awide variety of cells course. Thus thespleen provides ample opportunity forclose contact between M. leprac and thecentral cells of the immunologic response,namely the T and B lymphocytes and cellsof the monocyte series. However, the pre-cise sequence of immunological changesthat might occur as a result of particularalterations in the spleen in leprosy remainsspeculative. The perithelial infiltration oflepra cells around splenic arterioles appearsto he analogous to the paracortical infiltra-tion by histiocytes in lymph nodes, as re-ported by Turk and Waters W). However,the mechanism through which such an in-filtration might lead to impaired CMI res-

ponsivity is uncertain: decreased effectoror helper activity or increased suppressoractivity represent possibilities for futurestudy. These anatomical changes are con-veniently thought of as necessary but notsufficient conditions for modulation of im-mune responsivity in the lepromatous pa-tient.

SUMNIAKYThe histopathology of the spleen from a

young man with diffuse non-nodular lep-romatous leprosy is reported. As judged bythis case, other case reports, and necropsyseries, involvement of the spleen in lep-romatous leprosy is characterized by aggre-gations of large vacuolated histiocytes,containing individual bacilli and globi, inboth the red and white pulp. In the whitepulp the histiocytes localize about the ar-terioles. Findings in the present case,which may represent a comparatively earlychange, include numerous, small germinalcenters containing nonaggregated large,vacuolated histiocytes with intracellular ba-cilli.

KESUMENSe describe la histopatologia del bait) de un joven

con lepra lepromatosa difusa Ino nodular). A juzgarpor este caso, por otros casos publicados, y por las

necropsies efectuadas, la afecciOn del bozo en la lepralepromatosa esta caracterizada por la agregacion de

histiocitos grander y vacuolados, conteniendo hacilosindividuates y glohi tanto en la pulpit hlanca como en

la roja. En la pulpit hlanca, los histiocitos se localizan

alrededor de his arteriolar. Los hallazgos en el casoaqui presentado, los cuales pueden representar cam-

bios relativamente tempi - nos, incluyen numerosos

centros germinates pequenos conteniendo grandes his-tiocitos vacuolados no agregados, con bacilos intra-

celulares.

RESUMEOn rapporte l'observation histopathologique de la

rate chez tin homme jeune atteint de lepre leproma-

teuse diffuse non-nodulaire. Pour autant quepuisse en juger stir la base de ce cas, stir d'autres

rapports et stir des series d'autopsies, l'atteinte de la

rate dans la lepre lepromateuse est caracterisee par laconfluence d'histiocytes de grande dimension et vac-

uoles, contenant des hacilles individuels et des globi,la fois dans la pulpe rouge et dans la pulpe blanche.

Dans la pulpe blanche des histiocytes sont localises

autour des arterioles. Les observations faites dans ce

cas, qui temoignent petit-etre de modifications rela-tivement precoces, font etat de nombreux petits

290^ /Wen/at/Qua/ Journal o/ . /,cpro.sy^ 1980

centres germinatifs contenant des histiucytes degrande dimension, vacuok.s, et contenant des hacillesintracellulaires, mais ne pri!sentant pas de confluence.

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