Case Study 3

A medical student is working in a clinic in Hawai’i that frequently serves the indigent population and new immigrants. An elderly Micronesian woman who has recently immigrated to Hawai’i is brought to the clinic because of a hypopigmented lesion on her face. It appears to be vitiligo. However, to be thorough with the examination, the medical student tests the sensation in the lesion by touching it with a pin.

The patient speaks no English, but they work out a system of communication whereby the patient clearly indicates when she does and when she does not feel the pinprick. She clearly does not feel the pinprick in the central part of the lesion. The medical student makes a diagnosis of Hansen’s Disease (leprosy), and presents the patient to her attending physician.

The attending physician smirks at the medical student’s “zebra” diagnosis and gives her a lecture about vitiligo, and common things being common. He then examines the patient himself, fully prepared to send the patient on her way. However, much to his surprise, he confirms the medical student’s diagnosis!

Learning points

Hansen’s Disease is still frequently seen in Pacific Island peoples. One needs to be cognizant of this fact and consider Hansen’s Disease within the differential diagnosis of a skin lesion in someone who was raised in the Pacific region. To address this possibility, include an examination of the patient’s sensory changes, as well as an examination of superficial nerves, looking specifically for nodules occurring over peripheral nerves (i.e. sural, ulnar nerves).

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