Despite the overall decline in number of leprosy cases in the United States, small numbers of patients with the disease continue to be reported, predominantly among immigrant populations. Occasional cases occur among native-born American residents, predominantly from the southern United States. The source of the reservoir and transmission among indigenous HD cases remains unexplained, although armadillos in the state of Texas and Louisiana have been implicated. Since most patients among the indigenous cases occur in older age groups, the possibility of reactivation of the disease through immunosenescence has been raised. In most patients, unfamiliarity with the clinical picture of HD among physicians in the United States accounts for delayed or incorrect diagnosis. High index of suspicion in a patient with unusual skin lesions, particularly with sensory loss, should be followed by a biopsy looking for the characteristic histologic changes found in various forms of leprosy. Reversal reactions and erythema nodosum leprosum are relatively frequent complications of treatment. Treatment and periodic follow-up of these patients should be done, preferably by physicians with experience with the disease entity.
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