A previously well 15-year-old male presented to our institution with a 3-week history of sacral edema that began in his feet then spread to his hands, face, shins, and forearms. The edema was described as taut and shiny, and it was followed by rash of the extremities and trunk. Swelling of the hands made it difficult for the patient to make a fist. He complained of decreased appetite, a 10-lb weight loss, and some mild fatigue, but he denied having fevers, chills, and night sweats. He denied having any ill contacts, and all of his family members were well. The patient had immigrated to the United States from Haiti 3 years earlier. He had received one Mycobacterium bovis BCG vaccine. Physical examination revealed a well-grown, afebrile patient with normal vital signs who was essentially unremarkable except for diffuse, nonpitting edema of the face, hands, feet, and forearms that was not tender to palpation, with erythematous, raised plaques covering his chest, abdomen, back, and extremities. He had a normal joint and neurological exam. A complete blood count (CBC) and metabolic panel were unremarkable. He had a normal albumin level and normal urinalysis and thyroid function test results. His total serum protein was slightly elevated, and his erythrocyte sedimentation rate (ESR) was elevated, at 51 mm/h. A chest X ray was normal. A skin biopsy of a right arm lesion was performed and established the correct diagnosis (Fig. 1). Fig 1 Histopathological appearance of the skin lesion biopsy specimen stained with hematoxylin-phloxine B-saffron.(a) Low-power panoramic view. (b) Higher magnification. (c) Small nerves (arrow). (d) Modified Ziehl-Neelsen (Wade-Fite) stain. (For answer and discussion, see page 213 in this issue [doi:10.1128/JCM.05729-11])

Answer: Multibacillary borderline lepromatous Hansen's disease (leprosy). Figure 1 demonstrates the histopathological appearance of the skin lesion biopsy specimen obtained from our patient's right arm, stained with hematoxylin-phloxine B-saffron, which revealed well-delineated patches of