The clinical presentation is consistent with leprosy. Patients typically exhibit at least 2 of the following cardinal signs:

• a skin lesion with sensory loss
• thickened peripheral nerves
• acid-fast bacilli on skin smears or tissue biopsy

In a deep skin biopsy (down to the fat) of one of Mr. T.J. s skin lesions, no acid-fast bacilli were detected. The dermis, however, showed granulomatous infiltration and, most importantly, involvement of a cutaneous nerve. The biopsy was compatible with the clinical diagnosis of borderline-tuberculoid leprosy, in which cellular immunity is high but acid-fast bacilli are very scarce. Multidrug therapy was initiated with daily rifampin and dapsone for 6 months. Mr. T.J. was counselled to inspect his hands daily to detect injury to his anesthetic fingers. Also, he was forced to start alternate duties at work.