Leprosy presenting as acute sensory polyneuropathy

A middle-aged female had tingling in all four limbs for ten days. On examination she had a sensory polyneuropathy with bilateral tender, non-thickened ulnar nerves, with normal power. There were no skin lesions. Nerve conduction studies showed a sensory-motor, mixed axonal and demyelinating polyneuropathy. Other laboratory workup was negative. Differentials like Guillain Barre syndrome and vasculitic polyneuropathy were ruled out due to incongruent clinical features.

Because the patient lived in an endemic area for leprosy and had tender ulnar nerves, a slit skin smear study was done, which was positive. Common neurological manifestations of leprosy are mononeuropathy and mononeuritis multiplex. Uncommonly, leprosy presents as polyneuropathy – actually, a mononeuritis multiplex summation. Lepra reactions often present with neuritis and skin manifestations. Neuritis can occur without dermatological manifestations in 5–6% of lepra reactions. This case has acute polyneuropathy probably as manifestation of a lepra reaction without any skin features. In endemic regions, consider leprosy in any case of neuropathy, even if there are no skin lesions, and especialy if the findings do not suggest other causes.