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Pure neuritic leprosy with type 2 reaction
Abstract
Pure neuritic leprosy (PNL) is considered a distinct form of leprosy by Indian Association of Leprologists.
Reactions usually reported in PNL are Type 1 reactions manifesting as neuritis with a rare involvement of the
skin. We report a case of Type 2 reaction in PNL. This case, a 30 year old male, presented with history of shock
like sensation over both upper limbs and lower limbs and tingling numbness for duration of one year. Clinical
examination did not reveal any observable patches, plaques or nodules on the entire body. Touch, pain and
temperature sensations were impaired on the ulnar aspect of both upper limb and even over both lower
limbs. Motor examination revealed weakness of small muscles of both hand. Enlargement of ulnar, ulnar
cutaneous nerves, lateral popliteal, anterior tibial and sural nerve was found on both sides with minimal
tenderness over the ulnar nerves. Slit skin smears were negative for acid fast bacilli. Nerve conduction study
showed asymmetric mixed sensorimotor polyneuropathy. Biopsy from hypoaesthetic area on right forearm
revealed mild lymphocytic and macrophage accumulation around the dermal vessels, sweat glands and
neurovascular bundles, suggestive of Indeterminate Hansens. Nerve biopsy from right sural nerve gave
findings of Lepromatous Hansens neuritis with the epineurium thickened, medial hypertrophy of nutrient
artery and neovascularisation. Wade Fite Faraco stain showed multiple acid fast bacilli. Diagnosis of Pure
Neuritic Leprosy with Type 1 reaction was made and patient was started on MB-MDT. During the treatment he
developed ENL which was successfully managed with Steroids and Thalidomide. It will be important to keep
such mixed atypical presentations in mind when dealing with suspected cases of PNL.
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