Rare Presentation of Type 2 Lepra Reaction with Suppurative Lymphadenitis and Pustular Sweets Syndrome-like Lesions

The unusual presentations of lepra reactions (LRs) or leprosy often warrant the exclusion of close mimickers especially if cardinal signs of leprosy are lacking. In such cases, demonstration of acid-fast bacilli (AFB) either on slit skin smear microscopy (SSS) or histopathology or on cytology can aid in early diagnosis of leprosy. Here a 72-year-old untreated case of leprosy is reported for atypical presentation of type 2 lepra reaction (T2LR) in the form of massively enlarged, generalized lymphadenitis with secondary suppuration in groin and axillary groups. The patient also had fever, constitutional symptoms, sweets syndrome-like tender plaques, and pustules over the extensors of the extremities. Despite having visible deformities in her hands for the past 10 years, the patient denied any treatment for leprosy. The demonstration of AFB on lymph node cytology and subsequently on repeated SSS from ears confirmed the diagnosis of leprosy. After that other clinical possibilities like sweets syndrome with underlying lymphoma or concomitant tubercular lymphadenitis were excluded.