Uncommon Neurological Presentations of Leprosy (P1.323)

Objective: To acknowledge the importance of ruling out leprosy in patients presenting with atypical neurological presentation in tropics

Background: The diagnosis of leprosy becomes extremely challenging if the patient comes from a non-endemic zone, and presents with atypical neurological presentation to a neurologist without prior evaluation by a dermatologist. We describe two atypical cases that presented as type 1 lepra reaction in their first presentation.

Methods: Observational case study done in Institute of Neurology, MMC, Chennai.

Results: Our first patient presented with low grade fever -1 month followed by numbness of both foot and hands and distal weakness of all 4 limbs.Within 2 weeks he developed left hand clawing with left foot drop and intrinsic muscle wasting of hands and legs and bilateral severe painful wrist joint swelling. Nerve conduction study(NCS)- bilateral ulnar axonal degeneration, bilateral tibial and peroneal nerve not stimulatable,SNAP not obtained. All investigations including vasculitic profile were negative. Slit skin smear(SSS) positive for Mycobacterium leprae. He was diagnosed with type 1 lepra reaction. Started on treatment with steroids and Multidrug therapy(MDT) for leprosy. The second patient had multiple consultations for fever of unknown origin for 40 days. He presented to us with bilateral painful wrist swelling and weaknes,numbness of right hand and right foot for 3 week duration and clawing for 2 weeks. NCS showed axonal degeneration of right ulnar and peroneal nerve. SSS positive for M.leprae. diagnosed and treated for type 1 lepra reaction. Both the cases had new skin lesions discovered only on examination and not in history with mononeuritis multiplex pattern of peripheral neuropathy and subacute presentations. Both had tender peripheral nerve thickening.

Conclusions: Leprosy presenting as type 1 lepra reaction is rare. Leprosy might masquerade as atypical peripheral neuropathy. Leprosy work up should be considered for atypical peripheral neuropathy presentations in tropical countries.