Title : Denovo in denovo: Emerging challenges of leprosy in the postelimation era
Abstract:
Background: Erythema nodosum leprosum (ENL), is an immune-mediated type II leprosy reaction occurring as a complication in 50% lepromatous leprosy and 5-10% borderline lepromatous leprosy patients. Histoid leprosy, a rare variant of lepromatous leprosy, occurs with irregular or inadequate therapy, dapsone monotherapy, or rarely denovo. The occurrence of denovo histoid skin lesions following denovo ENL has not been previously reported in literature. We report two cases who presented for the first time with ENL and histoid lesions, with no history of taking dapsone or antileprosy treatment earlier, in the post-leprosy elimination era.
Case Report One: A 65 year old farmer, presented with multiple tender evanescent erythematous well-demarcated firm nodules over bilateral upper limbs and lower legs since 2 months. Two weeks following which he developed few discrete dome shaped skin-coloured nodules on normal looking skin over posterior trunk. There is history of tingling numbness over lower limbs with swelling, mild intermittent fever with chills, difficulty in holding objects, buttoning his shirt and slippage of slippers since 2 months. No similar complaints in past. No family history or contact with a known case of leprosy.
Moderate uniform non tender thickening of multiple nerve trunks. Hypoaesthesia over palms and soles, wasting of hand muscles and trophic ulcer over right foot. A clinical diagnosis of Type II reaction with histoid leprosy, ulnar claw hand deformity and trophic ulcer over foot, not on treatment was made.
Baseline investigations were normal. Slit skin smear and histopathology were suggestive of ENL with histoid leprosy. The patient was put on multibacillary multidrug therapy (MBMDT) and Tab Prednisolone 40 mg, od and is on regular follow-up.
Case Report Two: A 44-year old farmer presented with numerous tender erythematous evanescent nodules few showing ulceration on the body since 2 year, that used to resolve in 3-4 days on taking unknown medication. Skin coloured to hyperpigmented dome shaped nodules over normal looking skin on upper limbs and posterior trunk since six months. Non tender thickening of multiple nerve trunks. Patchy loss of sensation over dorsum of hands, forearms, legs and feet. No significant past history. No family history or contact with known case of leprosy. Baseline investigations were normal. Slit skin smear and histopathology suggested ENL with histoid leprosy. The patient has been put on multibacillary multidrug therapy (MBMDT) and Tab. Prednisolone 20 mg, od and is on regular follow-up.
Audience Take Away Notes:
- This a rare presentation of denovo ENL with denovo histoid leprosy, not reported previously in literature
- Histoid lesions suggest resistant bacilli and an intense lepromatous activity, complicating management and increasing the risk of transmission
- The emergence of such cases in India, which declared leprosy eliminated in 2005, underscores need for continued vigilance and enhanced awareness in the post-elimination era to effectively address these atypical manifestations and curb the endemic
