429. Delayed Diagnosis of Leprosy in a Non-Endemic Area: Lessons From a Retrospective Case Series
Background
While the epidemiology of Hansen’s Disease (leprosy) in endemic countries has been thoroughly investigated, similar studies in the United States are lacking, where fewer than 200 cases are diagnosed each year. We sought to assess the epidemiologic and clinical characteristics of leprosy cases seen at three large Boston teaching hospitals.
Methods
We conducted a retrospective analysis of all patients age ≥18 diagnosed with leprosy as defined by ICD codes at three academic medical centers from 1980 to 2017. Each record was independently reviewed for accuracy of the clinical and laboratory findings for each patient. Demographic, clinical, and laboratory data were extracted and analyzed.
Results
In total, 116 records were reviewed; 27 cases of leprosy were identified. Mean age at presentation was 40 years (range, 19–62); 66% of patients were male. Forty-eight percent of patients were Hispanic, 22.2% were Asian, and 18.5% were African. Most patients were immigrants (88.9%), originating from South America (33.3%), the Caribbean (18.5%), Sub-Saharan Africa (18.5%), and South Asia (14.8%). Both cutaneous and neurologic involvement was commonly observed (59.2%). Diagnosis was made by skin or nerve biopsy in 67.7% of cases. A prior diagnosis of leprosy was present in 51.9%. Interestingly, for cases of newly diagnosed leprosy, 25.9% of diagnoses were made by dermatologists, 11.1% by neurologists, and 3.7% by infectious diseases physicians. Fifty-six percent of patients had been incorrectly diagnosed by other healthcare providers prior to their leprosy diagnosis, and the median time from symptom onset to diagnosis was 25 months (range, 2–180).
Conclusion
Though not endemic to the United States, leprosy remains a clinical problem, particularly in immigrant populations. We observed that a sizeable proportion of leprosy cases were initially misdiagnosed by physicians, frequently resulting in months-long delays in diagnosis. Clinicians should have a high index of suspicion for leprosy in immigrants from endemic countries with cutaneous lesions and neuropathy, and opportunities for enhanced clinician awareness, targeted education, and multidisciplinary management exist.