Hansen's disease – clinically atypical presentation with atypical histopathology

Type II Lepra reaction is a Th2 mediated hypersensitivity reaction characterized by involvement of skin and nerves. Herein we report an unusual leprosy case that had a rheumatic mode of onset of Type II Lepra reaction. This case also had livedoid plaques, ulcers on the genitalia, extremities as the initial manifestation of Hansen's Disease and atypical histopathology. His symptoms had started 1 year back as polyarthralgia of both knees and small joints of hands and feet for which he was on immunosuppressant by a Rheumatologist who made a diagnosis of rheumatoid arthritis. After 6 months, patient developed red painful lesions; initially on arms, chest and trunk followed by legs. Subsequently, painful ulcerations developed on feet, knees and genitalia and a dermatology referral was made. Histopathology and slit skin smears led to diagnosis of Lepromatous leprosy in Type II Lepra reaction. Hansen's disease is a great imitator. Rheumatic manifestations can be the initial presentation of Type II Lepra reaction. Rheumatic manifestations thus can be the initial presentation of Type II Lepra reaction even before starting Multi drug therapy. High index of suspicion and routine slit skin smears in small peripheral settings can be helpful in diagnosing and treating such cases.