Interesting and unusual presentation(s) of leprosy resulting in delayed diagnosis
In the post elimination phase of leprosy programme, it continues to be an important health problem in India. Further various atypical forms are seen resulting in delayed diagnosis. A retrospective analysis of 2 years (January 2016 to December 2017) records of all in and out patients of leprosy cases who were treated at a service hospital in northern India was done. At this hospital a total of 97 leprosy cases were seen during the study period out of which 18 (18.5%) cases where the diagnosis was missed due to various reasons resulting in delay in initiation of MDT were included. These cases were examined to describe the clinical presentation, delay in diagnosis and its significant outcome. 61% (11/18) were males while 39% (7/18) females. 22.2% (4/97) had Histoid Hansen's disease; 22.2% (4/18) had chronic symmetrical polyarthritis, there was no hypoaesthetic or anesthetic patches or enlarged nerves in these patients and these were initially diagnosed and managed as Rheumatoid arthritis. 16.6% (3/18) had spontaneous ulceration of extremities and had no skin infiltration or thickened nerve on examination. Interestingly two of these three patients had associated hypoaethesia of extremities which was not taken into consideration for making diagnosis as no suspicion of leprosy was made, one patient in this group had developed foot drop (L) and Right ulnar claw. 16.6% (3/18) had pure neuritic leprosy while greater auricular nerve thickening was seen in 11.1% (2/18) atypical cases. 5.5% (1/18) patient had swelling of upper lip but there no lesion on face or nerve and was managed by a Dentist. Lichenoid lesions were seen in 5.5% (1/18) cases. Out of 18 atypical cases 83.3% (15/18) were in multibacillary pole while 16.6% (3/18) were in paucibacillary pole. 27.7% (5/18) each were BL and LL while 22.2% (4/18) each were Pure neuritic and Histoid Hansen's. 83.3% (15/18) patients were Bacillary positive. Grade 2 deformity developed in 22.2% (4/18) of these cases. The total duration elapsed between presenting to the primary care giver and the dermatology center where the final diagnosis was made ranged from 2 weeks to 3 years. Increase in awareness about various presentations of leprosy in post-elimination era should be emphasized to the health care physicians as well as other workers involved in detection/diagnosis of leprosy.