Case Studies
Lepromatous leprosy or rheumatoid arthritis with leprosy? A challenging case
Bharathraj MY1, Chandrashekara S2, Ghanti S3, Kori D4, Krishna R5
Author Affiliations
1-4ChanRe Rheumatology and Immunology Center and Research, Bengaluru, India
Correspondence: Dr. Bharathraj
IJRCI. 2019;7(1):CS3.
Submitted: 21 February 2019, Accepted: 8 April 2019, Published:23 April 2019
© IJRCI
Abstract
Rheumatoid arthritis (RA) manifestations in leprosy are very common, but often undiagnosed. The present study discusses a challenging case having dilemma in concluding the diagnosis as lepromatous leprosy or RA with leprosy.
Keywords: rheumatoid arthritis, leprosy, tenosynovitis
Introduction
Hansen’s disease, commonly known as lepromatous leprosy or leprosy, is a highly contagious and chronic systemic disease caused by Mycobacterium leprae.1 Cutaneous and peripheral nervous systems are mainly involved, and the disease may also affect visceral and musculoskeletal or joint systems. Though rheumatoid arthritis (RA) like manifestations is common in leprosy, it is often underreported and underdiagnosed. In leprosy patients, RA manifestations are most commonly presented as symmetrical or chronic polyarthritis.2 In some cases, leprosy may be associated with tenosynovitis or tenosynovitis arthritis.2 The present study discusses the case of an elderly woman with both symptoms and evidence of leprosy and RA.
Case report
An elderly housewife with a history of inflammatory joint pains for 4 years presented with puffiness of fingers, paleness of digits, and ulceration for 20 days (Fig. 1). There were no deformities of the joints. The pain involving finger tips aggravated on touching and on movements of the hands. Small areas of digit ulceration were present over right index finger, but there was no history of discharge or bleeding from ulcers. Dry mouth, fever, skin rashes, oral ulcers, muscle weakness, difficulty in breathing, dysphagia, dry eyes/vision disturbances, weight loss, alopecia and bluish discoloration of fingertips were absent. Other comorbidities such as diabetes, hypertension, asthma, tuberculosis, and seizure disorder were absent. Her vitals were stable and systemic examination was apparently normal. Peripheral nerve examination revealed asymmetrical palpable thickened right-side ulnar nerve without nodularity. Laboratory findings indicated: normal blood counts, ESR 48 mm/hr, CRP 16 mg/dl, RA factor 189, and ANA 2+. Nerve conduction test showed right ulnar motor-sensory axonal and demyelinating neuropathy. Histopathology of skin obtained from medial aspect of distal right forearm revealed papillary dermis showing non-caseating epithelioid granulomas involving dermal appendages and erector pili (Fig. 2). Inflammatory cells, comprising of lymphocytes and foamy macrophages, were present around the blood vessels. The presence of gram-positive bacilli confirmed the diagnosis of leprosy.
Fig. 1: Inflammation of joints and pale digits
Fig. 2: Inflammatory cells with lymphocytes and foamy macrophages
Discussion
Leprosy shows various clinical manifestations and some are typical to RA.3 Manifestations of RA or musculoskeletal involvement occur in 75% of leprosy cases and may lead to delayed treatment or improper diagnosis.4 RA manifestations occur either as a complication of disease or as a leprosy reaction, mainly during anti-bacterial treatment.5 RA manifestations include chronic or symmetrical polyarthritis, Charcot’s joint, and swollen hands and feet syndrome.6 The present case had all the typical symptoms of RA with positive RA factor and the same can be noted in a case of leprosy and negative anti- CCP. Diagnosis of leprosy was suspected, as there were additional signs of skin rash and thickened ulnar nerve.
Recent decades have witnessed significant reduction in the global burden of leprosy, and this could be mainly attributed to the wider use of multidrug therapy. India was successful in eliminating the leprosy by 2005, but the disease is remerging due to poor social standards, increased strategized approach and development of bacterial resistance.7 Annual New Case Detection Rate (ANCDR) for the year 2016-17 showed increase in the leprosy cases of around 10.17 per 100,000 population in India when compared to 2015-16.8 In the current case, leprosy was considered as the differential, owing to the positive biopsy result, despite the reduced prevalence of leprosy.
Neural involvement and articular involvement in leprosy have been reported since 600 B.C. in China.9 Neural involvement can be seen as mononeuropathy or polyneuropathy.10 Neuropathy may lead to neuropathic joint and septic arthritis in post-trauma stage.11 Acute and chronic symmetric polyarthritis involving hand joints, mimicking rheumatoid arthritis (RA), has been described with or without lepra reaction; however the exact physiology of joint involvement is not fully understood.12 Systemic immune effect and complex reaction may lead to the arthritis and related complications.2
A 2017 case study by Tatiana et al. has reported a case of lepromatous leprosy mimicking RA. The patient had both the symptoms of RA and leprosy with no considerable improvement in RA with treatment. The study highlighted the need of considering the possibility of leprosy, even in areas where the is disease is considered as eradicated.13 Non-leprotic manifestations are common in leprosy. The study by Haroon et al. has noted the presence of pure neuritic leprosy in 5 patients having inflammatory arthritis with/without tenosynovitis and tenosynovitis.14 A good understanding of arthritis and knowledge of arthritis manifestations in leprosy will help in proper and prior diagnosis. The present case is unique because, despite the confirmation of leprosy through biopsy, there was a prevailing dilemma on the possibility of co-existence of RA. As a thumb rule, treating the infection followed by wait and watch is recommended in such situations to further ascertain the co-existence of RA with leprosy.
Conclusion
Leprosy associated with RA is a rare scenario. However, there are possibilities for co-existence of RA with leprosy and possible presentation of symptoms mimicking RA in leprosy. The present case study underscores the need of considering leprosy as a differential diagnosis to RA while managing patients belonging to endemic areas.
Competing interests
The authors declare that they have no competing interests.
References
1. Gao L-N, Zhong B, Wang Y. Rheumatoid arthritis-like features in Hansen disease: A case report. Medicine. 2018 Jul;97(29):e11590.
2. Alam F, Emadi SA. Case of arthritis secondary to leprosy. Springer plus. 2014 Dec 15;3.
3. Gibson T, Ahsan Q, Hussein K. Arthritis of leprosy. Br J Rheumatol. 1994 Oct;33(10):963–6.
4. Wakhlu A, Sawlani KK, Himanshu D. Rheumatological manifestations of hansen’s disease. Indian Journal of Rheumatology. 2018 Jan 1;13(1):14.
5. PK S. A study of rheumatological manifestations of leprosy. Indian Journal of Dermatology, Venereology, and Leprology. 2004 Mar 1;70(2):76.
6. Shejpal A. Hansen’s Arthritis: An Overlooked Entity. Indian Journal of Clinical Practice, Vol. 24, No. 8, January 2014, 770-772.
7. Hamoud, H. (2016). Leprotic Arthritis. Journal of Rheumatology and Arthritic Diseases, 1(2), pp.1-5.
8. National Leprosy Eradication Programme; Annual report 2016 – 2017.
9. Messner RP. Arthritis due to tuberculosis, fungal infections, and parasites. CurrOpinRheumatol. 1991 Aug;3(4):617–20.
10. Pandey A. Current perspectives on leprosy as a public health challenge in India. Research and Reports in Tropical Medicine.2015;43.
11. Koopman WJ, editor. Arthritis and allied conditions: a textbook of rheumatology. 13th ed. Baltimore: Williams & Wilkins; 1997. 2 p.
12. Hartemann-Heurtier A, Van GH, Grimaldi A. The Charcot foot. Lancet. 2002 Nov 30;360(9347):1776–9.
13. de Andrade TCPC, Martins TY, Vieira BC, Santiago TM, Soares CT, Barreto JA. Lepromatous leprosy simulating rheumatoid arthritis - Report of a neglected disease. An Bras Dermatol. 2017;92(3):389–91.
14. Haroon N, Agarwal V, Aggarwal A, Kumari N, Krishnani N, Misra R. Arthritis as presenting manifestation of pure neuritic leprosy--a rheumatologist’s dilemma. Rheumatology (Oxford). 2007 Apr;46(4):653–6.