Musculoskeletal manifestations of leprosy.

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A 32-year-old lady presented with a 1-month history of recurrent painful nodules over her legs and forearms (Fig. 1A), bilateral symmetric small- and large-joint polyarthritis, swelling of dorsal hands and feet, and dactylitis (Fig. 1B–D). The possibilities of sarcoidosis, tuberculosis, leprosy, SLE, lymphomatoid granulomatosis, and s.c. panniculitis-like T-cell lymphoma were considered. The patient did not have constitutional symptoms, lymphadenopathy, pulmonary or ocular involvement, thickened nerves, or an anaesthetic skin patch, and had no relevant medical family history. A skin biopsy from a nodule showed granulomatous inflammation of foamy macrophages and lymphocytes surrounding the neurovascular bundle (Fig. 1E). Her haemogram, liver and renal function tests, and electrolytes were normal. Her ESR was 42 mm and CRP 24.7 mg/dl, and RF, anti-cyclic citrullinated peptide antibody, ANA, serum angiotensin-converting enzyme levels, and viral markers were negative. A slit skin smear and PCR for Mycobacteriumleprae were positive. A diagnosis of lepra reaction—erythema nodosum leprosum with swollen hands and feet was made. She was treated with prednisolone (40 mg/day) and multidrug therapy (rifampicin, clofazimine and dapsone). All symptoms improved within days to weeks of starting treatment. Musculoskeletal manifestations in leprosy can either present acutely—lepra reaction, swollen hands and feet syndrome, tenosynovitis—or chronically—symmetric polyarthritis as in RA or Charcot’s arthropathy, and can mimic various rheumatic diseases [1]. Arthritis with skin nodules is rarely an initial presentation of Hansen's. Thickened nerves, anaesthetic skin patches, ear lobule infiltration, and anti-cyclic citrullinated peptide antibody levels may help in differentiating [2].