Borderline Tuberculoid Leprosy Research Articles

Evaluation of agreement between clinical and histopathological diagnosis of subtype of leprosy by skin punch biopsy

Introduction: Leprosy is chronic granulomatous disease caused by Mycobacterium leprae. Clinically diagnosed cases of leprosy can be evaluated by punch biopsy. It can be classified according to Ridley and Jopling Classification.
 Objective: To study the different spectrum of leprosy and its Bacillary Index (BI), evaluate the agreement between clinical and histopathological diagnosis.
 Materials and Methods: This is a hospital based cross sectional retrospective study done for the period of 6 months from January to June 2019. The data were subjected to kappa analysis by using SPSS version 24 to see the agreement between clinical and histopathological diagnosis.
 Results: Out of 62 cases of clinically diagnosed cases of leprosy three (4.83%) cases turned out to be other granulomatous diseases. According to Ridley and Jopling classification, clinical and histopathological agreement was seen in 38 (61.29%) cases. Agreement of 100% was seen in Indeterminate leprosy (IL) and Borderline tuberculoid leprosy (BT). The BI was more in Lepromatous leprosy (LL), Borderline lepromatous (BL) whereas IL, BT and Tuberculoid leprosy (TT) showed less BI. Overall there was moderate agreement between clinical and histopathological diagnosis (kappa- 0.505) which was statistically significant (p value <0.05).
 Conclusion: There was moderate agreement between the clinical and histopathological diagnosis of subtype of leprosy. The Bacillary load was high in LL whereas least in TT and is determined by immune system.

Generalized idiopathic atrophodema of Pasini and Pierini misdiagnosed as relapse of disease in a patient with borderline tuberculoid leprosy

Idiopathic atrophoderma of Pasini and Pierini (APP) is a rare condition which is characterized by asymptomatic depressed hypopigmented patches with a classic ‘cliff drop’ edge, usually on the back. There are less than 100 cases reported in the literature till date. APP can mimic borderline tuberculoid (BT) leprosy due to its hypopigmented colour and loss of sensation as a result of damage to dermal nerves. We report a 51 years old man with BT leprosy who had already completed 6 months of PB-MDT adult regimen and subsequently developed new hypopigmented and hypoesthetic skin lesions over the trunk and extremities one year after completion of MDT. The lesions were misdiagnosed as relapse of BT leprosy and the patient was restarted MB-MDT. New lesions kept on appearing despite the intake of MDT. Later histopathology revealed the lesions to be atrophoderma.

Study of clinico-epidemiological profile of leprosy patients at tertiary care centre of South Gujarat region

<p class="abstract"><strong>Background:</strong> Leprosy is a chronic feared illness causes by <em>Mycobacterium leprae</em>. It was eliminated as a public health problem in India in 2005. But still, India contributes more than 60% of all new cases of leprosy.</p><p class="abstract"><strong>Methods:</strong> A retrospective analysis of 307 patients attending the leprosy clinic of the dermatology out patient department, SMIMER, was done for a period of five years from January 2014 to December 2018. The data was analysed for clinical and epidemiological characteristics of the patients.<strong></strong></p><p class="abstract"><strong>Results:</strong> A total of 307 patients visited the leprosy clinic during the study period. More than half patients (60.3%) were between 21-40 years age group. There were 213 males and 94 females with male female ratio of 2.3:1. 72.3% (222) patients were suffering from multibacillary leprosy and 27.7% (85) had paucibacillary disease. Borderline tuberculoid leprosy was the most common type found in 83 patients (27.1%). 16 cases (5.2%) of childhood leprosy (less than 14 years of age) were noted. A total of 214 patients (69.7%) were migrants.</p><p class="abstract"><strong>Conclusions:</strong> Despite of decline at global and national level, leprosy cases show gradual increase. The high proportion of total cases, MB cases, and grade 2 disability cases are warning signs. Continued efforts are required to manage and prevent the disease.</p><p class="abstract"> </p>

Evidence for Mycobacterium leprae Drug Resistance in a Large Cohort of Leprous Neuropathy Patients from India.

Resistance to anti-leprosy drugs is on the rise. Several studies have documented resistance to rifampicin, dapsone, and ofloxacin in patients with leprosy. We looked for point mutations within the folP1, rpoB, and gyrA gene regions of the Mycobacterium leprae genome predominantly in the neural form of leprosy. DNA samples from 77 nerve tissue samples were polymerase chain reaction (PCR)-amplified for M leprae DNA and sequenced for drug resistance-determining regions of genes rpoB, folP1, and gyrA. The mean age at presentation and onset was 38.2 ± 13.4 (range 14-71) years and 34.9 ± 12.6 years (range 10-63) years, respectively. The majority had borderline tuberculoid leprosy (53 [68.8%]). Mutations associated with resistance were identified in 6/77 (7.8%) specimens. Mutations seen were those associated with resistance to rifampicin, ofloxacin, and dapsone. All the six patients were drug-naive. The clinical and pathological manifestations in this group did not differ from the drug-sensitive group. This study highlights the occurrence of resistance to the standard multidrug therapy and ofloxacin in leprosy. Among the entire cohort, 1/77 (1.3%) showed resistance to rifampicin, 2/77 (2.6%) to dapsone, and 5/77 (6.4%) to ofloxacin. Six new patients showing infection by mutant strains indicated the emergence of primary resistance. Resistance to ofloxacin could be due to frequent use of quinolones for many bacterial infections. The results of the study indicate the need for development of a robust and strict surveillance system for detecting drug resistance in leprosy in India.

Clinical profile and deformities in leprosy patients: a record based study

<p class="abstract"><strong>Background:</strong> Leprosy is a chronic disease caused by <em>Mycobacterium leprae</em>, infectious in some cases, and affecting the peripheral nervous system, skin and certain other tissues. Even though leprosy was declared eliminated as a public health problem in India on December 2005, new cases of leprosy continue to appear. Hence a study on clinical profile and deformities in all leprosy cases registered in the last 5 years was done to know the current status of leprosy in this area.</p><p class="abstract"><strong>Methods: </strong>This was a retrospective record-based study of leprosy cases done at Government Medical College, Manjeri, for a period of 5 years from October 2014 to September 2019.<strong></strong></p><p class="abstract"><strong>Results:</strong> 42 cases from the record were included in the study. Maximum cases belonged to the age group of 31 to 40 and males were more than females. 81% of the patients were multibacillary leprosy (MB) and 8 cases belonged to paucibacillary (PB) leprosy. Four child cases were registered as PB cases. Mostly encountered clinical diagnosis was borderline tuberculoid leprosy (23 out of 42) and two had type 1 reaction. Seven patients had deformity of which two had grade 2 deformity and rest had grade 1 deformity.</p><p><strong>Conclusions:</strong> One patient who presented with grade 2 deformity and type 1 reaction was from tribal area indicating low awareness about leprosy among them. More number of cases in the multibacillary group and presence of child cases and deformities reinforces the need for strict surveillance to eradicate leprosy. </p>

Study of histomorphological variants of leprosy in correlation with bacilloscopy index in tertiary care hospital

Introduction: Leprosy is an infectious and contagious chronic disease, caused by Mycobacterium leprae, an obligate intracellular bacillus, that affects mainly the skin, nerves and mucous membranes. It can also affect the eye, nose, joints, lymph nodes, internal organs and bone marrow, especially in multibacillary patients (MB). In the majority of cases, it is transmitted from person to person through contact with patients having a high bacillary index and haven't been treated. Materials and Methods: This is an observational retrospective study of 52 cases conducted in histopathology section of Pathology department, Government Medical college, Bhavnagar, Gujarat. In this study, cases were included whose biopsy samples were received in the department with clinical suspicion of leprosy. All the case diagnosed as leprosy were evaluated by Fite Faraco stain and reported for bacilloscopy index. Results: Out of 52 cases, 40 were histomorphologically confirmed as leprosy. Maximum number of cases were observed in the age group of 31 to 40 years (47.5%). Among various anatomical site for cutaneous presentation of leprosy in maximum number of cases, the lesions were observed in upper extremity (50%). Higher number of type of leprosy observed were borderline tuberculoid leprosy (35%) followed by tuberculoid leprosy (30%). It is observed, mean bacilloscopic index is higher in cases of lepromatous leprosy whereas lower in tuberculoid leprosy. Conclusion: In our study, borderline tuberculoid and tuberculoid cases were reported with higher incidence. Bacteriological examination and bacilloscopy index add onto the morphological diagnosis and help to categorise multibacillary and paucibacillary leprosy. Keywords: Leprosy, Bacilloscopy index, Fite Faraco.

Role of Histopathology in Predicting type 1 Lepra Reaction in Borderline Tuberculoid Leprosy.

Context:Lepra reactions if not managed promptly are an important cause of sudden onset nerve palsy and disability due to leprosy.Aim:To evaluate the usefulness of histology in predicting type 1 lepra reaction.Setting and Design:After obtaining clearance from institutional research and ethics committees, all histologically proven borderline tuberculoid patients diagnosed at our center from 1.8.2016 to 31.7.2018 were included in this retrospective cross-sectional study.Method:Clinical details were collected from patient records. The pathologist who was blinded to clinical evidence of type 1 lepra reaction at the time of biopsy re-evaluated the histopathology slides for evidence of type 1 reaction. The data of individual patient was analyzed to identify those who had a type 1 reaction at the time of the biopsy or who developed a lepra reaction during follow up.Statistical Analysis Used:Association between histological evidence of type 1 reaction and clinical manifestation of the same subsequently, was assessed using Pearson's Chi square test.Results:Study group comprised of 22 females and 18 males. Clinicohistological concordance was noted in 27 patients (67.5%). Subclinical type 1 reaction was documented in 11 patients (27.5%) based on histopathology evaluation. Five (45.5%) of these 11 patients subsequently developed clinical features of type 1 reaction. This was found to be statistically significant (P value 0.02).Limitations:Main limitation was the small sample size.Conclusions:Histology could serve as a useful tool in predicting future type 1 lepra reaction.

A Clinicohistopathological Correlation of Hansen's Disease in a Rural Tertiary Care Hospital of Central India.

Background:Leprosy is an ancient, chronic granulomatous infectious disease caused by Mycobacterium leprae, principally affecting the skin and peripheral nerves. The clinical manifestations of leprosy are variable and can mimic a variety of other skin diseases. Thus, histopathological examination plays an important role in early diagnosis and management.Aim:The aim was to study the clinicohistopathological correlation of all suspected cases of Hansen's disease.Materials and Methods:A retrospective study was conducted on 207 skin biopsies obtained from patients clinically diagnosed as new lesion of leprosy in the department of pathology from 2016 to 2019. Demographic, clinical details of the patients were retrieved from hospital information system. Hematoxylin–eosin- and Fite–Faraco-stained sections were evaluated for features confirming leprosy and further categorized as per Ridley–Jopling system. Sensitivity, specificity, and concordance rates were studied.Results:The male-to-female ratio was 1.5:1. The agreement between histopathological and clinical diagnoses was more than 90% in all the subclasses except for borderline tuberculoid leprosy (BT) and tuberculoid leprosy (TT) which showed an agreement of 86.5% and 88.4%, respectively. The sensitivity of clinical diagnosis ranged from 69.70% for indeterminate to 100% for histoid and neuritic types. The specificity ranged from 90% for BT and TT to 100% for neuritic leprosy.Conclusion:Clinical diagnosis of early leprosy lesions offers difficulties even to experienced dermatologists as a patient presents in different clinicopathological forms, depending on host immune status. Thus, the correlation between clinical, histopathological, and bacteriological features is required for diagnosis and classification of leprosy. Nerve damage is irreversible; therefore, early detection and treatment is important to prevent Grade 2 disabilities.

Borderline tuberculoid hansens with type 1 reaction in a HIV patient: an IRIS phenomenon over an unusual site

<p class="abstract">Immune reconstitution inflammatory syndrome (IRIS) is an acute symptomatic expression of a latent infection during the recovery of the immune system and it occurs as a response to antiretroviral therapy. Opportunistic infections can act as a trigger for IRIS. Hansens disease is an infection caused by <em>Mycobacterium leprae</em>. There are very few case reports reporting the development of borderline tuberculoid hansens with type 1 reaction as IRIS. We here report a unique case of IRIS in a HIV patient who presented with borderline tuberculoid leprosy with type 1 lepra reaction presenting over unusual site following highly active antiretroviral therapy administration.</p>

Borderline Tuberculoid leprosy of the scalp mimicking alopecia areata-vitiligo overlap syndrome: A case report

The scalp is known to be a zone relatively immune to Mycobacterium leprae. Regardless, there have been multiple reports of multibacillary (MB) leprosy affecting the scalp. However, less than ten paucibacillary leprosy (PB) cases with scalp involvement are known, two of which also had patches of alopecia. Herein, we report the third case of ‘leprotic alopecia’ in a 26-year-old female secondary to PB leprosy. Although the clinical picture mimicked alopecia areata-vitiligo overlap syndrome, histopathological examination revealed borderline tuberculoid (BT) leprosy of the scalp.

A clinico pathological correlation in leprosy in a tertiary care teaching institution

<p class="abstract"><strong>Background:</strong> Leprosy is a chronic infectious granulomatous disease caused by <em>Mycobacterium leprae</em>. The disease primarily affects peripheral nervous system, the skin and certain other tissues. It is a spectral disease which is classified into five groups based on clinical, histopathological and bacteriological and immunological criteria as tuberculoid (TT), borderline tuberculoid (BT), mid-borderline (BB), borderline lepromatous (BL), lepromatous (LL) according to Ridley-Jopling classification. Adequate clinical information combined with histopathology and bacteriological index is helpful not only in classification of different types of leprosy, but also useful for management of cases.The objective of the study was to correlate clinical diagnosis with histopathological findings of leprosy.</p><p class="abstract"><strong>Methods:</strong> A retrospective study was conducted for one year from January to December 2018 in Leprosy clinic, Department of Dermatology, Rajiv Gandhi Government General Hospital and Madras Medical College, Chennai. The histopathological findings were compared with clinical diagnosis.<strong></strong></p><p class="abstract"><strong>Results:</strong> A total number of cases attended leprosy clinic from January 2018 to December 2018 was 167 cases, among those 49 clinically diagnosed cases were included in the study. Out of 49 cases, maximum number of patients belonged to 30-50 years age group. Male to female ratio was 3.9: 1. Hypopigmented, hypoaesthetic patches were commonly seen. Clinically as well as histopathologically BT leprosy was common.The maximum histological correlation seen in lepromatous leprosy (100%) followed by BT (80%).</p><p class="abstract"><strong>Conclusions:</strong> The study emphasises the role of skin biopsy in confirming the clinical diagnosis of leprosy and also as a therapeutic guide.</p>

A case of borderline tuberculoid leprosy with atypical and complicated manifestations

This article presents a clinical case of a 52-year-old man suffering from oligobacillary border-tuberculoid leprosy in the acute phase associated with an established diagnosis of pulmonary tuberculosis and hepatitis C.Aim: to present a clinical case of leprosy with atypical and complicated manifestations.Materials and methods. A 52-year-old patient had been receiving treatment for allergic dermatitis for a long time.Results. The patient was diagnosed with: A 30.2. Borderline tuberculoid leprosy (Paucibacillary Leprosy, Borderline tuberculoid form. Acute phase). The patient demonstrated atypical complications of the leprosy process in the form of ulcerative necrotic rashes.

Histopathological study of cutaneous granulomas

Background: Cutaneous granulomas comprise a wide spectrum of diseases that are frequently encountered. Since clinical assessment alone is insufficient in most of the cases, skin biopsies are a basic requisite in evaluating these lesions. Histopathological examination, although helpful in deciding the nature of granulomas and etiology in most of the cases, maybe noncontributory in some cases, thus requiring further ancillary tests such as microbial culture, polymerase chain reaction.
 Materials and Methods: This prospective cross sectional study enrolled 109 cases of skin biopsies after histopathological confirmation of granulomatous lesions. The specimens were received at the Department of Pathology from 14th April 2017 to 13th April 2018.
 Results: Out of 650 skin biopsies, 109 cases (16.8%) were diagnosed as granulomatous lesions on histology. Male predilection was noted and age group of 31 to 40 years was the commonest affected. Upper extremities were more commonly involved. Leprosy was the commonest etiological agent and tuberculoid granulomas were the commonest type based on their histology.
 Conclusions: Leprosy was the most common cause of cutaneous granuloma followed by Tuberculosis, fungal infection and foreign body reaction. Among the cases of leprosy, borderline tuberculoid leprosy and tuberculoid leprosy were the commonest subtype.

Alternative Leprosy Treatment Using Rifampicin Ofloxacin Minocycline (ROM) Regimen – Two Case Reports

Abstract Introduction. Leprosy is a disease that predominantly affects the skin and peripheral nerves, resulting in neuropathy and associated long-term consequences, including deformities and disabilities. According to the WHO classification, there are two categories of leprosy, paucibacillary (PB) and multibacillary (MB). The standard treatment for leprosy employs the use of WHO MDT (Multi Drug Treatment) regimen, despite its multiple downsides such as clofazimine-induced pigmentation, dapsone-induced haematological adverse effects, poor compliance due to long therapy duration, drug resistance, and relapse. Multiple studies and case reports using ROM regimen have reported satisfactory results. Nevertheless, there are still insufficient data to elucidate the optimum dosage and duration of ROM regimen as an alternative treatment for leprosy. Previous experience from our institution revealed that ROM regimen given three times weekly resulted in a satisfactory outcome. Case Reports. We report two cases of leprosy treated with ROM regimen from our institution. The first case was PB leprosy in a 64-year-old male who presented with a single scaly plaque with erythematous edge on the right popliteal fossa. Sensibility examination showed hypoesthesia with no peripheral nerve enlargement. Histopathological examination confirmed Borderline Tuberculoid leprosy. ROM regimen was started three times weekly for 6 weeks and the patient showed significant clinical improvement at the end of the treatment with no reaction or relapse until after 6 months after treatment. The second case was MB leprosy in a 24-year-old male patient with clawed hand on the 3rd-5th phalanges of the right hand and a hypoesthetic erythematous plaque on the forehead. Histopathology examination confirmed Borderline leprosy. The patients received ROM therapy 3 times a week with significant clinical improvement after 12 weeks. Conclusion. ROM regimen given three times weekly for 6 weeks in PB leprosy and 12 weeks in MB leprosy resulted in a significant clinical improvement. Thus, ROM regimen could be a more effective, safer, faster alternative treatment for leprosy.

A clinical profile of leprosy patients in a tertiary hospital, Karnataka: a retrospective study

<p class="abstract"><strong>Background:</strong> Leprosy is a chronic mycobacterial infection and is still a major health hazard in India.</p><p class="abstract"><strong>Methods:</strong> This was a retrospective study over 12 years of all cases diagnosed clinically as leprosy in a tertiary hospital at Hassan district, Karnataka. Confirmation of diagnosis was based on slit skin smear and biopsy was done in doubtful cases.<strong></strong></p><p class="abstract"><strong>Results:</strong> Out of 214 patients, 152 were males and 62 were females. The prevalence was maximum in the age group 21-30 years. Borderline group formed the major part of the spectrum, consisting of 154 (71.96%) patients. Maximum patients 97 (45.3%) were of borderline tuberculoid (BT) leprosy, followed by 59 (27.57%) cases of borderline lepromatous leprosy (BL). 25 (11.68%) cases had tuberculoid leprosy (TT) and 20 (9.34%)cases were of lepromatous leprosy among which 3 were diagnosed as histoid leprosy. 6 patients had pure neuritic leprosy and 4 patients were in relapse.</p><p><strong>Conclusions:</strong> Even though leprosy is eliminated, it continues to be a public health problem in our country. Stricter surveillance for early diagnosis and treatment is needed to eradicate leprosy from India.</p>

Clinicopathologic correlation of different types of leprosy lesions

Background: Leprosy is one of the major public health problems of the developing countries. The principle of reducing the load of infection in society, to break the chain of infection, is the cornerstone of leprosy control work today. Aim of the Study: To study clinicopathologic correlation of different types of leprosy lesions. Materials and Methods: The present study was conducted in the Department of Dermatology of the medical institute. The ethical clearance for the study was approved from the ethical committee of the hospital. A total of 90 leprosy skin biopsies were studied over a period of 12 months. All the biopsies were received in the Department of Pathology of the hospital. Cases were selected regardless of their age, sex, socio­economic status and occupation. Biopsies were fixed in 10% formalin and processed. 5 micron sections were stained with haematoxylin and eosin; modified Fite and studied. Results: There were 65 males and 25 females between 8 and 70 years of age. We observed that borderline tuberculoid leprosy was the most common cases in clinical and histopathological types, although more number of cases were seen in histopathological types of leprosy. We observed that the while correlating the histopathological diagnosis with clinical diagnosis, maximum correlation (75%) was noted in LL patients followed by BT (59%) and BB (50%). Conclusion: Within the limitations of the present study, it can be concluded that there is some degree of overlap between different types of leprosy, both clinically and histopathologically, correlation of clinical and histopathological features along with bacteriological index appears to be more useful for accurate typing of leprosy than considering any one of the single parameters alone.

MON-142 Neuropathy in a Patient with Diabetes Mellitus: Not Always a Diabetic Disease

Diabetic neuropathy (DN) is the most common form of neuropathy in patients with diabetes mellitus (DM). Although DN is very common, other etiologies for neuropathy can exist or co-exist in patients with DM. DN might be nonspecific and mimic neuropathies seen in other diseases. Therefore, its proper diagnosis requires a thorough history and exclusion of secondary causes such as leprosy. Due to increase in world-wide travel and migration, and because the transmission pathways of Mycobacterium leprae are not fully understood, it is now crucial to be aware of tropical diseases, such as leprosy, not generally seen or recognized in non-endemic countries. We report a case of 74-year old man with a 5-year history of DM who complained of feet paresthesia over the last four years, more pronounced on the left foot and progressively worse. Good glycemic control was achieved since diagnosis with Metformin. Microvascular complications were absent. Renal and thyroid function were normal as well as vitamin B12 levels. The patient denied alcohol or drug abuse, and did not have peripheral arterial disease, cancer, or use any neurotoxic drug. On examination of the lower limbs, deep tendon reflexes diminished. A mildly decreased vibration perception and numbness on the lower left limb were also observed. No other finding was present (normal pin-prick, normal gait and proprioception), nor did he present with muscle weakness. Amitriptyline and thioctic acid were prescribed with no clinical response. During the last year, multiple hyperpigmented anesthetic cutaneous lesions emerged in his legs and back. He subsequently developed a left foot drop and autonomic dysfunction. A diagnosis of borderline tuberculoid leprosy and type 1 reaction were established and a planned 12-month multidrug therapy (MDT) initiated. After six months of MDT, at last follow-up, the patient’s sensory neuropathy showed mild improvement. Resolution of autonomic symptoms was seen and nearly complete clearing of the skin lesions. In conclusion, leprosy and DM can cause progressive and irreversible nerve damage with similar clinical patterns. But, in cases of asymmetric neuropathy in a patient with DM, leprosy must be ruled out first before ascribing DM as the cause of the neuropathy. A thorough epidemiological history is mandatory to avoid misdiagnosis. If leprosy is not recognized and consequently left untreated, patients are at risk for permanent nerve damage. Leprosy is a potentially curable disease, contrary to DM. Other etiologies for neuropathy can exist in patients with DM.

Borderline tuberculoid leprosy, lupus vulgaris and pulmonary tuberculosis: A rare association

Tuberculosis and leprosy are chronic mycobacterial infections that elicit granulomatous inflammation. The incidence of co-existence of pulmonary tuberculosis and leprosy has ranged from 2.5%-13.4%.1 Cutaneous tuberculosis is a variant of extrapulmonary tuberculosis and its simultaneous occurrence with leprosy is uncommon. The concomitant presence of leprosy, pulmonary as well as cutaneous tuberculosis is rare.
 We report a case of borderline tuberculoid leprosy, lupus vulgaris and pulmonary tuberculosis in a 45 years male who presented to the dermatology outpatient department with three morphologically distinct skin lesions over the posterior aspect of right leg. Ours is presumably the first case reported from Nepal, a country where both of these mycobacterial infections are endemic.

A rare case of possible vacuolar degeneration of leprosy in brain with segmental necrotizing granulomatous neuritis and horner's syndrome

Leprosy has a predilection for peripheral nerves, but rarely does it involve the central nervous system (CNS). There is a single study of CNS involvement in leprosy showing vacuolar changes of motor neurons in medulla oblongata and spinal cord in autopsy findings. Besides this, there has been only one case report providing direct histopathological and molecular evidence of CNS involvement by leprosy in a living patient. Segmental necrotizing granulomatous neuritis (SNGN) is a rare condition affecting the peripheral nerves in leprosy usually seen as a complication of tuberculoid (TT) and borderline tuberculoid (BT) leprosy. We report the case of a 23-year-old male patient, a case of Hansen's disease (BT) who developed CNS involvement in the form of partial Horner's syndrome (right) and SNGN while on treatment. Magnetic resonance imaging of the brain revealed T2 hyperintense lesion on the dorsal aspect of left pontomedullary junction, suggestive of vacuolar degeneration of leprosy. Histopathology of greater auricular nerve (right) revealed SNGN.

Identical twins with borderline lepromatous leprosy mimicking extensive alopecia areata: A rare presentation

Nineteen-year old identical female twins presented with complaints of progressive hair loss all over the body, sparing the scalp, axillae and pubic region along with a few atrophic scars on the knees, thighs and elbows. A possible diagnosis of atypical presentation of alopecia areata was made. However, in view of history of borderline tuberculoid leprosy in their younger sibling, a complete examination for leprosy was done. There was asymmetrical enlargement of multiple peripheral nerves without any sensory or motor loss. Histopathology confirms the diagnosis of BL Hansens. Such a presentation of leprosy in identical twins is not reported in literature.