Leprosy-related joint involvement

Pressure Stockings for Edematous Feet in the Lepra Reaction: An Inexpensive Patronage

Leprosy has been known for its wide range of peripheral nerve and tissue involvement and causing disabilities. Early diagnosis and treatment with multi-drug therapy can save lives and limbs and prevent disabilities. However, management and drug therapy are usually lengthy and full of ups and downs of side effects. Further, the lepra reaction is frequently noted during management, requiring immunosuppression and leading to associated side effects. Limb edema per se due to leprosy is unusual and mostly a symptom of a reactional state. There is no specific management for edema in such cases, and it subsides with improving reactionary states. Nevertheless, the edema may be persistent and bothersome. The present report highlights one such unusual case in a 40-year-old man, diagnosed with borderline-tuberculoid leprosy and experiencing a type-1 reaction. Owing to ocular complications, steroid therapy for the reaction was tapered abruptly, and his limb edema did not subside with the improving lepra reaction. Compression stockings helped to manage edema. This case also makes us ponder the possible use of compression stockings as an opioid-sparing aid in lepra reaction-related edema.

New insights at the interface between leprosy and immune-mediated rheumatic diseases

Leprosy is an infectious and contagious disease of slow evolution, triggered by Mycobacterium leprae. Arthritis is its third most common manifestation, after cutaneous and peripheral nerve involvement. Since musculoskeletal symptoms may be the initial presentation of the disease, it is important for health professionals to recognize its rheumatic manifestations for early diagnosis and appropriate treatment, especially in endemic areas. In addition, cases of leprosy have increased globally, notably in patients undergoing treatment with TNF-α blockers and due to the increase in migration and travel of people from developing countries to developed countries. This review proposes to discuss the main scenarios of mimicry of different rheumatic diseases by leprosy, as well as the role of immunosuppressive drugs used in rheumatology practice in the treatment of reactional states and in the risk of developing the infection.

Swollen hands and feet syndrome: An uncommon presentation of a common disease

Leprosy is an infectious disease caused by M. leprae with predominant skin and neurological involvement. Although musculoskeletal involvement can occur in leprosy during the disease course, the first presentation of leprosy with musculoskeletal manifestation is relatively rare. Here we present a case that presented musculoskeletal manifestation as an initial feature.

Chronic Hand Swelling and Dactylitis in Leprosy: A Case Report and Review of the Literature

Leprosy is an infectious disease that is associated with various types of presentations. Diagnosis of the disease can be tricky in cases of atypical presentations. We report a unique case of leprosy characterized by chronic hand swelling, dactylitis, and seropositive laboratory markers, which was diagnosed in a rheumatology clinic.

Hansen's Disease and Complications among Marshallese Persons Residing in Northwest Arkansas, 2003-2017

Persons from the Republic of the Marshall Islands have among the highest rates of Hansen's disease (HD) in the world; the largest Marshallese community in the continental United States is in northwest Arkansas. In 2017, the HD Ambulatory Care Clinic in Springdale, Arkansas, informed the Arkansas Department of Health (ADH) that Marshallese persons with HD had severe disease with frequent complications. To characterize their illness, we reviewed ADH surveillance reports of HD among Marshallese persons in Arkansas treated during 2003-2017 (n = 42). Hansen's Disease prevalence among Marshallese in Arkansas (11.7/10,000) was greater than that in the general U.S. population. Complications included arthritis (38%), erythema nodosum leprosum (21%), and prolonged treatment lasting > 2 years (40%). The majority (82%) of patients treated for > 2 years had documented intermittent therapy. Culturally appropriate support for therapy and adherence is needed in Arkansas.

Case Report: Leprosy Osteoarticular Alterations Mimicking Rheumatoid Arthritis

Deformities of bones of the face and extremities are markers of leprosy (Hansen's disease) which contribute to stigma associated with this disease. Among these deformities are articular alterations that can mimic rheumatoid arthritis (RA). In this case, a 64-year-old man presented with a history of having been treated for lepromatous leprosy and erythema nodosum leprosum episodes, which evolved with joint alterations similar to those of RA. Most cases of leprosy-related arthritis are associated with reactional episodes, of which a large number do not respond to conventional therapy for leprosy reactions. In cases of chronic arthritis not associated with leprosy reactions, although patients show considerable relief with anti-leprosy therapy, arthritis is not completely resolved. This emphasizes the need for early diagnosis and treatment of leprosy to prevent the development of osteoarticular alterations.

Case for diagnosis. Infiltrated areas on the trunk

Leprosy is an infectious disease with chronic evolution, caused by Mycobacterium leprae, an acid-fast bacillus that mainly affects the skin and peripheral nervous tissue. Many of the clinical manifestations of leprosy can mimic connective tissue diseases. The authors present the case of a 49-year-old woman who had been treated for four years for systemic lupus erythematosus in a rheumatological service. Skin biopsy of a plaque on the inguinal region was compatible with borderline lepromatous leprosy associated with a type 1 lepra reaction. The patient is undergoing treatment with multibacillary multidrug therapy, showing clinical improvement.

Tuberculoid leprosy masquerading as systemic lupus erythematosus: an interesting observation

Leprosy is a chronic granulomatous infectious multisystem disease that may present with protean manifestations. It mimics many systemic and dermatological disorders. Here we report a case in which an elderly female presented with malar rash, intermittent fever, and arthralgia. Her diagnosis was significantly delayed due to a close clinical resemblance to systemic lupus erythematosus. It is important to be aware of such manifestations of leprosy and improve awareness of it in clinicians to avoid misdiagnosis and delay in treatment.

Swan Neck Deformity Mimicking Claw Hand Caused by Arthritis in Leprosy

Swan neck deformity is a hyperextension of the proximal interphalangeal (PIP) joints and flexion of the distal interphalangeal (DIP) joints. Claw hand is a hyperextension of the metacarpal joints and flexion of the PIP joints, accompanied by reduced motor strength. A 23-year-old female, who was released from leprosy treatment, presented with a bend of the second to fifth fingers of both hands. There was hyperextension of the PIP joints and flexion of the DIP joints from the second to fifth fingers of both hands, thickening of the ulnar nerves, and hypoesthesia without motor impairment of the fourth and fifth fingers of both hands. Radiograph examination revealed cupping of the base of the proximal phalangeal joints of the second, third, and fifth fingers of the left hand and of the second and fifth fingers of the right hand. Additionally, narrowing of the metacarpophalangeal joints of the second, third, and fifth fingers of the right hand and sclerosis of the second and fifth fingers of the right hand were also observed. Claw hand is frequently reported in leprosy, while swan neck deformity is frequently reported in rheumatoid arthritis. To our knowledge, this is the first reported case with swan neck deformity caused by arthritis in leprosy.

Evaluation of rheumatoid factor and anti-citrullinated peptide antibodies in relation to rheumatological manifestations in patients with leprosy from Southern Brazil

BACKGROUND

Leprosy patients may present several osteoarticular complaints, which require further evaluation of inflammatory diseases, such as rheumatoid arthritis (RA). Therefore, an adequate clinical assessment in addition to testing for rheumatoid factors (RF) and anticyclic citrullinated peptide antibodies (anti-CCP), can be useful in order to establish the correct diagnosis.

METHOD

In this study, the relation of RF and anti-CCP with rheumatological manifestations was evaluated in 97 leprosy patients from Southern Brazil. The results were compared to RA patients and healthy controls from the same geographical area and ethnic background.

RESULTS

Neuropathy was observed in 71.1% and arthritis in 35.1% of the leprosy patients. A high frequency of RF positivity was observed among the leprosy patients (41.2%, 40/97), with RF immunoglobulin A (IgA) significantly associated with arthritis (OR = 7.9, 95% CI = 1.5-40.6 P = 0.008). Anti-CCP was observed in 9.3% (9/97) of the patients, with anti-CCP2 being the most frequent subtype. Only 4.1% (4/97) of the patients were RF and anti-CCP concomitantly positive. RF IgM showed a significant association with leprosy when compared to healthy controls (P < 0.0001) whereas for anti-CCP2 no significant results were observed (P = 0.0585). However, both biomarkers showed a strong association with RA when compared to leprosy in patients from the same geographical area and ethnic background (anti-CCP2 OR = 38.6; 95% CI = 16.49-90.26; P < 0.0001 and RF IgM OR = 4.51; 95% CI = 2.62-7.77; P < 0.0001).

CONCLUSION

Due to the similarity of some rheumatological manifestations in leprosy with other inflammatory diseases, such as RA, clinical and laboratorial evaluation of affected patients must be carefully assessed in order to achieve proper diagnosis and treatment.

Health-related quality of life evaluated by Pediatric Quality of Life Inventory 4.0 in pediatric leprosy patients with musculoskeletal manifestations

OBJECTIVE

To evaluate the health-related quality of life (HRQL) in pediatric leprosy patients.

METHODS

A cross-sectional study included 47 leprosy patients and 45 healthy subjects. The HRQL was measured by Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0), and evaluated physical, emotional, social and school domains. The leprosy patients were classified by Ridley and Jopling classification criteria and assessed according to clinical musculoskeletal manifestations, laboratory and radiographic examinations.

RESULTS

The median of current age was similar in leprosy patients and controls [12(6-18) vs. 15(5-18)years, p = 0.384], likewise the frequencies of female gender (p = 0.835) and middle/lower Brazilian socio-economic classes (p = 1.0). The domain school activities according the child-self report was significantly lower in leprosy patients compared to controls in the age group of 13-18 years [75(45-100) vs. 90(45-100), p = 0.021]. The other domains were alike in both groups (p > 0.05). At least one musculoskeletal manifestation (arthralgia, arthritis and/or myalgia) was observed in 15% of leprosy patients and none in controls (p = 0.012). Further comparison between all leprosy patients showed that the median of the physical capacity domain [81.25(50-100) vs. 98.44(50-100), p = 0.036] and school activities domain by child-self report [60(50-85) vs. 80(45-100), p = 0.042] were significantly lower in patients with musculoskeletal manifestations compared to patients without these manifestations. No differences were evidenced between the other HRQL parameters in both groups, reported by patients and parents (p > 0.05).

CONCLUSIONS

Reduced physical capacity and school activities domains were observed in pediatric leprosy patients with musculoskeletal manifestations.

Arthritis and diagnosis of leprosy: a case report and review of the literature

Leprosy is clinically characterized by involvement of peripheral nerves and skin. The immunological profile of the individual defines the diversity of clinical manifestations, from skin disorders to systemic manifestations, especially the articulation ones, common in multibacillary forms, which may mimic collagen diseases and often posing diagnostic difficulties in endemic areas. This is a case report of asymmetric polyarthritis of small and large articulations associated with skin lesions which had been treated by a rheumatologist for 2 years with initial clinical diagnosis of rheumatoid arthritis, and later, with the appearance of skin lesions, of systemic lupus erythematosus.

Musculoskeletal manifestations and autoantibodies in children and adolescents with leprosy

OBJECTIVE

To evaluate musculoskeletal involvement and autoantibodies in pediatric leprosy patients.

METHODS

50 leprosy patients and 47 healthy children and adolescents were assessed according to musculoskeletal manifestations (arthralgia, arthritis, and myalgia), musculoskeletal pain syndromes (juvenile fibromyalgia, benign joint hypermobility syndrome, myofascial syndrome, and tendinitis), and a panel of autoantibodies and cryoglobulins. Health assessment scores and treatment were performed in leprosy patients.

RESULTS

At least one musculoskeletal manifestation was observed in 14% of leprosy patients and in none of the controls. Five leprosy patients had asymmetric polyarthritis of small hands joints. Nerve function impairment was observed in 22% of leprosy patients, type 1 leprosy reaction in 18%, and silent neuropathy in 16%. None of the patients and controls presented musculoskeletal pain syndromes, and the frequencies of all antibodies and cyoglobulins were similar in both groups (p > 0.05). Further analysis of leprosy patients demonstrated that the frequencies of nerve function impairment, type 1 leprosy reaction, and silent neuropathy were significantly observed in patients with versus without musculoskeletal manifestations (p = 0.0036, p = 0.0001, and p = 0.309, respectively), as well as multibacillary subtypes in leprosy (86% vs. 42%, p = 0.045). The median of physicians' visual analog scale (VAS), patients' VAS, pain VAS, and Childhood Health Assessment Questionnaire (CHAQ) were significantly higher in leprosy patients with musculoskeletal manifestations (p = 0.0001, p = 0.002, p = 0002, and p = 0.001, respectively).

CONCLUSIONS

This was the first study to identify musculoskeletal manifestations associated with nerve dysfunction in pediatric leprosy patients. Hansen's disease should be included in the differential diagnosis of asymmetric arthritis, especially in endemic regions.

Leprosy revealed in a rheumatology clinic: a case series

AIM

Leprosy classically presents with cutaneous and neural involvement. Rheumatological manifestations are frequent, although often under-recognized. At times, these may present to a rheumatology clinic prior to the diagnosis of leprosy. Herein, we present our experience with patients referred with various rheumatological disorders who were subsequently diagnosed as having leprosy.

METHODS

This retrospective study (January 2001-September 2010) was carried out at the Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, in northern India. Patients who were confirmed as having leprosy were included. Details regarding demographic and clinical presentations were collected.

RESULTS

Forty-four cases (30 male, mean age 40 ± 13.6 years and mean disease duration 18.7 ± 24.3 months) were identified. Musculoskeletal manifestations included arthritis (n = 22), swollen hands and feet syndrome (SHFS) (n = 11), tenosynovitis (n = 9), painful swollen feet (n = 9), arthralgias (n = 7) and vasculitis (n = 1). Distribution of joints mimicked rheumatoid arthritis (n = 14) and spondyloarthropathy (n = 7). Arthritis and/or tenosynovitis were part of spontaneous onset lepra reaction in 28 cases. Other clinical manifestations were: paresthesias (n = 28), erythematous nodules (n = 25) and anesthetic patches (n = 7). Thirty-one patients had thickened nerves (ulnar n = 28, common peroneal n = 21). Eight patients did not have any cutaneous manifestations and had presented with SHFS and arthritis or tenosynovitis. These were labeled as pure neuritic leprosy. Most of the patients responded to multidrug anti-leprosy therapy and glucocorticoids.

CONCLUSION

Rheumatological presentations of leprosy may mimic RA, spondyloarthropathy or vasculitis. Pure neuritic variety and spontaneous type 2 lepra reaction pose unique diagnostic challenges. Increased awareness may avoid delay in diagnosis.

Arthritis in leprosy

Leprosy, a chronic granulomatous infection caused by Mycobacterium leprae, classically presents with cutaneous and neurological manifestations. Musculoskeletal involvement though third most common is underdiagnosed and underreported. It may manifest in the form of Charcot's arthropathy, acute symmetrical polyarthritis or swollen hands and feet syndrome during lepra reactions, insidious-onset chronic symmetrical polyarthritis mimicking RA or as isolated tenosynovitis or tenosynovitis associated with arthritis or neuropathy. At times, articular involvement may be the sole presenting manifestation even without cutaneous lesions. Other rheumatological manifestations occasionally reported are enthesitis, sacroiliitis, cryoglobulinaemic vasculitis and DM. With increasing travel of population between tropical and temperate zones, it is likely that rheumatology clinics in countries free of leprosy may come across cases of leprosy with rheumatological manifestations. Delay in diagnosis and management may be detrimental and may result in deformities and loss of function. Not only this, but recent reports of leprosy being diagnosed in native white populations following anti-TNF-α therapy should alert rheumatologists across the globe to be more familiar with this disease. This review is aimed at presenting a comprehensive clinical scenario of various rheumatological manifestations of leprosy to sensitize rheumatologists and physicians across the continents.