Leprosy Masquerading as Systemic Rheumatic Diseases:

Lepra Reactions: Mimickers and Mirror to Unmask Complex Cases of Leprosy

Leprosy is a silent disease with protean manifestations, especially during lepra reactions (LRs). Cases with atypical leprosy or LR simulate a number of conditions misdiagnosed frequently. Here, three classical cases of leprosy are reported for their complex presentation. Leprosy was hidden in Case 1 due to co-existing diabetes. COVID vaccination induced LR unmasked all leprosy lesions, which were extensive, large, bizarre and spreading to various immune zones. Case 2 presented with high-grade fever, tachycardia, generalized erythema and body aches. A detailed workup unveiled his leprosy with a rare presentation of Type 1 lepra reaction (T1LR) with erythroderma and severe systemic symptoms. Case 3 mimicked sarcoidosis and lupus erythematosus (LE) on routine workup. She had facial lesions in the malar area, photosensitivity, joint pains, raised angiotensin-converting enzyme (ACE) levels and positive anti-nuclear antibodies. Peri-appendageal granulomas on histopathology and therapeutic response to multidrug therapy helped in the early diagnosis of leprosy.

Hansen’s disease masquerading as rheumatoid arthritis: A case report

Hansen's disease, a chronic granulomatous disease, classically has cutaneous and neurological manifestations. Musculoskeletal manifestation of the disease is underappreciated. This case report conveys that musculoskeletal manifestation of the disease should not be missed, as sometimes it is the only presenting symptom, to avoid delay in correct diagnosis and treatment.

Type 2 leprosy reaction presenting as a monoarthritis post multidrug therapy

Type 2 leprosy reaction, or erythema nodosum leprosum (ENL), involves a complex interaction between the host's immune system and Mycobacterium leprae. It may occur before, during, or after treatment and have a variable clinical presentation involving different body systems, such as skin, osteoarticular, kidneys, and others. Thus, the differential diagnosis, depending on its clinical presentation, can be broad and challenging. The authors report a case of a severe monoarthritis during a type 2 reaction after the multidrug therapy (MDT) was discharged and the investigation of the differential diagnoses.

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.

Autoimmune manifestations of infections

PURPOSE OF REVIEW

To provide an update about the interactions between infections and autoimmune diseases (AIDs), from the molecular perspective to the clinical spectrum and the differentiation between infection and disease activity.

RECENT FINDINGS

Any kind of infection may modify the innate and adaptive immune response through the following mechanisms: molecular mimicry, superantigens, epitope spreading and B-cell activation. The consequence is the overproduction of antibodies shared with those found in AIDs. Viral infections, especially HIV and hepatitis C virus, can stimulate the production of antiphospholipid antibodies and confer an increased risk to develop antiphospholipid syndrome.

SUMMARY

The identification of risk factors to develop infections in patients with AIDs is remarkable to prevent them. These factors are the use of steroids and immunosuppressants, the involvement of a major organ (lungs, brain and kidney) and severe activity. Biomarkers to differentiate infection from disease activity are scarce, but the combination of procalcitonine and C-reactive protein seems to have higher specificity and sensibility to identify infections in patients with AIDs. Finally, the clinical judgment is the hallmark to differentiate between infections and disease activity.

Leprosy presenting as remitting seronegative symmetrical synovitis with pitting oedema syndrome - a case report

Background

Leprosy typically manifests with skin and peripheral nerve involvement. Musculoskeletal complaints are the third most common, and can be the sole presenting manifestation. They range from arthralgia/arthritis in reactional states to full mimics of systemic rheumatic diseases. Remitting Seronegative Symmetrical Synovitis with Pitting Oedema syndrome has only been described once in a patient with already diagnosed Leprosy.

Case report

A 68-year-old male, from an endemic region of familial amyloid polyneuropathy, presented with an inaugural Remitting Seronegative Symmetrical Synovitis with Pitting Oedema like syndrome, more that 20 years after travelling to Leprosy endemic areas. Arthritis would resurface whenever oral prednisone was tapered, so methotrexate was started, controlling the complaints. Only one year later, after the appearance of peripheral neuropathy and skin lesions, it was possible to diagnose Leprosy, through the identification of Mycobacterium leprae bacilli in a peripheral nerve biopsy.

Conclusion

This report is an example of the heterogeneity of manifestations of Leprosy, namely rheumatic, and the challenge of diagnosing it when typical complaints are absent. It is also a reminder that this disease should be considered whenever a patient with a combination of skin/neurologic/rheumatic complaints has travelled to endemic countries in the past.

Rheumatoid arthritis-like features in Hansen disease: A case report

RATIONALE

Hansen disease is an infectious chronic disease with various clinical manifestations. Its joint performance may easily mimic rheumatoid arthritis.

PATIENT CONCERNS

We report a case of a 57-year-old woman diagnosed with Hansen disease 10 years ago, who suffered from joints swelling, pain and joints deformities of both hands for 19 years. The skin on the hands showed rashes, thickening, desquamation and chapping, with both thenar muscles atrophy. She also had severe hypoalgesia of the whole body, and morning stiffness for one hour.

DIAGNOSES

The final diagnosis was joint damage and peripheral neuropathy due to Hansen disease.

INTERVENTIONS

The patient received neurotrophic treatment instead of anti-rheumatic treatment.

OUTCOMES

At 1-year follow up, no further aggravation of joint swelling and pain was detected.

LESSONS

The correct diagnosis of Hansen disease involving joints depends on the combination of medical history, careful physical examination, and laboratory examination.