Leprosy in a rheumatology setting: a challenging mimic to expose
A 55-year-old male patient with chronic RA of 9 years in duration was well controlled (near remission) with long-term supervised administration of leflunomide and methotrexate. The patient developed acute urticaria-like rash on the neck, and upon consultation with the dermatologist, oral hydroxychloroquine and a short course of oral prednisolone were added. After a modest response, the patient developed erythematous papulonodular nontender itchy lesions (Fig. ) all over the body, but maximally over the lower trunk and abdomen along with polyarthralgias and severe painful right ankle swelling and a limping gait. The patient was afebrile and did not have any other systemic abnormality. Leflunomide was suspected to have caused the skin lesions and was stopped. Serum uric acid level was significantly elevated and allopurinol, prescribed. Orally given diclofenac was added for the symptomatic relief of arthritis but was discontinued (? hypersensitivity) because the skin lesions worsened (relapse of generalized urticaria lesions). The skin lesions were opined to be a drug-induced leucocytoclastic reaction/vasculitis; allopurinol was also stopped. A moderately high dose of orally given methyl prednisolone with a slow taper (over weeks) was started. A concurrent work-up was negative for ANA and other collagen vascular diseases. A week later, the patient had made little recovery, and a skin biopsy was carried out which demonstrated AFB and a histopathological picture consistent with a lepromatous reaction.\nThe patient was started on multidrug treatment (dapsone, rifampicin, clofazimine), and the patient responded clinically (bearable pain and mild limping) over 12 weeks or so. Oral weekly administration of 15 mg methotrexate, along with daily administration of 400 mg hydroxychloroquine and low-dose steroids (7.5–10 mg prednisolone), was continued. Moderate to severe polyarthritis continued, with elevated ESR, and hence, 2 g sulfasalazine and 100 mg minocycline were added. Few days later, the patient developed severe oral aphthous ulcers, requiring stoppage of methotrexate. The arthritis and skin lesions settled over almost 15 months of intense follow up. After a period of waxing and waning, the skin lesions of Hansen’s disease also subsided with diffusely scattered reddish brown macules.