Leprosy in a rheumatology setting: a challenging mimic to expose
A 33-year-old nonsmoker male, a known case of Hansen’s disease (skin biopsy-proven borderline lepromatous) on supervised long-term treatment (prednisolone and clofazimine) since 4 years was referred to the rheumatology clinic with an acute onset of feeling cold in the index, middle, and ring finger of the left hand; since 1 month, he recalled episodic severe pain and burning sensation in the fingers. The patient did not have diabetes or any other relevant disease. Ten days later, he developed painful gangrene of the digital pulps of the index, middle, and ring finger of the left hand (Fig. ).\nOn examination, he also had atrophied, nodular, and healed ulcerative scars over the face, neck, and extremities with few scattered diffuse hypopigmented hypoesthetic lesions; ulnar and peroneal nerves were thickened. New skin lesions or any other systemic abnormality was absent. Detailed laboratory investigations showed normal erythrocyte sedimentation rate (ESR) with mild normocytic normochromic anemia, marginally raised C-reactive protein; seronegativity for RF, ANA, anti-CCP, and anticardiolipin antibodies; and seropositivity for isolated anti-ds DNA (ELISA) in low titer. Routine cardiac evaluation (including Doppler/echo) was normal, and peripheral blood flow Doppler studies suggested reduced distal arterial blood flow in the right arm. A right subclavian artery angiography was consistent with focal distal arteritis lesions. Other causes like cervical rib and proximal subclavian/arterial compressive lesions were excluded. A diagnosis of vasculitis was made and considered to be a likely complication of leprosy. A short course of tapering high dose of orally administered prednisolone (begun at 30 mg daily and 6 weeks later on 5 mg daily), orally administered hydroxychloroquine, and antiplatelet agents was added to ongoing anti-leprosy drugs. The patient showed steady recovery, and the affected digital pulps healed with scars and some loss of pulp substance.