Hansen's disease associated with erythromelalgia mimicking Lupus erythematosus
A 39-year-old male teacher presented with reddish skin lesions over the face with history of increase in redness and burning sensation on sun exposure of 25-day duration. He had also noticed redness and burning over the finger tips which was relieved by immersion of hands in cold water. In addition, he had intermittent joint pains involving knee and interphalangeal joints of 4-year duration. There were no systemic complaints such as hematuria, seizures, dyspnea or palpitation, although there was one episode of oral ulcers 10 days ago.\nExamination revealed multiple well-defined, irregular erythematous mildly scaly plaques over the forehead, cheeks, ears, V area of neck []. There was erythema, warmth, and mild tenderness over the bilateral finger tips []. There was no sensory loss over the skin lesions or thickening of peripheral nerves. Sensory and motor examination of the extremities was normal. Hot and cold water immersion tests for erythromelalgia and Raynaud's phenomenon were negative with no worsening of redness or bluish discoloration of fingers, respectively.\nIn view of arthritis, photosensitivity, history of oral ulcers, a clinical diagnosis of acute cutaneous lupus erythematosus with erythromelalgia was considered and patient investigated. The hemogram, chest X-ray and renal function tests, serum C3 and C4 levels were normal. Liver function tests were normal except for mildly elevated ALT. ANA was negative. USG abdomen showed grade 2 fatty infiltration of liver. Blood sugars were elevated.\nSlit smear examination for lepra bacilli and direct immunofluorescence test of skin lesions were negative. Treatment was commenced with 32 mg of oral methylprednisolone per day along with subcutaneous insulin. H and E examination of skin biopsy specimen showed thinning and follicular plugging of epidermis, a grenz zone with ill-defined collections of lymphocytes, macrophages, and epitheloid cells in a perineural, periadnexal, and perivascular location [Figures -]. Fite stain was positive for lepra bacilli.\nA revised diagnosis of borderline tuberculoid leprosy with type 1 reaction was made and antileprosy treatment as for multibacillary regime with 3 drugs (oral pulse of Rifampicin 600 mg and clofazimine 300 mg once in 28 days, daily oral clofazimine 50 mg and dapsone 100 mg) was started along with oral steroids in tapering doses. The facial lesions and finger tip erythema resolved in 2-month time [] and patient is on regular follow-up.