Interesting and unusual clinical presentations in leprosy at a referral center
A 40-year-old female was referred with complaints of blisters on the right arm, forearm, and hand since two years. The patient had a history of tingling numbness in the right upper and lower extremity dating six years back. There was no history of hypopigmented patches or cutaneous lesions. There was no family history of leprosy or neuropathy. She was investigated with magnetic resonance imaging (MRI) of the spine and EMG/NCS three years before she was referred to our clinic. On examination, she was found to have a thickening of the right ulnar, median, and radial cutaneous nerves, and both posterior tibial nerves. Slit-skin smear was negative at multiple sites. Repeat EMG/NCS showed no sensory conduction in the right median, ulnar, radial, and both sural nerves, whereas amplitude and motor conduction velocity was reduced in the right median and both ulnar nerves. Laboratory investigations like hemogram, chest X-ray, urinalysis, liver function tests, renal function tests, and blood glucose levels were within normal limits. Finally, a biopsy of the left sural nerve was done which revealed three enlarged fascicles with a large number of infiltrating cells comprising lymphocytes, plasma cells, and macrophages in the endoneurium. Small clumps of acid-fast bacilli were seen in a good number of cells. A borderline lepromatous type of nerve lesion with evidence of type 1 reaction was diagnosed.