Case History/Examination

A 67-year male from Gorkha Nepal visited the outpatient clinic at Amppipal Hospital Gorkha with a complaint of multiple joint pain for 1.5 years, decreased sensation over the left ring and little fingers for 8 months, and frequent ulcerated lesions over the left hypothenar, ring, and little fingers for 3 months. Since the last 1.5 years, he has had multiple joint pains, especially over bilateral hands (CMC, MCP, PIP > DIP), bilateral elbow worsening with rest with morning stiffness with occasional swelling. He gradually had tingling and decreased sensation over his left ring and little fingers for 8 months with some decrease in grip strength. Multiple turbid fluid-filled eruptions followed by ulceration over the hypothenar, ring, and little fingers. He has been taking antihypertensive medication for 10 years. He didn’t have diabetes, and traumatic injury to the elbow and cervical spine. He has been visited multiple times in hospital and evaluated for Rheumatoid Arthritis. In blood investigations, Rheumatoid factor was negative, leucocyte counts of 6000/ml, 23% Lymphocyte 65% Neutrophil, Haemoglobin: 12.8 g/dl, ESR: 18 mm/hr and CRP negative, uric acid level of 4.4 mg/dl. With the suspicion of Seronegative Rheumatoid arthritis, NSAIDs, Methotrexate 15mg once a week, and Folic acid supplementation started. For ulcerated wounds, oral antibiotics as well as topical antibiotics were prescribed multiple times from different centers. The patient was non-compliant with all medication due to recurrence of symptoms and further worsening. On re-evaluation with thorough history and examination, he also had decreased sensation over the forehead and facial area with sensation of tough skin and changes in the shape of the nose. He worked in Bihar India for 20 years as a labourer. His mistress was also having similar symptoms and taking medication for Rheumatoid arthritis. Ill-defined erythematous plague with minimal whitish scales seen over right retro auricular, neck, left mid abdomen, left elbow, and forearm with intact touch but impaired temperature sensitivity. Madarosis was seen with the rough, thickened skin over the forehead, nose, and chin, resembling leonine facies (fig1). Enlarged bilateral greater auricular nerve right more prominent than the left (fig2), bilateral ulnar nerve left more than right were seen. Atrophy of interosseous muscles, hypothenar, and thenar muscle with an ulnar clawing, ulcerated wound at the tip of the little finger, and hypothenar area were present (fig3,4). Signs of ulnar nerve injury; Card test, Froment’s sign, and Egawa test were positive. A plain radiograph of the hand shows juxta-articular osteopenia with signs of erosion over CMC, MCP, PIP, and DIP. The leprosy was suspected, and a slit skin smear was sent for diagnosis which came to be positive with 1+ bacteriological index. The diagnosis of Lepromatous Leprosy with the left ulnar claw hand was made. Multidrug therapy (MDT) with pulse dose of 600mg Rifampicin, 300mg Clofazimine and 100mg Dapsone once a month, and daily dose of 50mg Clofazimine, 100mg Dapsone was started. Proper physiotherapy was taught, and he was well counselled about the drug reaction and possible complications.