Discussion

According to the World Health Organization (WHO), one of the following three features are essential for the diagnosis of leprosy:
Musculoskeletal symptoms such as arthritis are the third most common presenting manifestation of leprosy, after neurological and cutaneous features, and can mimic more common disorders such as rheumatoid arthritis (RA).12 Clinicians should be aware of this disease since some form of joint involvement is reported to occur in 75 % of cases of leprosy and at times may be the only obvious manifestation.9,13 Sometimes, patients with leprosy were treated for SLE, RA, dermatopolymyositis, and systemic vasculitis.14 Leonine facies and madarosis are one of the hallmarks of lepromatous leprosy.2 Radiographic changes in RA are usually more pronounced than those in leprosy arthritis.15 Early diagnosis and a full course of treatment are critical for preventing lifelong neuropathy and disability. Treatment consists of combination of three drugs: Dapsone, Rifampicin, and Clofazimine six months for paucibacillary and 12 months for multibacillary leprosy.5In patient with inflammatory rheumatic disorder prolonged use of steroid, immunosuppressive therapy, and biological agents might flare up the latent form of tuberculosis and leprosy in the patient. Sometimes autoantibodies like RF and ANA may also be false positive in leprosy9 but when both RF and anti CCP are negative, other causes including leprosy should be considered when patient is from endemic area.13 So not only leprosy patients mimicking Rheumatoid disease, but also patients with known case of Rheumatoid disorder may present with signs and symptoms of leprosy during the course of treatment if there was a latent infection. Ulnar nerve is the commonest nerve involved in leprosy ranging from neuritis sensory symptoms to clawing of hand.16Steroid therapy along with MDT is the common medical approach for treatment of ulnar neuritis. Surgical decompression of nerve is required in case who failed to respond by 12 weeks of combination therapy with steroid or in cases with severe ulnar neuritic pain disturbing daily activities, and with nerve abscess. Dose of steroid varies, commonly started with 1mg/kg/day gradually tapering weekly and continued for 6-9 months with maintenance dose of 5-10mg/day. In a study by Sajid et al. Pain recovery was seen in 100% cases, sensory recovery in 60-82% in 6-8 weeks period, and motor improvement (upgrading of MRC score) in 50-80% of cases depending on initial motor power in 24 to 54 weeks period. In our case, initially patient presented with polyarthritis and was treated for seronegative rheumatoid arthritis. Due to the persistence of symptoms and even worsening, he was noncompliant with medication. After a few months as he started developing neuropathic symptoms to ulnar distribution and subsequently ulnar clawing with cutaneous lesions, we suspected leprosy. With a thorough history, examinations and split skin smear, he was diagnosed with lepromatous leprosy and treatment started. This delay in diagnosis was due to misdiagnosis of clinical signs more towards Rheumatoid and also due to the inability of early detection and suspicion of leprosy with symptoms timeline. So, it is essential to recognize the association of arthritis in leprosy, its resemblance with other inflammatory causes, disease and symptoms progression for early detection and treatment.