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.