title: Leprosy revealed in a rheumatology clinic: a case series.
abstract: OBJECTIVE
  Leprosy classically presents with cutaneous and neural involvement. Rheumatological manifestations are frequent, although often under-recognized. At times, these may present to a rheumatology clinic prior to the diagnosis of leprosy. Herein, we present our experience with patients referred with various rheumatological disorders who were subsequently diagnosed as having leprosy.
  
  
  METHODS
  This retrospective study (January 2001-September 2010) was carried out at the Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, in northern India. Patients who were confirmed as having leprosy were included. Details regarding demographic and clinical presentations were collected.
  
  
  RESULTS
  Forty-four cases (30 male, mean age 40 ± 13.6 years and mean disease duration 18.7 ± 24.3 months) were identified. Musculoskeletal manifestations included arthritis (n = 22), swollen hands and feet syndrome (SHFS) (n = 11), tenosynovitis (n = 9), painful swollen feet (n = 9), arthralgias (n = 7) and vasculitis (n = 1). Distribution of joints mimicked rheumatoid arthritis (n = 14) and spondyloarthropathy (n = 7). Arthritis and/or tenosynovitis were part of spontaneous onset lepra reaction in 28 cases. Other clinical manifestations were: paresthesias (n = 28), erythematous nodules (n = 25) and anesthetic patches (n = 7). Thirty-one patients had thickened nerves (ulnar n = 28, common peroneal n = 21). Eight patients did not have any cutaneous manifestations and had presented with SHFS and arthritis or tenosynovitis. These were labeled as pure neuritic leprosy. Most of the patients responded to multidrug anti-leprosy therapy and glucocorticoids.
  
  
  CONCLUSIONS
  Rheumatological presentations of leprosy may mimic RA, spondyloarthropathy or vasculitis. Pure neuritic variety and spontaneous type 2 lepra reaction pose unique diagnostic challenges. Increased awareness may avoid delay in diagnosis.
authors.affiliation: Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
authors.forename: Shiva
authors.initials: S
authors.lastname: Prasad
authors.forename: Ramnath
authors.initials: R
authors.lastname: Misra
authors.forename: Amita
authors.initials: A
authors.lastname: Aggarwal
authors.forename: Able
authors.initials: A
authors.lastname: Lawrence
authors.forename: Nigil
authors.initials: N
authors.lastname: Haroon
authors.forename: Anupam
authors.initials: A
authors.lastname: Wakhlu
authors.forename: Narendra
authors.initials: N
authors.lastname: Krishnani
authors.forename: Vinita
authors.initials: V
authors.lastname: Agrawal
authors.forename: Vimal K
authors.initials: VK
authors.lastname: Paliwal
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Jha
authors.forename: Vikas
authors.initials: V
authors.lastname: Agarwal
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D057210:Delayed Diagnosis; D003951:Diagnostic Errors; D004359:Drug Therapy, Combination; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007194:India; D007917:Leprostatic Agents / Q000627:therapeutic use; D007918:Leprosy / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D008297:Male; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital; D011237:Predictive Value of Tests; D012017:Referral and Consultation; D012189:Retrospective Studies; D012219:Rheumatology; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D005938:Glucocorticoids; D007917:Leprostatic Agents