Acute exudative arthritis in leprosy--rheumatoid-arthritis-like syndrome in association with erythema nodosum leprosum

Type 2 leprosy reaction presenting as a monoarthritis post multidrug therapy

Type 2 leprosy reaction, or erythema nodosum leprosum (ENL), involves a complex interaction between the host's immune system and Mycobacterium leprae. It may occur before, during, or after treatment and have a variable clinical presentation involving different body systems, such as skin, osteoarticular, kidneys, and others. Thus, the differential diagnosis, depending on its clinical presentation, can be broad and challenging. The authors report a case of a severe monoarthritis during a type 2 reaction after the multidrug therapy (MDT) was discharged and the investigation of the differential diagnoses.

Ocular leprosy

Ocular involvement in leprosy is estimated to be 70-75%, about 10-50% of leprosy patients suffer from severe ocular symptoms, and blindness occurs in about 5% of patients. The disease leads to many ophthalmologic symptoms and signs in the range of the eyeball itself, as well as of the bulb adnexa, ie, eyebrows, eyelids with eyelashes, and lacrimal drainage system. Especially dangerous are complications of lagophthalmos and corneal hypoanesthesia, neurotrophic or infectious keratitis, and iridocyclitis and cataract formation, which may lead to significant decrease of visual acuity or even blindness. Multidrug treatment rapidly interrupts transmission of Mycobacterium leprae by infectious patients, but even after being completed, it does not guarantee the withholding of ocular complications.

[Application of the diagnostic criteria for systemic lupus erythematosus to patients with multibacillary leprosy]

INTRODUCTION

Systemic lupus erythematosus (SLE) is a chronic inflammatory disease that affects multiple organs or systems. There is no pathognomonic clinical or laboratory test sensitive and specific enough for a specific diagnosis. The criteria proposed by the American College of Rheumatology (ACR), as modified in 1997, are used for the diagnosis. The presence of four or more criteria presents sensitivity and specificity of 96%. However, these diagnostic criteria for SLE may have lower specificity in areas that are endemic for chronic infectious diseases, such as Brazil (endemic for leprosy), which may have similar clinical and laboratory manifestations.

METHODS

A prevalence study was conducted, applying the SLE criteria to patients with recently diagnosed multibacillary leprosy who were registered at the leprosy outpatient clinic, Department of Dermatology, Federal University of Pernambuco (UFPE), during the data gathering period. The specificity and the number of false positives in this group were calculated.

RESULTS

One hundred patients were included. The prevalences of some of the SLE criteria were high. The criteria with the highest prevalence were malar erythema (44%), arthritis (23%), photosensitivity (29%), lymphopenia (19%) and presence of antiphospholipid antibodies, including immunological criteria (20%). The specificity found (84%) was lower than the specificity allocated to the criteria in 1997 by the ACR.

CONCLUSIONS

Diseases in our setting, such as leprosy in multibacillary forms, mimic the clinical and laboratory characteristics of SLE, and thus physicians need to be aware of the realities of local infectious diseases before affirming a definitive diagnosis of SLE.

Subcutaneous nodules and joint deformity in leprosy: case report and review

Leprosy (Hansen's disease), known to be caused by Mycobacterium leprae, is a well-known illness with multiple rheumatologic manifestations. This chronic granulomatous infection has clinical features that are variable, depending on the immune response of the host. Manifestations consist mainly of involvement of the peripheral nerves, skin, upper respiratory system, eyes, and testes, as well as joints. Musculoskeletal manifestations include arthralgias, arthritis, Charcot arthropathy, and positive autoantibodies. We report a case of a Puerto Rican-born woman who was living within the northeastern United States and had subcutaneous nodules, saddle nose deformity, and painless contractures of her fingers and toes. This case illustrates some of the musculoskeletal manifestations of leprosy to raise awareness of this disease as part of the differential diagnosis of articular abnormalities with subcutaneous nodules in a nonendemic country.

First report of leprosy presenting as acute polyarthritis in the setting of type I downgrading lepra reaction

Leprosy is a rare cause of acute polyarthritis. We describe the occurrence of oedema of the hands and feet and acute polyarthritis in the setting of type I (downgrading) lepra reaction in an untreated patient with borderline leprosy. This case report further expands the range of articular manifestations that can occur in leprosy.

Delay in diagnosis: indeterminate leprosy presenting with rheumatic manifestations

BACKGROUND

Rheumatic complications are common in leprosy (Hansen's disease) and can be the primary complaint delaying accurate diagnosis.

OBJECTIVE

Such a case is reported here: a 61-year-old woman with indeterminate leprosy presented with symmetric arthritis and purpura. Despite biopsy and evaluation by several physicians, leprosy was not suspected. After 2 years of progressive symptoms, a second biopsy revealed lepromatous leprosy.

CONCLUSION

In this case, lack of clinical suspicion and unfamiliarity with the histology of indeterminate leprosy delayed diagnosis and treatment. Leprosy should be considered in the differential diagnosis of patients presenting with unusual rheumatic and persistent cutaneous manifestations.

Humoral immunity in Hansen's disease

For many years immune response in leprosy has been studied. Since 1960 several reports dealing with humoral immunity have been described in the literature. Different autoantibody rates occur in leprosy. There is an increase in the prevalence of autoantibodies in elderly patients with long standing disease, in lepromatous leprosy and in those with reactional states. The differences in rates among various studies are attributed to different methods and variations among patient samples concerning age, gender, polar forms, therapy and other elements. The prevalence of numerous antibodies, immune complexes, cryoglobulins and complement levels have been studied by many authors. This also highlights the importance of the more recent reviews of anti-Mycobacterium leprae glycolipid antibodies such as the anti-phenolic glycolipid-I antibodies in which titers are variable and depend on genetic factors.

Bacterial infections: the arthritis of leprosy

Arthritis is a common feature of leprosy and contributes to disability. Direct invasion of joints and bones by mycobacteria may lead to a destructive arthritis in lepromatous disease. The infective process may involve few or many joints. Reactional states may occur spontaneously but usually after the initiation of anti-mycobacterial treatment. In both the type 1 reaction of borderline case and the type 2 reaction of the lepromatous disease, intense inflammation may occur at sites of infection. The immunology of the reactions is different but they share clinical features including a polyarthritis which may resemble rheumatoid disease. The joint disease may be chronic or relapsing, affecting the wrists and small joints of the hands in particular. Radiological erosions may occur. Mycobacterium leprae is not found in the synovium in this pattern of arthritis. Further study of this phenomenon might yield useful information above the mechanism of joint inflammation in other rheumatic diseases.

The rheumatic manifestations of leprosy

We investigated the rheumatic and laboratory features in 25 patients with Hansen's disease. Sixteen (64%) developed a broad range of rheumatic manifestations, the most common being a distinctive syndrome of swollen hands observed in 10 patients (66.5%). These manifestations were more frequent in patients with lepromatous leprosy. There was no correlation between articular clinical findings and X-ray or laboratory abnormalities. A careful clinical history and the recognition of rheumatic features will help to differentiate patients with leprosy and rheumatic manifestations from those with a primary rheumatic disease.

Clinical and laboratory studies in patients with leprosy and enthesitis

In a combined clinical, radiological, and laboratory study of 77 patients throughout the leprosy spectrum, 10 patients had an enthesitis which has not been described previously as far as is known and which was not associated with the characteristics of erythema nodosum leprosum reactions. C reactive protein and alpha 1 acid glycoprotein values were significantly lowered only in those patients with leprosy and enthesitis. No radiological abnormalities were found.

Unusual arthritis: be on the alert for leprosy

A 50-year-old Indonesian man presented with arthritis of the left ankle, wrist and hand joints and a diffusely swollen left hand and foot. A few months later granulomatous skin lesions developed and renewed physical examination revealed a paresis of the intrinsic muscles of the left hand and the left M. extensor hallucis longes and thickening of several peripheral nerves. The skin lesions appeared to be anesthetic. A diagnosis of borderline tuberculoid leprosy was made and treatment resulted in cure with permanent peripheral nerve damage. This case emphasizes the importance of early recognition and treatment of leprosy to prevent nerve damage.

Clinical and laboratory studies of arthritis in leprosy

Arthritis associated with leprosy is underreported. In Egypt 66 patients from a leprosy colony were studied, 20 of whom had arthropathy. This was characterised by an inflammatory symmetrical peripheral polyarthritis. The wrist, metacarpal and proximal interphalangeal joints of the hands, the knees, and the metatarsophalangeal joints of the feet were affected with associated morning stiffness. The arthritis was erosive in 11 out of 20 patients, had no features of the arthritis associated with erythema nodosum leprosum reactions, but symptomatically responded to antileprosy treatment. This arthritis would seem to be a previously unrecognised feature of leprosy.

Clinical and laboratory studies of inflammatory polyarthritis in patients with leprosy in Papua New Guinea

The results of a combined clinical and laboratory study in 55 patients throughout the leprosy spectrum are reported. Thirty one of these patients suffered from an inflammatory peripheral polyarthritis which has not been previously described and which was unassociated with the characteristics of erythema nodosum leprosum reactions or with Charcot's joints. alpha 2 Macroglobulin was raised significantly only in those patients with leprosy and arthritis.

An unusual cause of arthritis

We present a case of leprosy, an uncommon infection in the United Kingdom, which mimicked features of widely known rheumatic diseases and resulted in subsequent delay of diagnosis.

Lepromatous leprosy masquerading as disseminated tuberculosis

A patients with disseminated leprosy is described. A 57 year old man from Cuba presented with fever and pancytopenia. Bone marrow aspirate showed numerous acid-fast bacilli and a liver biopsy specimen contained multiple granulomas. The patient was considered to have tuberculosis and was treated with isoniazid and rifampin, with initial clinical improvement, only to have the fever recur and to show deterioration in hematologic and hepatic function. Failure to grow M. tuberculosis suggested a diagnosis of leprosy which was proved by skin biopsy. How lepromatous leprosy can masquerade as disseminated tuberculosis is discussed.

Lepromatous leprosy presenting with polyarthritis, myositis, and immune-complex glomerulonephritis

A Pakistani man aged 19 years was admitted to a rheumatological unit in the United Kingdom with acute widespread polyarthritis accompanied by night sweats and fever. Preliminary examination suggested Reiter's disease, but further investigation showed acute glomerulonephritis with uraemia. The possibility of periarteritis nodosa, and the prominence of muscle tenderness in the legs, led to biopsies of striated muscle and skin, in both of which were changes typical of lepromatous leprosy, with many Mycobacterium leprae on Ziehl-Neelsen staining. Serum showed IgG-IgM cryoglobulinaemia without antiglobulin activity, and in the recovery phase renal biopsy showed a resolving proliferative glomerulonephritis with linear IgG and IgM immunofluorescence and granular deposits of C3. Clinical signs subsided rapidly under steroid treatment and subsequent progress on anti-leprosy drugs was uneventful. The term erythema nodosum leprosum is inadequate and misleading as a title for a common and important immune-complex reaction of lepromatous leprosy, in which numerous body systems may be involved.

Clinical recognition of leprosy: some factors leading to delays in diagnosis

The case histories of eight patients in the United Kingdom admitted to hospital for the diagnosis of leprosy are examined in detail. Review of their early symptoms and signs showed that there had been delays in diagnosis, ranging from a few months to many years. Possible reasons for delay are discussed, and attention is called to the importance of nasal symptoms in the early diagnosis of lepromatous leprosy.

An appraisal of diagnostic paracentesis of the abdomen

A simple method of paracentesis is described and shown to provide a safe, easy, and reliable means of examining abdominal fluid. The characteristics of the fluid associated with a variety of pathological conditions are discussed and the results of 100 consecutive taps are analysed. The technique is shown to be especially useful in certain groups of patients who otherwise present considerable diagnostic difficulty.

Acute necrotizing lepromatous lymphadenitis: an erythema-nodosum-leprosum-like reaction in lymph nodes

Histological examination of lymph-node biopsy specimens in 12 patients with erythema nodosum leprosum showed almost complete replacement of the node by lepromatous granuloma, together with considerable polymorph infiltration. Ziehl-Neelsen staining demonstrated numerous Mycobacterium leprae present in the nodes. The majority of these patients were very ill, and responded to prednisolone or corticotrophin.It is suggested that the histological appearances may represent an intensive inflammatory response in the lymph nodes followed by avascular aseptic necrosis.