Erythema Nodosum Leprosum in a Treatment-Naïve Patient: Clinical Clues Not to Miss in Primary Care
DOI:
https://doi.org/10.70672/7sqe5g76Keywords:
clofazimine, erythema nodosum, Mycobacterium leprae, multibacillary leprosyAbstract
Leprosy is known as a “great mimicker” due to its broad spectrum of clinical presentations. Erythema nodosum leprosum (ENL), a Type 2 lepra reaction, typically manifests as acute, painful erythematous nodules during or after initiation of multidrug therapy (MDT) in multibacillary patients. We report a case of a 66-year-old treatment-naïve man who presented to primary care with chronic and painless nodules in the absence of classical lepromatous features or prior therapy. Slit-skin smear (SSS) confirmed multibacillary leprosy with a moderate bacterial index (BI) and an inactive morphological index (MI), supporting the diagnosis of chronic ENL. The patient responded well to a second-line MDT regimen and corticosteroids. This case highlights an unusual presentation of ENL preceding treatment and underscores the diagnostic challenges faced in primary care, particularly when classical signs of leprosy are absent. We discuss key differential diagnoses and the importance of early recognition to avoid misdiagnosis and prevent complications.
References
[1]. World Health Organization. Guidelines for the diagnosis, treatment, and prevention of leprosy. New Delhi: WHO Regional Office for South-East Asia; 2018.
[2]. World Health Organization. Global leprosy (Hansen disease) update, 2023: elimination of leprosy disease is possible – time to act. Wkly Epidemiol Rec. 2024 Sep 13;99(37):497–522.
[3]. Kwan Z, Pailoor J, Tan LL, Robinson S, Wong SM, Ismail R. Leprosy—an imported disease. Lepr Rev. 2014 Sep;85(3):170–6. PMID: 25509717
[4]. Walker SL, Lockwood DNJ. The clinical and immunological features of leprosy. Br Med Bull. 2006:77-78:103-21. doi: 10.1093/bmb/ldl010.
[5]. Walker SL, Balagon M, Darlong J, Doni SN, Hagge DA, Halwai V, et al. ENLIST 1: An International Multi-centre Cross-sectional Study of the Clinical Features of Erythema Nodosum Leprosum. PLoS Negl Trop Dis. 2015 Sep 9;9(9). doi: 10.1371/journal.pntd.0004065
[6]. Alakad R, Nofal A, Assaf M. Atypical presentations of erythema nodosum leprosum: Diagnostic and therapeutic aspects. J Dtsch Dermatol Ges. 2021 Aug;19(8):1133-1143. doi: 10.1111/ddg.14449
[7]. Akpolat ND, Akkus A, Kaynak E. An update on the epidemiology, diagnosis and treatment of leprosy. In: Ribón W, editor. Hansen’s disease: the forgotten and neglected disease. London: IntechOpen; 2018. doi:10.5772/intechopen.82427
[8]. Koneti J, Cherukuri SP, Gadde S, Kalluru R, Chikatimalla R, Dasaradhan T. Sarcoidosis and Its Dermatological Manifestations: A Narrative Review. Cureus. 2022 Aug 16;14(8)
[9]. Irifune S, Yamamoto K, Ishijima S, Koike Y, Fukuoka J, Mukae H. Erythema induratum of Bazin: a subcutaneous granulomatous vasculitis that caused difficulty in walking. Int J Infect Dis. 2021 May; 106:183–4. doi: 10.1016/j.ijid.2021.03.077
[10]. Koley S, Sarkar J, Choudhary SV, Choudhury M, Banerjee G, Bar C, et al. Lupus erythematosus panniculitis: a case report. J Pak Assoc Dermatol. 2011;21(1):63–6.
[11]. Dewi DAR, Djatmiko CBP, Rachmawati I, Arkania N, Wiliantari NM, Nadhira F. Immunopathogenesis of Type 1 and Type 2 Leprosy Reaction: An Update Review. Cureus 2023 Nov 21;15(11): e49155.
[12]. Mahajan VK. Slit-skin smear in leprosy: lest we forget it! Indian J Lepr. 2013 Oct-Dec;85(4):177-83. PMID: 24834639
[13]. Roy K, Sil A, Das NK, Bandyopadhyay D. Effectiveness and safety of clofazimine and pentoxifylline in type 2 lepra reaction: a double-blind, randomized, controlled study. Int J Dermatol. 2015 Nov;54(11):1325-32. doi: 10.1111/ijd.12793.
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Asian Journal of Medicine & Health Sciences
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Journal of Engineering Technology (JET) is an open-access journal that follows the Creative Commons Attribution-Non-commercial 4.0 International License (CC BY-NC 4.0)
