Recurrent arthritis - unusual presentation of leprosyAA Chikhalikar, AF Golwalla, AB Shah, GS Hattangadi
Department of Medicine, Seth G. S. Medical College and K. E. M. Hospital, Bombay-400 012, India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 1032830
Source of Support: None, Conflict of Interest: None
A case of leprosy which presented in lepra reaction with painful involvement of joints over a period of months with remissions and exacerbations is presented. The mechanisms by which leprosy ,nay cause painful joints are discussed. Attention is drawn to the concept that every case of "resistant or recurrent arthritis" should be scrutinised for evidence of leprosy.
Leprosy is a common disease in our country. It has a wide range of manifestations. Painful involvement of joints is known to occur in leprosy but when the patient presents for the first time with arthritis, the diagnosis of leprosy may be overlooked. We report here one such case.
S.K., a 39 year old male patient, was admitted with complaints of fever and joint pains for two weeks. The pain and swelling mainly affected both ankle and knee joints, but the wrists and small joints of the hands were also involved. The patient had been suffering from such pains for the previous one and a half years. He had been diagnosed as a case of rheumatoid arthritis and treated with salicylates and phenylbutazone. The response to treatment had been poor and there had been exacerbations and remissions. He had suffered from tuberculous pleural effusion in the past and was taking anti-tuberculous treatment.
On examination, the patient had fever warm swelling of both ankles and knee joints and spindle-shaped swellings of the interphalangeal joints of the hands. Rest of the examination revealed no abnormality.
Laboratory investigations were as follows: Hb.-11.5 g.%. W.B.C. count9,600/c.mm., polymorphs-67 %, lymphocytes-31%, eosinophils-2% , E.S.R. 107 mm at the end of 1st hour; Urinalysis- I NAD; X-ray chest-NAD. No evidence of active tuberculous lesion. E.C.G. - NAD; Serum Uric acid-4.6 mg%.
The patient was treated with aspirin 3.6 gm daily. The dose was gradually increased to 7.2 gm daily, but the response was poor. While receiving this treatment, he developed a rash consisting of multiple discrete raised erythematous lesions with distinct margins, mainly on the face and the extremities. He reported that during the previous attack of joint pains, he had developed a similar rash which disappeared spontaneously, leaving behind pigmented patches. Simultaneously with the rash, the patient had paraesthesiae on the right hand. Examination revealed diminished pinprick sensation over middle, ring and little fingers of the right hand and corresponding area of the right palm. The ulnar and lateral popliteal nerves were thickened on both sides. A leprologist was consulted and a skin biopsy taken. The biopsy was positive for lepra bacilli. The patient was diagnoses to be a case of lepra reaction with erythema nodosum leprosum (ENL).
Aspirin was omitted and the patient was treated with 3 tablets of chloroquine (200 mg of base each) daily. This was followed by a dramatic response and at the end of 48 hours he was afebrile and the joint pains had markedly subsided, After control of lepra reaction Dapsone therapy was started. Follow-up at the end of two months showed that the patient had remained more or less free of joins pains without the use of anti-arthritic drugs.
Neuropathic joints of leprosy, with painless destruction of joint structure are wellknown. However leprosy may also cause painful joints by one of the following mechanisms: infiltration of joint capsule, synovial membrane and tendon: around the joint may occur, especially in those joints which are directly covered by the skin. The appearance produced may closely mimic that of rheumatoid arthritis. During the course of the disease, acute exacerbations called a: lepra reactions may occur which manifest by arthritis, fever, acute neuritis erythema nodosum and lymphadenopathy. Occasionally, the patient may remain in reaction for a period of few weeks. If the patient presents himself to the doctor for the first time with arthritis, the diagnosis of leprosy may be overlooked unless the patient is carefully scrutinised.
Lele et al  reported a series of 13 patients who presented with arthritis and were later diagnosed as leprosy. They reported that in an institution in Lousiana, 4.5% of 425 patients of leprosy had a previous diagnosis of arthritis. It is important to rule out a chance association of leprosy and rheumatoid arthritis in such cases. Lele et al  performed synovial biopsies on their patients and reported that six patients "had epitheloid cells and giant cells which are not a feature of histopathology of rheumatoid arthritis".
In the case discussed here, synovial biopsy was not performed. However, the following points strongly suggest that arthritis was a manifestation of leprosy in this patient:
(1) Acute exacerbations of joint pains had been associated with appearance of erythema nodosum and acute neuritic symptoms on at least two occasions.
(2) The patient who had not responded to large doses of aspirin, responded quickly to chloroquine.The dramatic response to smalldose of chloroquine points to the specific effect of chloroquine in control of lepra reaction rather than its general antipyretic or antirheumatoid action.
(3) Following the therapy for leprosy, the patient remained free of joint pains without any treatment for arthritis.
The importance of scrutinising ever case of "resistant or recurrent arthritis' for evidence of leprosy, therefore, cannot he overemphasised.
We wish to thank the Dean, K. E. M. Hospital and Seth G. S. Medical College. for allowing us to publish this case report.