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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 159-160

Multiple peroneal nerve abscesses: The first presentation of borderline tuberculoid leprosy


1 Department of Medicine, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
2 Department of Neurology, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
3 Department of Pathology, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India

Date of Web Publication14-Jun-2018

Correspondence Address:
Dr. Aanchal Arora
Vardhaman Mahavir Medical College and Safdarjang Hospital, 113 F/F Meera Enclave, New Delhi 110 018
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bbrj.bbrj_23_18

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  Abstract 


A 53-year-old male presented with multiple swellings over the left leg associated with sensory loss and weak dorsiflexion of the left foot for 4 months. Neurophysiological studies revealed absent sensory and motor action potentials in the left common peroneal nerve. Multiple hypoechoic areas were seen in the subcutaneous plane on ultrasound and were found to be nerve abscesses along the peroneal neurovascular bundle on magnetic resonance imaging of the left leg. Skin biopsy was suggestive of borderline tuberculoid leprosy. He was started on corticosteroids and paucibacillary multidrug therapy. The swelling subsided over the next 1 month, and the motor paralysis improved gradually with treatment.

Keywords: Leprosy, nerve thickening, subcutaneous nodules


How to cite this article:
Arora A, Kaul B, Singh A. Multiple peroneal nerve abscesses: The first presentation of borderline tuberculoid leprosy. Biomed Biotechnol Res J 2018;2:159-60

How to cite this URL:
Arora A, Kaul B, Singh A. Multiple peroneal nerve abscesses: The first presentation of borderline tuberculoid leprosy. Biomed Biotechnol Res J [serial online] 2018 [cited 2020 May 28];2:159-60. Available from: http://www.bmbtrj.org/text.asp?2018/2/2/159/234453




  Introduction Top


The spectrum of leprosy ranges from tuberculoid (TT) to borderline tuberculoid (BT) to mid borderline (BB) to borderline lepromatous to lepromatous (LL) disease and is associated with the evolution of varied skin manifestations. Nerve abscesses are an unusual presentation of leprosy. Patients with, particularly paucibacillary spectrum (TT and BT), may have nerve abscesses.[1] Rarely, however, nerve abscess may also develop in other types of leprosy.[2] Although any cutaneous nerve may be involved, ulnar nerve is most commonly affected.[3] We hereby report a case of BT leprosy with peroneal nerve abscesses as the initial manifestation of the disease.


  Case Report Top


A 53-year-old male presented to our outpatient department with multiple swellings in the left leg for 4 months. He developed tingling and numbness in the left leg and foot 1 month after the onset of swelling. The swellings were localized to the lateral aspect of the left leg and gradually grew in size. They were associated with pain and itching. There was no pus discharge from swelling. There was no history of fever or joint pains. On examination, three well-defined subcutaneous nodules of soft to firm in consistency were palpable on the lateral aspect of the left leg. They were not attached to the overlying skin. The local temperature was not raised, and mild tenderness was elicited over the swelling [Figure 1]a. Multiple vesicles and papules were noted over the left foot [Figure 1]b. Neurological examination revealed weak dorsiflexion and sensory loss over dorsal aspect of the left foot. No other peripheral nerve was thickened. Neither hypopigmented patches nor abscesses were found elsewhere on the body. Systemic examination was unremarkable. A clinical diagnosis of erythema nodosum with vasculitis was kept. In view of nerve thickening, a diagnosis of leprosy was also kept. Herpes was also considered as a differential diagnosis in view of significant pain and burning sensation.
Figure 1: (a) Multiple well-defined subcutaneous swellings over the lateral aspect of the left leg. (b) Erythema and papules seen over the left foot. (c) Magnetic resonance imaging of the left leg showing altered signal intensity with multiple abscesses along the peroneal neurovascular bundle. (d) The upper dermis shows epithelioid granulomas, and mid-dermis shows granulomatous infiltrates around the neurovascular bundles. Fite stain did not show any acid-fast bacilli

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Hematological and urine analysis were normal. Tests for antinuclear antibodies and antineutrophil antibodies were negative. Neurophysiological studies found absent sensory nerve action potentials and motor action potentials in the left peroneal nerve suggestive of common peroneal axonal neuropathy. Ultrasonography (USG) of the left leg showed multiple hypoechoic areas located in subcutaneous and intramuscular plane communicating with each other. Magnetic resonance imaging (MRI) of the left leg revealed altered signal intensity with multiple abscesses along the peroneal neurovascular bundle up to the ankle [Figure 1]c. One of the nerve abscesses was excised and subjected to a histopathological examination which was suggestive of BT leprosy [Figure 1]d.

Based on these findings, a diagnosis of BT leprosy with peroneal nerve abscesses was made. The patient was started on multidrug therapy (the WHO paucibacillary regimen) and 40 mg of oral prednisolone once daily which was tapered gradually over 3 months. Follow-up after 1 month showed resolving abscesses and improvement in sensory symptoms of the patient.


  Discussion Top


Leprosy is characterized by the involvement of nerves by the primary infection and by immunologically mediated reversal reactions. Bacterial parasitization of the nerves leads to the formation of granulomatous lesions. They are formed due to anoxia produced by stretching and pressure on the nerve secondary to inflammation and vascular damage. Caseous necrosis of these nerve lesions occasionally coalesces to form a nerve abscess (cold abscess) particularly when the immunity is high. Progression to abscess formation is most commonly seen in patients with tuberculoid leprosy, especially in India.[4],[5] In a retrospective analysis of 686 patients of leprosy, nerve abscess was observed in four cases.[6] Nerve abscesses have been reported most commonly in the ulnar nerve (57·9%), followed by cutaneous nerves of the upper and lower limbs, peroneal nerve, and median nerve.[7],[8] Our case is unique where peroneal nerve abscess was found to be the first manifestation of BT leprosy. The differentials that were considered in our case were reversal reaction and herpes zoster infection. Diagnostic modalities that helped confirm the diagnosis of peroneal nerve abscess were USG and MRI. The treatment options for peroneal nerve abscess include tapering doses of corticosteroids and surgery. Surgery is indicated when pain is not controlled by corticosteroids, and there is a requirement of high dosages of steroids and increasing sensory and/or motor deficit. Surgery is advised because it causes less morbidity than long-term steroids.[7] Our patient showed a satisfactory response to oral corticosteroids, and hence, he was treated conservatively. In conclusion, the nerve abscess as the first manifestation of leprosy is uncommon, and a high index of suspicion is required to make a correct diagnosis.


  Conclusions Top


Nerve abscesses are an unusual presentation of leprosy. When found, they are particularly seen in paucibacillary spectrum of the disease and commonly involve the ulnar nerve. Thus, a high index of suspicion is required to make a correct diagnosis of leprosy in a case with nerve abscesses as the first presentation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumar GR, Ramana PV, Vasundhara N, Reddy MK. Two unusual nerve abscesses – Lepromatous leprosy and pure neural leprosy: Case reports. Lepr Rev 1996;67:217-21.  Back to cited text no. 1
    
2.
Kumar P, Saxena R, Mohan L, Thacker AK, Mukhija RD. Peripheral nerve abscess in leprosy: Report of twenty cases. Indian J Lepr 1997;69:143-7.  Back to cited text no. 2
    
3.
Gelber RH. Leprosy. In: Fauci AS, Braunwald KJ, Iselbacher KJ, editors. Harrison's Principles of Internal Medicine. 15th ed. New York: McGraw Hill; 2001. p. 1035-40.  Back to cited text no. 3
    
4.
Char G, Cross JN. Ulnar nerve abscess in Hansen's disease. West Indian Med J 1986;35:66-8.  Back to cited text no. 4
    
5.
Singh G, Ojha D. Leprotic nerve abscesses. Dermatologica 1969;139:409-12.  Back to cited text no. 5
    
6.
Mendiratta V, Khan A, Jain A. Primary neuritic leprosy: A reappraisal at a tertiary care hospital. Indian J Lepr 2006;78:261-7.  Back to cited text no. 6
    
7.
Salafia A, Chauhan G. Nerve abscess in children and adults leprosy patients: Analysis of 145 cases and review of the literature. Acta Leprol 1996;10:45-50.  Back to cited text no. 7
    
8.
Chauhan SL, Girdhar A, Mishra B, Malaviya GN, Venkatesan K, Girdhar BK, et al. Calcification of peripheral nerves in leprosy. Acta Leprol 1996;10:51-6.  Back to cited text no. 8
    


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