By Gautam Debroy
A recent study published in the Indian Journal of Medical Research has highlighted the growing concerns over possible misdiagnosis of leprosy by non-dermatologists, citing it as a major factor in the continued prevalence of the disease. This concerning trend even extends to tertiary hospitals with misdiagnosis by specialists including physicians, neurologists, and even infertility specialists.
Even as the treatment of leprosy has been simplified by adopting uniform multidrug therapy (MDT), the high number of new cases and associated disabilities remain a pressing issue now, revealed the study authored by three top dermatologists of India - Dr Kabir Sardana, Dr Savitha Sharath and Dr Ananta Khurana.
In an exclusive conversation with ETV Bharat, Dr Kabir Sardana, HoD of Dermatology department in RML hospital in New Delhi, and lead author of 'Misdiagnosis of leprosy: An underappreciated reason for its continued prevalence', stated that misdiagnosis is reported both at primary level and secondary level.
“This (Leprosy) could partly be attributed to possible misdiagnosis by non-dermatologists. We have noticed that this trend extends to tertiary hospitals with misdiagnosis by specialists across the spectrum, including physicians, neurologists, and even infertility specialists. The multisystem involvement of leprosy and reactions can have myriad manifestations, and we aim to highlight these clinical differentials, including neural involvement, so that early diagnosis of leprosy patients is ensured, as dermatologists are rarely the first point of contact for them,” the author highlighted.
“Many clinicians in their routine posting of MBBS training do not attend dermatology postings where leprosy is seen. A few cases are even misdiagnosed by tertiary level doctors,” said Dr Sardana.
The other two authors of the study include Dr Savitha Sharath and Dr Ananta Khurana, both from the Department of Dermatology at Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, respectively.
“There are multiple issues that pose hindrance in leprosy eradication, and even a single case of misdiagnosis can lead to spread of infection to others. The time for a disease to manifest is seven years,” said Dr Sardana, adding that "Poverty, poor sanitation and overcrowding trigger its spread and without a holistic approach, it is very difficult to achieve the goal of leprosy eradication."
According to the study, leprosy has a wide spectrum of clinical presentations that often simulate many other dermatological conditions, making it difficult to differentiate, particularly in non-endemic areas.
“The diverse cutaneous lesions of leprosy include subtle hypopigmented macules, raised plaques of varying sizes, annular plaques, nodules, and diffuse infiltration,” it said.
“Leprosy has occasionally been mislabeled as systemic sclerosis in patients developing skin thickening and digital resorption. Borderline tuberculoid (BT) leprosy presenting as chronic macrocheilia can be mistaken for granulomatous cheilitis, and the distinction between the two conditions is often challenging to gauge because of the paucibacillary nature of this leprosy spectrum,” the study revealed.
Leprosy Reactions And Their Mimickers
Type I (T1R) and Type II (T2R) are leprosy reactions presenting inflammatory-looking edematous plaques (T1R) or evanescent painful nodules (T2R). Leprosy reactions have often been misdiagnosed as systemic lupus erythematosus, erythema multiforme, sweet syndrome, vasculitis, arthritis, or collagenosis. T2Rs frequently have joint symptoms and may be misdiagnosed as rheumatoid arthritis. An edematous and intensely erythematous leprosy plaque undergoing T1R can be mistaken for cellulitis, especially over the face. Erythematous papules and nodules, along with systemic features like fever, polyarthritis, and eye involvement in T2R, can be mistaken as sarcoidosis.
“Leprosy reaction misdiagnosed as urticaria is also not uncommon. T2R can mimic cutaneous tuberculosis and differentiating the two conditions is paramount, especially in areas endemic for both these infections. There are reports of T2R without typical ENL lesions masquerading as lymphomas. We have encountered instances of necrotic (ulcerated) ENL patients being admitted to the surgical wards diagnosed as necrotizing fasciitis and cases of ENL necroticans being misdiagnosed as vasculitis. However, signs of underlying leprosy are evident with facial and ear lobe infiltration (thickened skin) apart from the clinical features of leprosy (vide supra),” the study revealed.
Neural Leprosy, A Missed Cause Of Mononeuritis Multiplex
Mononeuropathy multiplex, defined as an affliction of two or more nerves that cannot be explained by a single root or plexus injury, with asymmetric, non–length-dependent subacute damage, is often not suspected to be consequent to leprosy. While Mononeuritis multiplex (MM) is the most common neuropathy in leprosy, there are other patterns like polyneuropathy (distal, symmetric small fiber sensory polyneuropathy), autonomic neuropathy, cranial nerve affliction, ganglionitis, and neuritis. In addition to this, leprosy can cause neuropathic pain.
Addressing 'Misdiagnosis-Mistreatment' Is The Key
"Without addressing misdiagnosis and mistreatment, the WHO’s goal of achieving a 70 percent reduction in the annual number of new leprosy cases is a deceptive target, as it does not account for the large number of missed cases by non-dermatologists, which contribute to continued transmission," the study stated.
The authors of the study highlighted that there is an urgent need to include clinical specialists from endemic countries (where leprosy remains a concern) in the advisory groups, alongside 'eminence-based' experts, as the ground reality of misdiagnosis rarely finds its way into the guidelines.
“To achieve these goals in an endemic country, physicians and neurologists should also be made aware of leprosy and its varied presentations,” the study suggested.
Government’s Stand
In 2023, the Government of India launched the National Strategic Plan (NSP) & Roadmap for Leprosy (2023-27), to achieve zero transmission of leprosy by 2027, three years ahead of the Sustainable Development Goal (SDG).
“The NSP and Roadmap contain implementation strategies, year-wise targets, public health approaches and overall technical guidance for the programme. The strategy and roadmap focuses on awareness for zero stigma and discrimination, promotion of early case detection, prevention of disease transmission by prophylaxis (Leprosy Post Exposure Prophylaxis) and roll out of web-based information portal (Nikusth 2.0) for reporting of leprosy cases,” Dr Bharati Pravin Pawar, Union Minister of State for Health and Family Welfare has said.
After achieving elimination status at national level, National Leprosy Eradication Programme (NLEP) has taken a number of initiatives to encourage early case detection of leprosy patients to prevent Grade-II Disabilities, and ensure free of cost treatment of leprosy patients.
“With various interventions introduced under NLEP in the last few years, the number of new leprosy cases detected have come down to 75,394 in 2021-22 from 1,25,785 in 2014-15, accounting for 53.6 percent of new leprosy cases globally,” Dr Pawar said.
