Leprosy Mimicking as Remitting Seronegative Symmetrical Synovitis with Pitting Edema Syndrome

Sir, A 48-year-old female was referred to the rheumatology clinic with a history of painful swelling of both hands and feet associated with ulceration of fingers and toes for 1 month. On examination, there was diffuse edema of hands and feet extending beyond joint line associated with extensive pitting [Figure 1a and b blue arrow]. It was also associated with multiple vesicles and ulcers in the hands and feet [Figure 1a and b yellow arrow]. Close examination revealed impaired pain and touch sensation over extremities. There were multiple hypopigmented skin lesions over the hands and both ulnar nerves were thickened. Her hematological and biochemical parameters were normal except for mild anemia and raised erythrocyte sedimentation rate (ESR).Figure 1: (a and b) Blue arrow: Swollen hands and feet. Yellow arrow: Ulcers and vesicles over hands and feet. (c) Ill-formed granuloma (red arrow) periadnexal inflammation comprising of foamy histiocytes and lymphocytes (green arrow)Her acute-phase reactants, rheumatoid factor, and anti- cyclic citrullinated peptide (CCP) were normal. There were no erosions on hand and feet radiographs. Hand ultrasound revealed tenosynovitis of both flexor and extensor compartment. Slit-skin smear from the skin lesions showed acid-fast bacilli, punch biopsy revealed ill formed granuloma with periadnexal, perivascular, and perineural inflammation comprising of foamy histiocytes and lymphocytes [Figure 1c]. A diagnosis of lepromatous leprosy with type 1 leprae reaction was made and she was started on multidrug therapy for leprosy (rifampicin, clofazimine, and dapsone) along with steroids with good response to therapy. Leprosy may mimic various rheumatic diseases such as rheumatoid arthritis, systemic vasculitis, remitting seronegative symmetrical synovitis with pitting edema (RS3PE) in endemic areas.[1,2] Although arthritis is the most common manifestation, swollen hands and feet due to tenosynovitis may be a presenting manifestation, especially in lepromatous form of leprosy and leprae reactions which can mimic RS3PE. Careful clinical examination to look for hypopigmented patches and nerve thickening in case of “swollen hands and feet syndrome” is warranted for the early diagnosis as well as to avoid misdiagnosis.[3] We highlight this case in view of the fact that the incidence of leprosy is declining rapidly even in developing countries such as India and hence can be easily overlooked by physicians and rheumatologists in the busy outpatient department, if the index of suspicion is low. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.