Grade 2 Disability in Leprosy in the Post-Elimination Era: A Case Report Highlighting Stigma and Programmatic Blind Spots

Leprosy has achieved elimination targets in many countries; however, patients continue to present with established disability. The presence of grade 2 disability (G2D) at diagnosis reflects delayed detection and persistent gaps in surveillance. I report a family cluster of three leprosy cases identified during routine program monitoring in Telangana, India, indicating a localized transmission pocket despite elimination status. The index case, a 35-year-old male with multibacillary leprosy, presented with advanced disability, including clawing of the right hand, plantar ulceration, and bilateral lagophthalmos. A structured G2D investigation revealed an overall diagnostic delay of approximately four years, including patient delay, provider delay associated with informal care, and missed detection during three consecutive rounds of leprosy case detection campaigns. Stigma further limited acceptance of home-based follow-up. Screening of four household contacts identified two children with paucibacillary leprosy without disability, suggesting earlier detection. The patient was managed according to national strategic plan guidelines, enrolled under the disability prevention and medical rehabilitation (DPMR) program, and provided multidisciplinary and community-based rehabilitation support. This case underscores the ongoing risk of preventable disability in the post-elimination era and highlights the need for structured G2D case audits, quality assurance of active case detection campaigns, strengthened surveillance, and stigma-sensitive community engagement to prevent delayed diagnosis in endemic pockets.