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E-IJD® - CORRESPONDENCE |
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| Year : 2021 | Volume
: 66
| Issue : 4 | Page : 446 |
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| Filarial Bursitis Complicating Leprosy Reaction |
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Ghanshyam K Verma, Saru Thakur, Gita R Tegta, Ajeet K Negi
Department of Dermatology, Venereology and Leprosy Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| Date of Web Publication | 17-Sep-2021 |
Correspondence Address:
Ghanshyam K Verma
Department of Dermatology, Venereology and Leprosy Indira Gandhi Medical College, Shimla, Himachal Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.IJD_110_19
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How to cite this article:
Verma GK, Thakur S, Tegta GR, Negi AK. Filarial Bursitis Complicating Leprosy Reaction. Indian J Dermatol 2021;66:446 |
Sir
Hansen's disease, caused by Mycobacterium leprae, is known to involve the visceral organs including the musculoskeletal system, apart from the skin and nerves in the lepromatous pole due to widespread hematogenous dissemination. Its chronic course may sometimes be complicated by lepra reactions. The type 2 lepra, reaction is a Gell and Coombs type III hypersensitivity characterized by erythema nodosum leprosum (ENL) lesions, lymphadenitis, and systemic symptoms such as high-grade fever, arthralgia, arthritis, myalgia, orchitis, uveitis, neuritis, and other systemic involvements. This reaction can be triggered by a number of factors such as physical and mental stress, pregnancy, lactation, vaccinations, drugs, as well as infections including malaria and filariasis.[1]
Filariasis,[2] human immunodeficiency virus infection,[3] and chromoblastomycosis[4] are a few reported infectious triggers. Filariasis is an infection caused by the parasitic nematode Wuchereria bancrofti, Brugia malayi or Brugia timori. Dual infection with filariasis and leprosy which are endemic in India contribute to functional limitation and deformities.
We present a 36-year-old gentleman, resident of Bihar, who was diagnosed as a case of lepromatous leprosy with severe type II reaction and grade I deformities of hand and feet with no deformities of eyes. He presented with ENL lesions, fever, body aches, and joint pains. He complained of a mildly painful swelling over the left elbow for 5 months. On examination, multiple ENL lesions over the face, upper and lower limbs [Figure 1] were observed. | Figure 1: Multiple erythema nodosum leprosum (ENL) lesions over the face and upper limbs
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Over the extensor aspect of the left elbow, an ill-defined skin-colored swelling [Figure 2] of approximately 5 cm × 4 cm in size, cystic, non-mobile, and mildly tender was seen. Slit skin smear examination revealed a bacterial index (BI) of 6 + and morphological index (MI) of 10%. Routine laboratory investigations were within normal limits. Ultrasonography of the left elbow [Figure 3] reported areas of heterogeneous echogenicity with hypoechoic as well as hyperechoic areas below the triceps in the olecranon region of the left elbow, suggestive of chronic bursitis. Fine needle aspiration cytology (FNAC) from the swelling revealed the presence of microfilaria in a moderately cellular smear with the predominance of macrophages [Figure 4]. The microfilaria was again confirmed on a midnight peripheral blood smear [Figure 5]. The patient was initiated on Multi drug therapy multibacillary (MDT-MB) pack and tapering dose of oral steroids as per the WHO schedule. The patient was also prescribed oral ivermectin 400 μg/kg stat on two occasions 1 week apart. The second dose of ivermectin was followed by a fresh crop of ENL lesions with severe systemic features despite being on steroids, reflecting the sudden release of antigens of dying microfilaria. The patient was managed by increasing the dose of steroid. | Figure 2: Left elbow reveals an ill-defined, cystic, non-mobile, and non-tender swelling with no secondary changes of the overlying skin
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 | Figure 3: Ultrasonography of the left elbow revealed areas of heterogeneous echogenicity with hypoechoic as well as hyperechoic areas below triceps in the olecranon region suggestive of chronic bursitis
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 | Figure 4: FNAC revealed the presence of microfilaria in a moderately cellular smear with a predominance of macrophages
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Filariasis affects more than 120 million people globally with the greatest prevalence in Asia, Africa, and Western Pacific.[5] The acute manifestations of lymphatic filariasis are typically characterized by retrograde adenolymphangitis with inguinal, axillary, and epitrochlear nodes being the most commonly involved.[6] Filariasis triggering and complicating reactions in leprosy had been reported previously.[7] Acute bouts of filariasis and lepra reactions in a known case of leprosy can have similar presentations, hence, posing difficulty in reaction diagnosis.[2]
Extra lymphatic presentations of filariasis like arthritis, tropical pulmonary eosinophilia, splenomegaly, and renal involvement[8] are known.
A case of filariasis developing histoid leprosy "de novo" has also been reported.[9] Cases with leprosy and filariasis with deformities have been reported by Rawson TM et al.[10]
Early diagnosis and management are of great importance so that the development of disability and deformity can be prevented. Recognizing filariasis as a precipitant of lepra reactions in patients coming from endemic areas where filariasis and leprosy coexist to a non-endemic area like ours is an eye-opener to health providers in our state to suspect this kind of dual infection.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Singh SK, Sharma T, Nath G, Singh TB, Shrivastava MK. Association of type II lepra reaction with filariasis and malaria. Indian J Dermatol Venereol Leprol 2015;81:224.  |
| 2. | Nigam P, Goyal BM, Mishra DN, Samuel KC. Reaction in leprosy complicated by filariasis. Lepr India 1977;49:344-8. |
| 3. | Sharma NL, Mahajan VK, Sharma VC, Sarin S, Sharma RC. Erythema nodosum leprosum and HIV infection: A therapeutic experience. Int J Lepr Other Mycobact Dis 2005;73:189-93. |
| 4. | Apte G, Gedam JR, Poojary S, Nagpur NG, Pai VV, Ganapathi R. Chromoblastomycosis in a case of borderline lepromatous leprosy with recurrent type II lepra reaction. Lepr Rev 2011;82:310-5. |
| 5. | Chandy A, Thakur AS, Singh MP, Manigauha A. A review of neglected tropical diseases: Filariasis. Asian Pac J Trop Med 2011;4:581-6. |
| 6. | Partono F. The spectrum of disease in lymphatic filariasis. Ciba Found Symp 1987;127:15-31. |
| 7. | Bedi BM, Sardari L, Arunthathi S. Filariasis complicating reactions in leprosy. Indian J Dermatol Venereal 1972;38:85-6. |
| 8. | Dreyer BG, Dreyer P, Piessens WF. Extra lymphatic disease due to bancroftian filariasis. Braz J Med Biol Res 1999;32:1467-72. |
| 9. | Aggrawal K, Jain VK, Dayal S. Histoid leprosy with filariasis. Indian J Dermatol Venereol Leprol 2002;68:345-6. [ PUBMED] [Full text] |
| 10. | Rawson TM, Rao PV. Leprosy and lymphatic filariasis comorbidity: The case for an integrated functional limitation grading system. Lepr Rev 2014;85:63-7. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] |
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