Indian Journal of Dermatology
: 2021  |  Volume : 66  |  Issue : 4  |  Page : 446-

Filarial Bursitis Complicating Leprosy Reaction

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

Correspondence Address:
Ghanshyam K Verma
Department of Dermatology, Venereology and Leprosy Indira Gandhi Medical College, Shimla, Himachal Pradesh

How to cite this article:
Verma GK, Thakur S, Tegta GR, Negi AK. Filarial Bursitis Complicating Leprosy Reaction.Indian J Dermatol 2021;66:446-446

How to cite this URL:
Verma GK, Thakur S, Tegta GR, Negi AK. Filarial Bursitis Complicating Leprosy Reaction. Indian J Dermatol [serial online] 2021 [cited 2023 Feb 7 ];66:446-446
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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}

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}{Figure 3}{Figure 4}{Figure 5}

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.

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