E-Poster Presentation ESA-SRB-ANZBMS 2021

The majority of individuals that present with diabetes-related foot complications have painless neuropathy, therefore pain should raise clinical suspicion for other diagnoses. Although deep-seated infections, acute Charcot arthropathy and ischaemia may present with pain, Hansen’s disease can cause pain in this patient cohort, particularly given that trauma of amputation is a recognised precipitant. It is also important to differentiate the neuropathy of Hansen’s disease from that of diabetes mellitus.

We report the case of a 47-year-old male of Samoan descent with Hansen’s disease. This was diagnosed following increasing pain and erythematous rash post bilateral below knee amputations for necrotic feet secondary to ischaemia from severe cardiomyopathy. On day 24 post amputation, he developed a raised, erythematous rash to his right stump that was tender on palpation (Figure 1). Subsequently, he developed acute right fifth finger dactylitis, left eye conjunctival injection and left distal forearm swelling. The dactylitis and swelling were reported as tenosynovitis on ultrasound, and the conjunctival erythema was attributed to a dry eye. 

The Mycobacterium leprae PCR on the skin biopsy returned positive. He was diagnosed with tuberculoid leprosy with a type 1 reaction, and commenced a 12-month course of dapsone, clofazimine and monthly rifampicin, and weaning prednisolone. The iritis, dactylitis and rash improved following treatment commencement.

Hansen’s disease should be considered as a differential for diabetic neuropathy, especially when the classical distal, symmetrical pattern typically seen with diabetes is absent, or if other clinical features are present. In our multicultural society, it is important to consider Hansen’s disease as timely identification and treatment prevents permanent disability. With ongoing vigilance, we may edge closer to the leprosy-free world envisioned by the WHO Global Leprosy Strategy 2016-2020. Moreover, in our patients with diabetes, we should never assume new symptoms are secondary to diabetes.

Figure 1. Rash in Hansen's disease