Introduction : Leprosy, though declining globally, continues to present diagnostic challenges due to its varied clinical manifestations. Pure neuritic leprosy accounts for about 5–10% of cases in India and less than 5% globally. Neurological involvement may be the first or predominant symptom, yet lack of awareness among non-dermatology specialists often leads to misdiagnosis. Overreliance on negative slit-skin smears, incomplete clinical correlation, and diversion into alternate differential diagnoses may result in prolonged delays in initiating multidrug therapy (MDT), thereby worsening disability outcomes. Reporting such cases highlights existing gaps in clinical practice and reinforces the importance of maintaining a high index of suspicion for leprosy in endemic regions.
Methods : We describe the clinical course of a 72-year-old male from Chennai evaluated over a three-year period across multiple healthcare facilities. Clinical history, diagnostic investigations, specialist referrals, and management strategies were systematically reviewed. The diagnostic pathway was mapped to identify missed opportunities and causes for delay in establishing the diagnosis of Hansen’s disease.
RESULTS: The patient first presented in July 2022 with bilateral hand numbness, difficulty buttoning shirts, and spontaneous blisters. A private neurologist diagnosed carpal tunnel syndrome, and carpal tunnel release surgery was performed without improvement. At a government tertiary hospital, slit-skin smears tested negative for Mycobacterium leprae, leading to exclusion of leprosy and referral to neurology. Nerve conduction studies suggested median nerve neuropathy, and extensive work-up for autoimmune and vascular causes remained inconclusive. The patient was repeatedly managed with intermittent steroids for presumed neuropathy, yielding only temporary relief.
Over the next two years, symptoms progressed, with recurrent hand ulcers and extension of numbness to the lower limbs. In August 2025, the neurologist referred the patient to a central government neurology research institute, where a sural nerve biopsy confirmed Hansen’s disease, with Fite-Faraco stain demonstrating clusters of lepra bacilli. The patient was subsequently referred back to the government tertiary hospital, where MDT was initiated in September 2025, more than three years after symptom onset.
CONCLUSION: This case illustrates the diagnostic challenges of leprosy in the absence of skin lesions and negative slit-skin smears, particularly for specialists outside dermatology in endemic regions. The prolonged delay in initiating MDT underscores systemic gaps in physician awareness beyond dermatology and public health. The lessons learned reinforce the importance of integrating leprosy training into continuing medical education for neurologists, rheumatologists, and general practitioners. Early recognition of neuropathy patterns, judicious use of confirmatory tools such as nerve biopsy when smears are negative, and timely referral are essential to prevent irreversible morbidity. Strengthening clinical vigilance and interdisciplinary collaboration remains a cornerstone in advancing toward the goal of true leprosy elimination.