LEPROSY NEUROPATHY MIMICKING CHRONIC INFLAMMATORY DEMYELINATING POLYRADICULONEUROPATHY: A DIAGNOSTIC DILEMMA

Dr. Nimakunvarba Devda*, Dr. N. K. Gupta

ABSTRACT

Background: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an immune-mediated peripheral neuropathy in which the clinical phenotype should be supported by objective evidence of demyelination. Motor-predominant presentations and severe axonal loss may create substantial diagnostic difficulty. Case presentation: A 33 year old man had seven months of worsening neurological symptoms. He developed motor problems especially he could not lift the foot upward (dorsiflex ankle) while pushing the foot downward (plantar flexion) remained normal. Sensory tests done at the bedside were said to be normal. Sharp pain triggered by a gentle touch indicated allodynia. Cranial nerves were not affected. Ultrasound of nerves showed uneven thickening of both ulnar nerves both common peroneal nerves and the left greater auricular nerve. Higher blood flow was seen in the right ulnar and peroneal nerves. A skin biopsy taken from a lesion on the upper back revealed chronic inflammation, around nerves and skin appendages; it also suggested borderline leprosy as a possibility. Nerve conduction studies of all four limbs found no CMAPs in the common peroneal and right ulnar nerves. The right median nerve had a CMAP amplitude. Sensory responses that were tested stayed normal. F waves could not be recorded. The formal conclusion was motor axonal neuropathy affecting all four limbs. HBsAg and HBeAg tests were reactive. Hbv DNA was 1.93 × 10^8 IU/mL (log 8.29). Conclusion: The available evidence supports a chronic painful motor-predominant polyneuropathy with severe motor axonal abnormalities and peripheral nerve enlargement. CIDP is an important clinical consideration but is not established by the available electrodiagnostic data. Possible borderline leprosy, vasculitic neuropathy and HBV-associated neuropathy remain relevant alternatives.

Keywords: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP); Motor-predominant neuropathy; Axonal neuropathy; Leprosy; Hansen disease; Alodynia; Hepatitis B; Peripheral neuropathy.