Optic Neuropathy and Scleritis as the Presenting Feature of Lepra Reaction

A major problem in the management of leprosy patients is the occurrence of "reactions". These reactions are the consequences of the dynamic nature of the immune response to Mycobacterium leprae (M. leprae) that may occur before, during, or following the completion of multi-drug therapy (MDT). They can be of two types- Type 1 lepra reaction and Type 2 lepra reaction also known as Erythema Nodosum Leprosum (ENL). We report an unusual case of a 35 year old male patient who initially presented with complaints of a central scotoma. He neither had visible skin lesion suggestive of leprosy nor a history of either completion or concurrent anti leprosy drug treatment. He was diagnosed to be a case of anterior ischemic optic neuropathy for which he was treated with intravenous injections of methylprednisolone to which he significantly responded. Two months later, he complained of diminution of vision, redness and pain in the left eye which was diagnosed as scleritis. He was managed with topical prednisolone acetate eye drops. Within a week, the patient developed skin lesions over the cheekbones, ear lobules and the back of his hands. He was referred to a rheumatologist and a dermatologist for the same. The dermatologist suspected the lesions to be a manifestation of a Lepra Reaction. The presence of lepra bacilli was confirmed after taking a biopsy from the raised lesions and he turned out to be a case of undiagnosed lepromatous leprosy. He was subsequently treated with anti-leprosy drugs according to the WHO-MDT-MB along with a cover of steroids. After three months of initiation of this treatment, his ocular and dermatological lesions completely resolved. This is a unique case in which anterior ischemic optic neuropathy and scleritis preceded the symptom of leprosy, manifested as skin lesions.