A 60-year-old Nigerian man, who had lived in Europe for 30 years but had returned home frequently, presented with right frontalis muscle weakness and right ulnar nerve palsy, without skin lesions. Neurophysiology showed a generalised neuropathy with demyelinating features. Blood tests were positive for HIV, with a normal CD4 count. There was nerve thickening both clinically and on MRI. Nerve biopsy showed chronic endoneuritis and perineuritis (indicating leprosy) without visible mycobacteria. His neuropathy continued to deteriorate (lepra reaction) before starting treatment with WHO multidrug therapy, highly active antiretroviral therapy and corticosteroids. There are 10 new cases of leprosy diagnosed annually in the UK. Coinfection with HIV is rare but paradoxically does not usually adversely affect the outcome of leprosy or change treatment. However, permanent nerve damage in leprosy is common despite optimal therapy. Leprosy should be considered in patients from endemic areas who present with mononeuritis multiplex.
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Contributors CMG drafted the manuscript, designed the figures and tables and then revised the manuscript. HM performed and interpreted the neurophysiology for the manuscript and reviewed the manuscript. ZJ and SB performed and interpreted the neuropathology and made the neuropathology figure and reviewed the manuscript. AMR, MMR and HM saw the patient, arranged and reviewed the investigations and made the diagnosis and reviewed the manuscript. DNJL reviewed the patient and confirmed the diagnosis, started treatment and supervised follow-up and reviewed the manuscript. FS saw the patient initially and for ongoing review and conceived the idea for the case report and reviewed the manuscript.
Provenance and peer review Not commissioned; externally peer reviewed. This paper was reviewed by Rob Hadden, London UK.
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