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Abstract
Two patients presented with side-locked frontal head pain, involving the supraorbital nerve territory, with an associated hypopigmented macule. The clinical progress and nerve biopsy in one indicated leprosy. In endemic regions, supraorbital neuralgia may be caused by leprosy sometimes without other neurocutaneous markers.
- LEPROSY
Data availability statement
Data are available in a public, open access repository. Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Introduction
Supraorbital neuralgia is characterised by pain in the region supplied by the supraorbital nerve. The usual cause is inflammation of the supraorbital nerve following periorbital trauma.1 Key diagnostic features include paroxysmal or constant pain at the supraorbital notch and medial aspect of the forehead, tenderness over the nerve in the supraorbital notch, and abolition of pain by blockade (local anaesthetic) or by ablation of the supraorbital nerve.
Leprosy is a chronic granulomatous disorder caused by Mycobacterium leprae. Rarely, this may affect an isolated cranial nerve before other cutaneous manifestations appear, posing a diagnostic challenge and risking delayed treatment.
Case 1
A 30-year-old man reported 2 years of recurring, short-lasting, severe pain in the right frontal region, with associated itching and decreased sensation over the eyebrows. He was from the endemic region of Chhattisgarh state, India, There was a palpable cord-like thickening between the supraorbital ridge and mid-forehead, tapping this evoked an electric pain. Investigations included a normal erythrocyte sedimentation rate and antinuclear antibody profile. CT scan of head showed an enlarged supraorbital nerve manifesting as a medium-sized nodular lesion in the periorbital area. Six months later he developed ulnar nerve thickening with associated skin lesions, suggesting leprosy (figure 1).
Clinical and CT scan images showing a thickened right supraorbital nerve.
Case 2
A 23-year-old man reported 1 year of paroxysmal pain in the left frontal region, with a patch of decreased sensation over the left eyebrow. The supraorbital nerve was thickened and tender to percussion. He had lost the lateral one-third of the left eyebrow with an associated patch of hypopigmentation and decreased sensation. CT scan of head showed an enlarged left supraorbital nerve. Skin biopsy showed perineurovascular chronic inflammatory infiltrate, consistent within paucibacillary leprosy (figure 2).
Clinical and CT scan images showing loss of the lateral one third of eyebrow with a hypopigmented patch and a thickened left supraorbital nerve.
Discussion
Sjaastad et al described supraorbital neuralgia in 1999.2 Four of the 18 patients reported in literature also had reduced touch or pinprick sensation in the frontal strip above the eyebrows.3 ‘Swimmer’s headache’ is a variant probably resulting from ill-fitted swimming goggles.4 5
In patients with leprosy, the two cranial cutaneous nerves that commonly thicken are the greater auricular nerve and supraorbital nerve above the eyebrow (figure 3). Patients may notice an enlarged nerve, especially if painful or tender. Hansen’s neuritis might include decreased sensation in the area innervated by the nerve, depigmentation, hair loss, and tenderness on palpation.6
Diagrammatic representation of an enlarged supraorbital nerve in leprosy.
Although the prevalence of leprosy has fallen greatly, some states of India are still endemic zones.7 Leprosy remains an important cause of painful cranial neuritis in endemic regions.
Key points
Leprosy is an important cause of secondary supraorbital neuralgia in endemic regions.
Neuroimaging may show enlarged supraorbital nerves.
Data availability statement
Data are available in a public, open access repository. Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Participants gave informed consent to participate in the study before taking part.
Footnotes
Contributors SS: served as scientific advisors, critically reviewed the study proposal; PS: collected data, served as scientific advisors; UKC: provided and cared for study patients, collected data, SK: collected data.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally reviewed by Mark Ellul, Liverpool, UK.
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