Ulcero-necrotic erythema nodosum leprosum and perforation of the palate in relapsed lepromatous leprosy: A rare challenge

Lepromatous leprosy (LL) sits at the multibacillary end of the leprosy spectrum, with defective cell mediated immunity. Apart from its neuro-cutaneous manifestations, organs like eyes, mucosae, testes, adrenals and kidneys can be affected in long-standing, untreated cases. While nasal and nasopharyngeal involvement is relatively common, palatal and oral lesions are unusual. Erythema nodosum leprosum (ENL), though frequent in LL patients, may progress to the ulcero-necrotic form with multi-system involvement, which is a rare and devastating event. Case report A young male presented with recurrent and recalcitrant steroid dependent necrotic ENL with neuritis, glomerulonephritis, myositis, arthritis, iridocyclitis and palatal perforation in the setting of relapsed lepromatous leprosy. This challenging scenario necessitated cautious tapering of steroids along with concomitant use of multiple anti-reactional modalities. The oro-nasal fistula closed spontaneously with multi-drug therapy and conservative management. Conclusion Events such as palatal perforation and fulminant necrotic ENL, albeit rare in the post-elimination era of leprosy, warrant sound clinical acumen and judicious use of combination therapies to minimise unforeseen complications. Keywords: Lepromatous leprosy, palatal perforation, relapse, steroid dependent, ulcero-necrotic ENL