Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings

Assessment

Data collection was conducted using a Minimum Data Set (MDS) to gather demographic information, health history, and health status, including details of previous treatments. The assessment followed a head-to-toe approach, focusing on the eyes, hands, and feet (Ebenezer & Scollard, 2021). We inspected the eyebrows for the eyes, comparing the symmetry between the right and left eyes. The inspection was then extended to the hands and feet, comparing the right and left sides. A foot assessment was performed to identify the status of neuropathy and angiopathy. Neuropathy was confirmed through the Semmes Weinstein Monofilament test (10g), applied to the plantar hallux, first metatarsal, third metatarsal, and fifth metatarsal. Angiopathy status was assessed by palpating the dorsal pedis and posterior tibialis pulses.

Wound care

The wound care interventions included cleansing, debridement, and dressing. We used mineral water and liquid soap for the peri-wound skin and the wound bed for wound cleansing. Sharp debridement and mechanical debridement were performed to remove the callus surrounding the wound. Dressing selection was based on the specific needs of the wound bed. It included three layers: a primary dressing (in direct contact with the wound bed), a secondary dressing (to absorb exudate), and a tertiary dressing (for fixation).

Wound evaluation

Photographs were taken using a mobile phone without photographic applications to avoid image manipulation. The photos were cropped using the cropping feature in MS Word to remove unnecessary elements while ensuring the observation area (the foot) remained intact. Since the Leprosy-related neuropathic ulcers’ characteristics are similar to those of DM related neuropathic ulcer, we use the DMIST tool for wound healing evaluation. DMIST is a valid healing score for diabetic foot ulcers (Oe et al., 2020) and is useful for predicting healing (Tsuchiya et al., 2023). The DMIST tool was utilized to evaluate each wound treatment following cleansing and debridement, which were performed by a certified wound care nurse with a doctoral degree.

Demographics, medical history, and wound history

The patient is a 48-year-old woman, a high school graduate, and a housewife. She reported no history of Hypertension, Diabetes Mellitus, or Tuberculosis. The patient also stated that no family members have had similar wounds. The onset of the wound occurred in November 2023, beginning with the development of thick, numb calluses. The patient attempted to pinch and peel the calluses using her nails, which caused the wound to enlarge, become red (inflamed), and eventually exude fluid. Following advice from her family, the patient sought treatment at a general clinic in November 2023.

Treatment history

Figure 1. Head to toe assessment.

A: We observed an asymmetrical pattern in the patient's eyebrows. B: The inspection revealed a rash on the dorsal side of the left hand. C: Rashes were also found on the left and right tibial areas.

Wound care process

Wound care was administered by a wound care specialist and involved three modalities of intervention: cleansing, debridement, and dressing. Mineral water and liquid soap were used for wound cleansing. Sharp debridement was performed to remove necrotic tissue and calluses surrounding the wound, in combination with mechanical debridement.

During the first week, Cadexomer Iodine powder was applied as the primary dressing to control bacterial growth at the wound bed, with foam as the tertiary dressing. From the second week onward, honey-based gel was applied to stimulate granulation tissue growth, low-adherent dressing was used as the secondary layer, and gauze was applied during the final phase of care. Adhesive tape was used for fixation ( Table 3).

Wound care began on March 20 and continued until May 21, 2024, spanning 62 days with a total of 11 treatments. The average dressing change interval was 5.6 days. The patient’s total DMIST score was 12 at the first treatment, decreased to 9 in the second month, and reached four at the end of the treatment period ( Figure 2).

Figure 2. Documentation of wound healing process.

A. March, 20^th 2024. B. March, 22^nd 2024. C. March, 26^th 2024. D. March, 29^th 2024. E. April, 4^th 2024. F. April, 16^th 2024. G. April, 23^rd 2024. H. April, 30^th 2024. I. May, 7^th 2024. J. May, 14^th 2024. K. May, 21^st 2024.

Clinical challenges

The patient works as a household assistant, remaining physically active, which often causes the wound dressing to be wet. As a result, the patient was educated on self-care for the wound, including how to replace the dressing when it became wet. The patient was instructed to clean the wound, apply ointment, and cover it with gauze independently when needed.

Patient perspective

The patient reported visiting three healthcare facilities, none establishing a diagnosis of Leprosy. The first facility considered it a regular wound, while the third suspected gout—none of the three healthcare facilities performed any tests on the rashes on her hands or feet. The patient stated that the diagnosis of Leprosy was confirmed only after visiting the wound care clinic, where a monofilament test was conducted, followed by a referral back to the healthcare clinic. Only after receiving the monofilament test results was a tissue test performed at the healthcare clinic, and the patient was subsequently referred to the dermatological center for further evaluation. The patient responded to the diagnostic test results with acceptance but mentioned that she would not disclose her leprosy diagnosis to her husband.

New finding

An exciting aspect of this case is that, despite having a neuropathic ulcer, the patient remained active, walking and working without developing edema or erythema in the affected foot during the two-month treatment period. This is in stark contrast to neuropathic ulcers in patients with DM, where the absence of offloading typically leads to edema, erythema, and local inflammation. Additionally, the healing rate was relatively rapid, with complete recovery achieved in just 62 days, which differs significantly from the prolonged healing process often observed in diabetic patients with similar wounds.

Diagnostic challenge

The interesting aspect of this case lies in the healthcare facility’s oversight in recognizing and diagnosing the existing neuropathic wounds as a sign of leprosy. Proper diagnosis of neuropathy requires a thorough assessment of patient history, physical examination, and laboratory test results. Early-stage neuropathy is characterized by progressive sensory changes, including the loss of sensation, numbness, pain, or burning sensations in a “stocking and glove” distribution of the extremities. This can progress to proximal numbness, distal weakness, or muscle atrophy (Castelli et al., 2020). The clinical manifestations of diabetic peripheral neuropathy (DPN) range from asymptomatic to painful neuropathic symptoms (Abdissa et al., 2020). Common clinical features of DPN include bilateral limb pain, numbness, and paresthesia, which may lead to the development of foot ulcers (Zhu et al., 2024). The pain pattern in DPN is often described as “glove and stocking” with burning, electric, sharp, or dull aching sensations of varying intensities (Chang & Yang, 2023). In this case, we observed clinical signs of numbness in the hands and soles of the feet. The absence of pain in the neuropathic wounds is consistent with the characteristics of Leprosy-related neuropathic ulcers (Khadilkar et al., 2021). and the monofilament test was negative. Skin lesions tend to be hypoesthetic or anesthetic and are typically found on the back, buttocks, trunk, face, and earlobes (Khadilkar et al., 2021).

Monofilament TEST as key

In this case, our suspicion arose from the presence of neuropathic wounds without any history or status of DM. Inspecting the eyes, hands, and feet raised concerns about Leprosy. Our approach aligned with recommendations for assessing nerve function impairment in leprosy neuropathy, which typically focuses on the hands, feet, and eyes (Ebenezer & Scollard, 2021); we then confirmed these findings through a monofilament test. The monofilament test is recognized as a diagnostic tool for leprosy neuropathy (Frade et al., 2021), being straightforward, practical, cost-efficient, and demonstrating high accuracy in diagnosing clinical Leprosy (Frade et al., 2022); in Indonesia, the monofilament test is also used to diagnose leprosy-related neuropathy. 95.2% of patients reported experiencing neuropathy symptoms, with 52.4% having symptoms for one year or less and 52.4% exhibiting neuropathy primarily in the lower bilateral extremities (Dalimunthe et al., 2023). Unfortunately, monofilament tests are not yet widely available in Indonesia, which may contribute to delays in diagnosing leprosy-related neuropathy. Nevertheless, the IpTT examination can serve as an alternative for diagnosing neuropathy (Basir et al., 2020) when the monofilament test is unavailable.

Healing process

In this case, we performed sharp debridement to remove the callus surrounding the ulcer. For infection control, we applied Cadexomer Iodine. Cadexomer iodine, an advanced iodine formulation utilizing microbead technology, offers a unique approach to wound care by effectively managing biofilm and exudate while demonstrating superior desloughing capabilities (Ruke & Savai, 2019). At the end of the second week of treatment, we used a honey-based gel to promote granulation tissue formation. Based on our clinical experience, honey accelerates the growth of granulation tissue. A randomized controlled trial (RCT) is currently investigating the role of honey in ulcer healing in Leprosy (Udo et al., 2024). In this case, the wound healed within 62 days, similar to previous studies. The median healing time for wounds was 75 days for neuropathic ulcers, compared to 136 days for ischemic ulcers and 171 days for neuroischemic ulcers (Singh et al., 2023).

Lesson learning

An important learning point from this case is the failure to detect Leprosy. The patient had been experiencing neuropathic wounds for six months and had visited four healthcare facilities, yet none recognized the neuropathic wounds as a consequence of Leprosy. This aligns with classic reports that leprosy patients experience a diagnostic delay of approximately 1.8 years (ranging from 0.2 to 15.2 years) (Lockwood & Reid, 2001). Another noteworthy issue is that, according to the patient, none of the four healthcare facilities performed a physical examination, relying only on routine interviews. Several factors contributed to the delayed diagnosis, including a lack of awareness among healthcare workers regarding the symptoms of Leprosy, low clinical suspicion from physicians, and delayed referral to specialist facilities (Khadilkar et al., 2021). The diagnosis of Leprosy was eventually made after the patient was referred to a Private Wound Care Clinic, despite patient have to pay which her own budget, since it uncover by national insurance (Oe, 2024). Current case also highlights that health literacy not only important for patient with chronic disease, but also healthcare professional, to avoid delay in clinical decision (Kadar, 2024).