Multibacillary Leprosy With Type 2 Reaction, Sweet-Like Lesions, and Acalculous Cholecystitis as the Initial Presentation

Type 2 leprosy reactions (erythema nodosum leprosum, ENL) can involve severe systemic inflammation and, although uncommon, visceral involvement. We describe a case in which multibacillary leprosy initially manifested as a type 2 reaction with Sweet-like lesions and acalculous cholecystitis, presumably secondary to systemic inflammation. A previously healthy 38-year-old man presented with recurrent fever for 4 weeks, arthralgias, and multiple infiltrated, erythematous, painful nodules and papules, some ulcerated, on trunk and limbs, along with right upper quadrant pain and a positive Murphy sign. Intradermal scraping smear from a lesion on the right elbow revealed abundant acid-fast bacilli. CBC showed hemoglobin 10.5 g/dL, leukocytosis (18,200 cells/mm³), and CRP 470 mg/L. Abdominal CT showed a distended gallbladder with wall thickening and delamination, without stones, confirmed by ultrasound, consistent with acute acalculous cholecystitis. Treatment was initiated with prednisone at 1 mg/kg/day and thalidomide 300 mg at night for ENL. The initiation of multidrug therapy was postponed due to elevated transaminases (AST 193 U/L, ALT 154 U/L), in addition to increased gamma-glutamyl transferase (GGT 187 U/L) and alkaline phosphatase (ALP 184.3 U/L). As abdominal pain persisted, the patient underwent laparoscopic cholecystectomy. He evolved with a reduction in C-reactive protein from 470 mg/L to 43 mg/L and in transaminase levels (AST from 193 to 59 U/L) within seven days, with marked remission of cutaneous lesions and clinical improvement. He was discharged afebrile, without antibiotics, with a plan for gradual tapering of corticosteroids, progressive reduction of thalidomide, and initiation of outpatient multidrug therapy. This report highlights a rare initial presentation of multibacillary leprosy in a Sweet-like form associated with acalculous cholecystitis, a likely visceral repercussion of type 2 leprosy reaction, underscoring the need to recognize atypical visceral manifestations and to promptly initiate appropriate immunomodulation in endemic areas.