Borderline leprosy with unilateral blepharoptosis in reversal reaction

Case Report A 39-year-old man presented with multiple, raised lesions over his face for 1 year. He has experienced increasing redness and mild burning sensation for the past 2 months. On cutaneous examination, he had multiple, erythematous, edematous papules and plaques with mild sensory impairment over the forehead, upper lip, and ears. The largest plaque was well defined, measuring 9.75 cm × 8.75 cm and extending over the right forehead, temporal region, upper eyelid, and root of the nose Figure 1a. The patient also had 3-month history of gradual worsening of ptosis Figure 1b.Figure 1: (a) Multiple, erythematous, edematous papules and plaques over the forehead, upper lip, and ear. (b) Ptosis of right eyelidThe ophthalmic examination showed a palpebral aperture measuring 6mm on the left and 1 mm on the right side. The marginal reflex distance-1 (MRD-1) was 2 mm on the left and −1.5 mm on the right. The left eye showed an aponeurotic component of ptosis correlating with the reduced MRD-1. No other significant ophthalmic findings were observed. The cranial nerve examination was normal. A 3 mm punch biopsy taken from the lesion revealed epitheloid granulomas in the dermis with perivascular and periadnexal lymphocytes and neutrophils Figure 2. Fite-Faraco staining showed lepra bacilli with bacillary index of 3+ Figure 3. A diagnosis of borderline leprosy with unilateral blepharoptosis in reversal reaction was made. The patient was started on multibacillary multidrug therapy comprising capsule rifampicin 600 mg once a month, capsule Clofazimine 300 mg once a month, tablet dapsone 100 mg once a day, and capsule cofazimine 50 mg once a day. The patient is under follow-up.Figure 2: (a) Multiple well-defined epitheloid granulomas in the dermis. (b) Perivascular and periadnexal lymphocyte and neutrophil infiltrationFigure 3: Fite-Faraco stain showing lepra bacillus with a bacillary index of 3+. (×100)Discussion Among any human bacterial infection, Hansen's disease has the highest incidence of ocular involvement.1 Blepharoptosis can be defined as an abnormally low-lying upper eyelid margin in primary gaze, which results in the narrowing of the palpebral opening and fissure.2Mycobacterium leprae can directly infiltrate and cause thickening of the eyelid in 5% of patients.3 In Hansen's disease, ptosis can occur either as a result of direct infiltration of the eyelid by the bacillus or due to oculomotor nerve involvement.1 Our case is a form of extrinsic mechanical ptosis as the leprosy lesion has weighed down the upper eyelid. Other eyelid changes reported in leprosy are erythema, edema, diffuse or nodular infiltration, loss of eyelashes (madarosis), entropion, ectropion, trichiasis, and lagopthalmos.1,4 Untreated ptosis can cause eyelid fatigue, headaches secondary to frontalis recruitment, decreased peripheral vision, difficulty reading or driving, chin-up head tilt, neck pain, and cosmetic impairment.5 Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.