High resolution ultrasound in evaluation of peripheral nerves in leprosy

Fifty-year-old man presented with two, tender, cord like, and non-pulsatile swellings on the right side of neck of 1 month duration and right-sided facial palsy affecting the lower half of face of 2 weeks duration [Figure 1]. We noted a hypoesthetic, erythematous patch (7 × 6 cm) on the right side of the lower half of cheek extending to the neck [Figure 1]. Histopathology confirmed borderline tuberculoid leprosy with Type 1 lepra reaction [Figure 2]. Considering the possibility of grossly enlarged great auricular and transverse cervical nerves appearing as cord like swellings, we did a high resolution ultrasound (HRUS) imaging, which revealed [Figure 3] two grossly enlarged fascicles of great auricular nerve (cross-sectional area 55mm²), underscoring the importance of HRUS in evaluation of peripheral nerves in leprosy.

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Figure 1:: Cord like, swellings on the right side of neck (white arrow), and hypoesthetic, erythematous patch on the right side of the lower cheek extending to the neck (borders marked by black arrows) in a patient with borderline tuberculoid leprosy.

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Figure 2:: Skin biopsy from the hypoesthetic, erythematous patch on the lower half of cheek showing epithelioid granuloma impinging on the epidermis, Langhan’s giant cells, and intra-granuloma and dermal edema suggestive of borderline tuberculoid leprosy with type 1 lepra reaction (H and E, ×200).

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Figure 3:: High resolution ultrasound imaging done using 8–18 MHZ linear transducer of Esaote ultrasound machine in a patient with borderline tuberculoid leprosy with type 1 lepra reaction: Longitudinal sonogram showing linear hypoechoic structure suggestive of enlarged great auricular nerve (area between the white arrows); inset: Transverse sonogram showing two well defined, oval, hypoechoic structures suggestive of enlarged fascicles (encircled area) of great auricular nerve (cross-sectional area 55 mm2).

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