What is the diagnosis and treatment for a patient with a paralyzed hand, skin lesions, and coughing?

Diagnosis: Leprosy (Hansen's Disease)

The combination of a paralyzed hand, skin lesions, and cough strongly suggests leprosy (Hansen's disease), a chronic infectious disease caused by Mycobacterium leprae that affects the skin, peripheral nerves, and respiratory tract. This clinical triad is pathognomonic for leprosy, particularly when nerve involvement causes motor deficits like hand paralysis.

Clinical Reasoning

Why Leprosy Fits This Presentation

• Peripheral nerve involvement in leprosy commonly causes motor deficits, with hand paralysis (claw hand deformity) being a classic manifestation due to ulnar and median nerve damage 1
• Skin lesions are the hallmark dermatologic feature, presenting as hypopigmented or erythematous patches, plaques, or nodules with sensory loss 2
• Respiratory symptoms including cough occur because M. leprae colonizes the nasal mucosa and upper respiratory tract, making it a route of transmission and a source of symptoms 2

Differential Considerations Ruled Out

The evidence provided focuses heavily on cough management, but the combination of paralyzed hand plus skin lesions makes isolated respiratory pathology unlikely 3. The cough guidelines address post-infectious cough, upper airway cough syndrome, asthma, and GERD—none of which explain the neurologic and dermatologic findings 4.

• Coccidioidomycosis can present with skin lesions and cough but typically doesn't cause isolated peripheral nerve paralysis 2
• Tuberous sclerosis causes skin lesions and neurologic symptoms but presents with seizures and developmental delays, not isolated hand paralysis 5
• Neuropathic pain syndromes don't typically present with this specific triad 6

Diagnostic Approach

Essential Clinical Examination

• Neurologic assessment should identify the specific nerve distribution of paralysis, looking for ulnar nerve involvement (claw hand), median nerve involvement (ape hand), or radial nerve involvement (wrist drop) 1
• Skin examination must document the number, distribution, and characteristics of lesions, specifically assessing for sensory loss within the lesions—a pathognomonic feature of leprosy 2
• Respiratory evaluation should assess for nasal stuffiness, epistaxis, or nasal septal perforation, which are common in lepromatous leprosy 3

Confirmatory Testing

• Skin biopsy from the edge of an active lesion for histopathology and acid-fast bacilli staining is the gold standard for diagnosis 2
• Slit-skin smear from multiple sites (earlobes, lesions) to detect acid-fast bacilli and determine bacterial load 2
• Nerve biopsy may be considered if skin biopsy is non-diagnostic but clinical suspicion remains high 1

Treatment Protocol

Multidrug Therapy (MDT)

Treatment must be initiated immediately upon diagnosis to prevent further nerve damage and disability. The World Health Organization recommends multidrug therapy based on disease classification:

For Paucibacillary Leprosy (1-5 skin lesions)

• Rifampin 600 mg once monthly (supervised)
• Dapsone 100 mg daily (self-administered)
• Duration: 6 months

For Multibacillary Leprosy (>5 skin lesions or nerve involvement)

• Rifampin 600 mg once monthly (supervised)
• Dapsone 100 mg daily (self-administered)
• Clofazimine 300 mg once monthly (supervised) plus 50 mg daily (self-administered)
• Duration: 12 months

Given the presence of hand paralysis indicating nerve involvement, this patient likely requires multibacillary treatment for 12 months.

Management of Cough

• The cough in leprosy is typically due to nasal/respiratory colonization and should improve with antimycobacterial therapy 2
• Avoid empiric antibiotics for the cough, as guidelines explicitly state antibiotics have no role in non-bacterial respiratory symptoms 4, 7
• If cough persists beyond 3-8 weeks after starting leprosy treatment, consider post-infectious cough management with inhaled ipratropium bromide 2-3 puffs four times daily 4

Nerve Damage Management

• Corticosteroids (prednisone 40-60 mg daily) should be started immediately if there is acute neuritis or recent-onset paralysis to prevent permanent disability
• Physical therapy and occupational therapy are essential to prevent contractures and maintain hand function 1
• Surgical intervention (nerve decompression, tendon transfers) may be needed for established paralysis after completing MDT 1

Critical Pitfalls to Avoid

• Do not delay treatment while awaiting biopsy results if clinical suspicion is high—nerve damage is irreversible 1
• Do not treat the cough with antibiotics like azithromycin or amoxicillin, as this provides no benefit for leprosy-related respiratory symptoms 4, 7
• Do not miss leprosy reactions (Type 1 reversal reaction or Type 2 erythema nodosum leprosum), which require urgent corticosteroid therapy to prevent further nerve damage
• Do not assume post-infectious cough without ruling out systemic causes when neurologic and dermatologic findings are present 4

Monitoring and Follow-Up

• Monthly supervised medication administration to ensure adherence to MDT
• Regular neurologic examinations (monthly for first 6 months) to detect new nerve involvement or reactions
• Skin examination to monitor lesion resolution and detect reactions
• Respiratory symptom monitoring—if cough persists beyond 8 weeks, systematically evaluate for upper airway cough syndrome, asthma, or GERD 4

Public Health Considerations

• Contact tracing of household members and close contacts for screening
• Patient education about the non-contagious nature of leprosy after starting treatment
• Reporting to public health authorities as leprosy is a notifiable disease in most jurisdictions