Delayed diagnosis and poor treatment compliance remain key challenges in leprosy control: a case of lepromatous leprosy with type 2 reaction

Leprosy (Hansen’s disease) is a chronic granulomatous infection primarily caused by Mycobacterium leprae. Since 2008, Mycobacterium lepromatosis has also been identified as an additional causative pathogen. Without timely treatment, the disease can progress to serious neuropathy and permanent disability. Lepromatous leprosy, the most infectious form, is associated with high bacillary load, systemic involvement, and immune-mediated complications such as type 2 reaction. Treatment with multidrug therapy is effective, but patient non-adherence remains a major challenge to disease control. This case report details a 39-year-old unmarried male mechanic from Colombo, Sri Lanka, diagnosed with lepromatous leprosy, characterized by facial skin and earlobe infiltration, madarosis, ichthyosis, saddle nose deformity, symmetrical skin lesions, and peripheral neuropathy. Initially diagnosed in December 2023, the patient defaulted on treatment and returned in June 2025 with worsened symptoms, including grade 2 disability and type 2 reaction. Slit skin smears revealed a persistent bacterial index of + 6, while the morphological index declined from 15% to 2%, suggesting chronic progression. Multidrug therapy was re-initiated, and type 2 reaction was managed with systemic corticosteroids and supportive physiotherapy. This case highlights the severe consequences of multidrug therapy non-adherence in lepromatous leprosy, including progression to type 2 reaction and disability. It reinforces the importance of prompt diagnosis, treatment persistence, patient education, and consistent follow-up to prevent complications, reduce type 2 reaction associated morbidity, and interrupt transmission. Regular follow-up is essential to ensure timely intervention and improved outcomes.