443 Y MR, et al. Postgrad Med J 2020;96:443. doi:10.1136/postgradmedj-2020-137703 Images High-resolution ultrasound features of greater auricular nerve in leprosy Muralidhar Reddy Y , 1 Lalitha Pidaparthi, 1 Vijaya Tourani, 2 Anusha Penneru, 1 JMK Murthy 1 To cite: Y MR, Pidaparthi L, Tourani V, et al. Postgrad Med J 2020;96:443. 1 Neurology, Care Hospital Banjara Hills, Hyderabad, Telangana, India 2 Pathology, Care Hospital Banjara Hills, Hyderabad, Telangana, India Correspondence to Dr Muralidhar Reddy Y, Neurology, Care Hospital Banjara Hills, Hyderabad, Telangana 500034, India; muralidharnims@gmail.com Received 15 March 2020 Accepted 19 March 2020 Published Online First 30 March 2020 © Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ. Figure 1 (A–J) Clinical photograph of patient showing thickened GAN and hypoanesthetic patch over leg (A–B); transverse and longitudinal ultrasound views showing enlarged GAN bilaterally (C–F); skin biopsy showing dense dermal infltrate (G), periappendegeal infltrate of foamy histiocytes (H), grenz zone (I) and modifed acid- fast bacilli stain showing lepra bacilli (J). Figure 2 (A–C) Clinical photograph showing patient positioning and technique of scanning GAN(A-B); Normal appearance of GAN shown by arrow over sternocleidomastoid muscle (C). A 42-yr-male presented with left foot drop of 2 months duration. General examination showed enlarged greater auricular nerve (GAN) and hypoanesthetic patch over dorsum of left leg (figure 1A,B). Neuro- logical examination showed thickened left common peroneal nerve (CPN) at fibular neck and weak dorsi- flexors of left leg. Electrophysiological study showed left CPN involvement. High-resolution ultrasound (HRUS) of nerves was done with 15–7 MHz hockey- stick transducer on Philips HD15 machine. GAN was enlarged bilaterally with completely effaced fascicular architecture and thickened epineurium (figure 1C–F). HRUS also revealed enlarged left CPN and distorted fascicles. Biopsy of hypoanesthetic patch showed features of leprosy (figure 2G–J). HRUS is a novel imaging technique to assess morphology of peripheral nerves. 1 Leprosy is a chronic debilitating disease of skin and nerves. HRUS studies, largely done on diseased deep nerves in leprosy, showed features as nerve enlarge- ment, distorted fascicles, epineurial thickening and abnormal vascularity. 2 Though GAN is commonly involved superficial nerve in leprosy and reported to be involved in 19%, there is scant literature on HRUS features. 3 4 It can be easily visualised on HRUS, with patient lying in prone and head turned to side of examining nerve, as it courses superiorly over ster- nocleidomastoid (figure 2A–C). HRUS features of GAN described in our case were similar to more commonly involved deep nerves described in litera- ture. In addition, we detected subclinical disease on left side. HRUS of GAN is an easy technique which can identify nerve damage and subclinical disease. It should be included in sonographic evaluation of leprous neuropathy. Twitter Muralidhar Reddy Y @Murali_Doctor Acknowledgements Authors acknowledge Mr.Kiran for compiling the images. Contributors MRY has done clinical examination and HRUS, conceptualised the paper, written the manuscript and taken consent from patients. LP and JM have edited the manuscript. VT has reported the skin biopsy. AP has taken the clinical photographs and edited the scan images. Funding The authors have not declared a specifc grant for this research from any funding agency in the public, commercial or not-for-proft sectors. Competing interests None declared. Patient consent for publication Obtained. Provenance and peer review Not commissioned; internally peer reviewed. Author note Consent: Taken from patients in accordance with COPE guidelines. ORCID iD Muralidhar Reddy Y http://orcid.org/0000-0002-4805-6252 REFERENCES 1 Beekman R, Visser LH. High-Resolution sonography of the peripheral nervous system -- a review of the literature. Eur J Neurol 2004;11:305–14. 2 Jain S, Visser LH, Praveen TLN, et al. High-Resolution sonography: a new technique to detect nerve damage in leprosy. PLoS Negl Trop Dis 2009;3:e498. 3 Ramesh V, Jain RK, Avninder S. Great auricular nerve involvement in leprosy: scope for misdiagnosis. J Postgrad Med 2007;53:253–4. 4 Fonseca EKUN, Nogueira FM, Dos Santos SS, et al. Thickening of the greater auricular nerve in leprosy: clinical correlation by ultrasound. Radiol Bras 2018;51:339–40. Downloaded from https://academic.oup.com/pmj/article/96/1137/443/6958873 by guest on 10 January 2023