A strange case of facial nerve palsy.

A 69 years gentleman, a non-diabetic with history of CAD, came to our OPD with complaints of altered sensation in the left supraorbital region, which he noticed while washing his face in the morning. Clinical examination revealed decreased sensations to fine touch, pain and temperature over left supraorbital region, improper eye closure on the left side, and strangely, absence of forehead wrinkling on the opposite side (Figs.1, 2 and 3). Detailed examination was normal except for a few erythematous hypoaesthetic patches over his back and thickened right greater auricular and left common peroneal nerves. Nerve conduction study was suggestive of left trigeminal and facial neuropathy. Nerve biopsy showed chronic granulomatous inflammation consistent with tuberculoid leprosy. His neurological status improved considerably (see Fig. 4; shows complete eye closure) after a course of dapsone and rifampicin. Hansen’s disease can have varying atypical presentations of nerve involvement and can be easily overlooked if a thorough clinical examination is not done. It is very likely that in addition to the left trigeminal nerve, both facial nerves were affected partially, giving the appearance of absent forehead wrinkling on one side and eye closure weakness on the other side. this case illustrates that partial nerve involvement could be the only pointer to the diagnosis of Hansen's disease.