Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings

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Leprosy-related neuropathic ulcers are frequently misdiagnosed as DM-related, causing delays in appropriate care. This case report underscores the importance of timely recognition and a better understanding of Leprosy-related neuropathic ulcers to prevent misdiagnosis and improve patient outcomes. Methods The case report adopt the CARE Guidelines and was conducted at the Wound Care Specialist Clinic, Griya Afiat, Makassar, East Indonesia. Data were collected using a Minimum Data Sheet (MDS) to capture demographics, health history, and history of treatments. A head-to-toe assessment focused on the eyes, hands, and feet, with neuropathy, confirmed using the Semmes Weinstein Monofilament test, and angiopathy was assessed by palpating the dorsal pedis and posterior tibialis pulse. Wound care interventions consisted of cleansing, debridement, and dressing. Given the similarities between Leprosy-related neuropathic ulcers and DM-related neuropathic ulcers, the DMIST (depth, maceration, inflammation/infection, size, tissue type of the wound bed, type of wound edge, and tunnelling/undermining) tool was used to evaluate wound healing progress. Results Anamnesis indicated patient has no DM, with normal blood glucose; however, the patient had neuropathic wounds on her feet, asymmetrical eyebrow distribution, and rashes on her hands and calves, with neuropathy confirmed by a monofilament test—initial treatment involved Cadexomer Iodine powder to control bacterial growth and Honey-based gel to promote granulation. Over 62 days, 11 treatments were administered, with an average dressing change every 5.6 days, which improved the DMIST score from 12 to 4 by the end of observation day. Conclusions This case report highlights the significance of distinguishing leprosy-related neuropathic ulcers from those associated with DM to ensure accurate diagnosis and timely treatment. By employing comprehensive assessment tools and targeted wound care interventions, significant improvements in wound healing were achieved, emphasizing the need for greater awareness and clinical vigilance in managing Leprosy-related neuropathic ulcers. 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F1000Research 2024, 13 :1211 ( https://doi.org/10.12688/f1000research.157023.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings [version 1; peer review: 1 approved, 1 approved with reservations] Saldy Yusuf https://orcid.org/0000-0002-5993-9325 Saldy Yusuf https://orcid.org/0000-0002-5993-9325 PUBLISHED 11 Oct 2024 Author details Author details Faculty of Nursing, Hasanuddin University, Makassar, Indonesia, 90245, Indonesia Saldy Yusuf Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Neuropathy is common in both Diabetes Mellitus (DM) and Leprosy, often resulting in neuropathic ulcers. Leprosy-related neuropathic ulcers are frequently misdiagnosed as DM-related, causing delays in appropriate care. This case report underscores the importance of timely recognition and a better understanding of Leprosy-related neuropathic ulcers to prevent misdiagnosis and improve patient outcomes. Methods The case report adopt the CARE Guidelines and was conducted at the Wound Care Specialist Clinic, Griya Afiat, Makassar, East Indonesia. Data were collected using a Minimum Data Sheet (MDS) to capture demographics, health history, and history of treatments. A head-to-toe assessment focused on the eyes, hands, and feet, with neuropathy, confirmed using the Semmes Weinstein Monofilament test, and angiopathy was assessed by palpating the dorsal pedis and posterior tibialis pulse. Wound care interventions consisted of cleansing, debridement, and dressing. Given the similarities between Leprosy-related neuropathic ulcers and DM-related neuropathic ulcers, the DMIST (depth, maceration, inflammation/infection, size, tissue type of the wound bed, type of wound edge, and tunnelling/undermining) tool was used to evaluate wound healing progress. Results Anamnesis indicated patient has no DM, with normal blood glucose; however, the patient had neuropathic wounds on her feet, asymmetrical eyebrow distribution, and rashes on her hands and calves, with neuropathy confirmed by a monofilament test—initial treatment involved Cadexomer Iodine powder to control bacterial growth and Honey-based gel to promote granulation. Over 62 days, 11 treatments were administered, with an average dressing change every 5.6 days, which improved the DMIST score from 12 to 4 by the end of observation day. Conclusions This case report highlights the significance of distinguishing leprosy-related neuropathic ulcers from those associated with DM to ensure accurate diagnosis and timely treatment. By employing comprehensive assessment tools and targeted wound care interventions, significant improvements in wound healing were achieved, emphasizing the need for greater awareness and clinical vigilance in managing Leprosy-related neuropathic ulcers. READ ALL READ LESS Keywords Neuropathy, Leprosy, Diabetes mellitus, Neuropathic ulcers, Delayed diagnosis Wound care, DMIST tool, Semmes Weinstein Monofilament test. Corresponding Author(s) Saldy Yusuf ( [email protected] ) Close Corresponding author: Saldy Yusuf Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Yusuf S. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Yusuf S. Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 13 :1211 ( https://doi.org/10.12688/f1000research.157023.1 ) First published: 11 Oct 2024, 13 :1211 ( https://doi.org/10.12688/f1000research.157023.1 ) Latest published: 12 Sep 2025, 13 :1211 ( https://doi.org/10.12688/f1000research.157023.2 )  There is a newer version of this article available. Suppress this message for one day. Introduction Neuropathy is known as loss of sensation, commonly in both upper and lower extremities. Some term regarding neuropathy, including peripheral neuropathy or peripheral polyneuropathy, encompasses a wide array of disorders that result in damage and dysfunction of the peripheral nervous system’s nerves in various patterns ( Plaut & Weiss, 2021 ). Epidemiological studies report various ranges of prevalence neuropathy, from a lower rate of 1% to 7% ( Castelli et al., 2020 ), a moderate rate of 10-15% ( Zhu et al., 2024 ), and a high rate in Ethiopia 53.6% ( Abdissa et al., 2020 ) and China 67.6% ( Wang et al., 2023 ). Different types of diagnostic tests also determine the prevalence. Self-administered questionnaires confirmed 44.4% and 51.1% based on foot examinations ( Perveen et al., 2024 ). Various diagnostic tests result in clinical challenges in investigating neuropathy. Diagnosing neuropathy remains challenging. Currently, a triangulation approach that includes clinical evaluations, laboratory tests, and nerve conduction studies (electrodiagnostic test) is the primary method for diagnosing polyneuropathy ( Goedee et al., 2013 ). Other methods include Diabetic Peripheral Neuropathy, Diagnostic tests including stimulus tests, Screening Scores, Quantitative tests (monofilament, IpTT, Neruothesiometer, Vibratip), and nerve conduction studies ( Galiero et al., 2023 ). Meanwhile, the diagnostic test for neuropathic Leprosy is challenging. Routine examinations to assess nerve function impairment in Leprosy typically focus on the hands, feet, and eyes. Techniques for evaluating nerve function in leprosy neuropathy include nerve conduction studies (NCS), quantitative sensory tests (QST), assessment of tactile sensitivity in skin lesions using Semmes-Weinstein monofilament testing (MFT) or ballpoint tests, and motor function evaluation through voluntary muscle testing ( Ebenezer & Scollard, 2021 ). Neuropathy can be diagnosed with advanced tests using electromyography, high-resolution sonography serology, and PCR ( Marques, 2024 ). The problem in clinical settings is the relative unavailability of standard diagnostic tests, making diagnosing neuropathy challenging. Additionally, patients with neuropathy may not experience discomfort or pain, further complicating diagnosis. Meanwhile, healthcare professionals often seem unaware of neuropathic ulcers, particularly those related to Leprosy. Neuropathy is notably prevalent among patients with DM and Leprosy, frequently leading to the development of neuropathic ulcers. As a result, Leprosy-related neuropathic ulcers are sometimes misdiagnosed as DM-related or overlooked entirely as a leprosy complication. This lack of recognition among healthcare professionals leads to frequent misdiagnosis or delayed diagnosis of Leprosy-related neuropathic ulcers. This case report highlights the challenges in accurately diagnosing Leprosy-related neuropathic ulcers, emphasizing the need for timely recognition and a deeper understanding of Leprosy-related neuropathy’s conceptual, clinical, and therapeutic aspects. This is crucial to prevent delays in wound care and improve patient outcomes. Case report The study is a case report which reported based on the CARE Guidelines ( https://www.care-statement.org/checklist ). The case was conducted at the Wound Care Specialist Clinic, Griya Afiat, Makassar, East Indonesia. A wound care specialist administered wound care, while a wound care specialist with a doctoral qualification in wound care carried out the healing evaluation. Assessment Data collection was conducted using a Minimum Data Sheet (MDS) to gather demographic information, health history, and health status, including details of previous treatments. The assessment followed a head-to-toe approach, focusing on the eyes, hands, and feet ( Ebenezer & Scollard, 2021 ). We inspected the eyebrows for the eyes, comparing the symmetry between the right and left eyes. The inspection was then extended to the hands and feet, comparing the right and left sides. A foot assessment was performed to identify the status of neuropathy and angiopathy. Neuropathy was confirmed through the Semmes Weinstein Monofilament test (10g), applied to the plantar hallux, first metatarsal, third metatarsal, and fifth metatarsal. Angiopathy status was assessed by palpating the dorsal pedis and posterior tibialis pulses. Wound care The wound care interventions included cleansing, debridement, and dressing. We used mineral water and liquid soap for the peri-wound skin and the wound bed for wound cleansing. Sharp debridement and mechanical debridement were performed to remove the callus surrounding the wound. Dressing selection was based on the specific needs of the wound bed. It included three layers: a primary dressing (in direct contact with the wound bed), a secondary dressing (to absorb exudate), and a tertiary dressing (for fixation). Wound evaluation Photographs were taken using a mobile phone without photographic applications to avoid image manipulation. The photos were cropped using the cropping feature in MS Word to remove unnecessary elements while ensuring the observation area (the foot) remained intact. Since the Leprosy-related neuropathic ulcers’ characteristics are similar to those of DM related neuropathic ulcer, we use the DMIST tool for wound healing evaluation. DMIST is a valid healing score for diabetic foot ulcers ( Oe et al., 2020 ) and is useful for predicting healing ( Tsuchiya et al., 2023 ). Demographics, medical history, and wound history The patient is a 48-year-old woman, a high school graduate, and a housewife. She reported no history of Hypertension, Diabetes Mellitus, or Tuberculosis. The patient also stated that no family members have had similar wounds. The onset of the wound occurred in November 2023, beginning with the development of thick, numb calluses. The patient attempted to pinch and peel the calluses using her nails, which caused the wound to enlarge, become red (inflamed), and eventually exude fluid. Following advice from her family, the patient sought treatment at a general clinic in November 2023. Treatment history 1. Prior identification of Leprosy status a. November 2023, Visit to a General Clinic. The patient presented to the general clinic with a complaint of a wound on the sole of her foot. During the visit, she reported that she was only interviewed without undergoing any physical examination, including screening for Leprosy. The patient was referred to a hospital for further evaluation. b. November 2023, Visit to the Hospital. The patient underwent an examination at the hospital, but no diagnosis of Leprosy was made at that time. The doctor advised the patient not to peel the calluses and recommended using a moisturizer. Wound care included cleansing with NaCl 0.9%, soap, and povidone-iodine and covering the wound with gauze. The patient was instructed to attend three wound care sessions at the hospital before continuing wound care at home. c. February 2024, Visit to a General Practitioner’s Office. The patient visited a general practitioner’s office due to the persistence of the wound, along with the development of bruises on her hands and calves. The doctor advised her to avoid prolonged contact with water, detergents, and dishwashing soap. Unfortunately, the doctor suspected the condition was related to gout or rheumatism. The patient was prescribed three types of medications, although she could not recall their names, stating only that one was for muscle cramps. There was no noticeable improvement following this treatment. d. March 2024, Second Visit to the General Clinic. Due to the lack of improvement after the consultation at the general practitioner’s office, the patient returned to the same general clinic she visited in November 2023 for a second evaluation. The doctor observed the wound and measured her blood sugar, 85 mg/dL. The doctor explained that the wound required regular care and referred the patient to a specialized wound care clinic. The prescribed treatments included paracetamol, an analgesic, and gentamicin ointment. 2. After identification, Leprosy status a. March 2024, Visit to a Wound Care Specialist Clinic. The patient visited the Wound Care Specialist Clinic, where anamnesis, a physical examination, and a monofilament test were conducted. The patient’s weight was 43 kg, blood pressure 90 mmHg, blood glucose 71 mg/dL, cholesterol 196 mg/dL, and uric acid 5.1 mg/dL ( Table 1 ). Anamnesis confirmed that the patient had no history of diabetes mellitus, and her random blood glucose was within the normal range. However, she had neuropathic wounds on her feet. A head-to-toe examination revealed asymmetrical eyebrow distribution, rashes on the dorsal side of her hands, and rashes on both calves ( Figure 1 ). The monofilament test confirmed neuropathy in the right foot. Palpation of the dorsalis pedis and posterior tibialis pulses was positive in both the left and right feet ( Table 2 ). Based on these findings, the patient was referred to a health clinic for further referral to a specialized facility to diagnose Leprosy. b. March 2024, Third Visit to the General Clinic. The patient returned to the general clinic (third visit), bringing the monofilament test results from the Wound Care Specialist Clinic. The doctor confirmed the findings using a rolled tissue test on the rash-covered areas but obtained negative results. The patient was then referred to a dermatological center for further diagnostic evaluation. c. March 2024, Visit to the Dermatological Center. The attending physician conducted a series of tests at the dermatological center. The first test used tissue, followed by a skin smear from the area behind the patient’s ears and both calves. The patient did not receive medication or wound care and was referred to the health clinic for further evaluation. d. March 2024, Fourth Visit to the General Clinic. The patient returned to the health clinic (fourth visit) with results from the dermatological center, confirming Leprosy diagnosis. No medication or wound care was provided at the clinic. The patient was referred to a public health center for treatment. e. March 2024, Visit to the Public Health Center. The patient visited the public health center, where the doctor performed a ballpoint test and confirmed neuropathy. The doctor explained that the patient would undergo one year of treatment for Leprosy and was advised to continue wound care independently at home. f. March 2024, Return to the Wound Care Clinic. The patient returned to the wound care clinic to receive wound care until complete healing was achieved. Table 1. Demographic characteristics and health status. Demography characteristics Finding Age 48 years Sex Female Education background Literate Occupation Housewife Health history • No Diabetes Mellitus • No Hypertension • No Tuberculosis Laboratory finding • Blood sugar: 71 mg/dl • Cholesterol: 196 mg/dl • Uric Acid: 5.1 mg/dl Figure 1. Head to toe assessment. A: We observed an asymmetrical pattern in the patient's eyebrows. B: The inspection revealed a rash on the dorsal side of the left hand. C: Rashes were also found on the left and right tibial areas. Table 2. Foot assessment between right and left foot. Foot assessment Right foot Left foot Angiopathy test (Palpation) Dorsalis Pedis Present Present Posterior Tibilias Present Present Neuorpathy test (Monofilament) Plantar hallux Present Present 1 st metatarsal Absent Present 3 rd metatarsal Present Present 5 th metatarsal Absent Present Wound care process Wound care was administered by a wound care specialist and involved three modalities of intervention: cleansing, debridement, and dressing. Mineral water and liquid soap were used for wound cleansing. Sharp debridement was performed to remove necrotic tissue and calluses surrounding the wound, in combination with mechanical debridement. During the first week, Cadexomer Iodine powder was applied as the primary dressing to control bacterial growth at the wound bed, with foam as the tertiary dressing. From the second week onward, honey-based gel was applied to stimulate granulation tissue growth, low-adherent dressing was used as the secondary layer, and gauze was applied during the final phase of care. Adhesive tape was used for fixation ( Table 3 ). Table 3. Wound care process for each visitation day. Visitation Date Wound dressing Primary dressing Secondary dressing Tertiary dressing 1 March, 20 th 2024 Cadexomer Iodine Foam Adhesive tape 2 March, 22 nd 2024 Cadexomer Iodine Foam Adhesive tape 3 March, 26 th 2024 Cadexomer Iodine Foam Adhesive tape 4 March, 29 th 2024 Honey based gel Low Adherent Adhesive tape 5 April, 4 th 2024 Honey based gel Low Adherent Adhesive tape 6 April, 16 th 2024 Honey based gel Low Adherent Adhesive tape 7 April, 23 rd 2024 Honey based gel Low Adherent Adhesive tape 8 April, 30 th 2024 Honey based gel Low Adherent Adhesive tape 9 May, 7 th 2024 Honey based gel Low Adherent Adhesive tape 10 May, 14 th 2024 Honey based gel Low Adherent Adhesive tape 11 May, 21 st 2024 Honey based gel Gauze Adhesive tape Wound care began on March 20 and continued until May 21, 2024, spanning 62 days with a total of 11 treatments. The average dressing change interval was 5.6 days. The patient’s total DMIST score was 12 at the first treatment, decreased to 9 in the second month, and reached four at the end of the treatment period ( Figure 2 ). Figure 2. Documentation of wound healing process. A. March, 20 th 2024. B. March, 22 nd 2024. C. March, 26 th 2024. D. March, 29 th 2024. E. April, 4 th 2024. F. April, 16 th 2024. G. April, 23 rd 2024. H. April, 30 th 2024. I. May, 7 th 2024. J. May, 14 th 2024. K. May, 21 st 2024. Clinical challenges The patient works as a household assistant, remaining physically active, which often causes the wound dressing to be wet. As a result, the patient was educated on self-care for the wound, including how to replace the dressing when it became wet. The patient was instructed to clean the wound, apply ointment, and cover it with gauze independently when needed. Patient perspective The patient reported visiting three healthcare facilities, none establishing a diagnosis of Leprosy. The first facility considered it a regular wound, while the third suspected gout—none of the three healthcare facilities performed any tests on the rashes on her hands or feet. The patient stated that the diagnosis of Leprosy was confirmed only after visiting the wound care clinic, where a monofilament test was conducted, followed by a referral back to the healthcare clinic. Only after receiving the monofilament test results was a tissue test performed at the healthcare clinic, and the patient was subsequently referred to the dermatological center for further evaluation. The patient responded to the diagnostic test results with acceptance but mentioned that she would not disclose her leprosy diagnosis to her husband. New finding An exciting aspect of this case is that, despite having a neuropathic ulcer, the patient remained active, walking and working without developing edema or erythema in the affected foot during the two-month treatment period. This is in stark contrast to neuropathic ulcers in patients with DM, where the absence of offloading typically leads to edema, erythema, and local inflammation. Additionally, the healing rate was relatively rapid, with complete recovery achieved in just 62 days, which differs significantly from the prolonged healing process often observed in diabetic patients with similar wounds. Discussion Diagnostic challenge The interesting aspect of this case lies in the healthcare facility’s oversight in recognizing and diagnosing the existing neuropathic wounds as a sign of leprosy. Proper diagnosis of neuropathy requires a thorough assessment of patient history, physical examination, and laboratory test results. Early-stage neuropathy is characterized by progressive sensory changes, including the loss of sensation, numbness, pain, or burning sensations in a “stocking and glove” distribution of the extremities. This can progress to proximal numbness, distal weakness, or muscle atrophy ( Castelli et al., 2020 ). The clinical manifestations of diabetic peripheral neuropathy (DPN) range from asymptomatic to painful neuropathic symptoms ( Abdissa et al., 2020 ). Common clinical features of DPN include bilateral limb pain, numbness, and paresthesia, which may lead to the development of foot ulcers ( Zhu et al., 2024 ). The pain pattern in DPN is often described as “glove and stocking” with burning, electric, sharp, or dull aching sensations of varying intensities ( Chang & Yang, 2023 ). In this case, we observed clinical signs of numbness in the hands and soles of the feet. The absence of pain in the neuropathic wounds is consistent with the characteristics of Leprosy-related neuropathic ulcers ( Khadilkar et al., 2021 ). and the monofilament test was negative. Skin lesions tend to be hypoesthetic or anesthetic and are typically found on the back, buttocks, trunk, face, and earlobes ( Khadilkar et al., 2021 ). Monofilament TEST as key In this case, our suspicion arose from the presence of neuropathic wounds without any history or status of DM. Inspecting the eyes, hands, and feet raised concerns about Leprosy. Our approach aligned with recommendations for assessing nerve function impairment in leprosy neuropathy, which typically focuses on the hands, feet, and eyes ( Ebenezer & Scollard, 2021 ); we then confirmed these findings through a monofilament test. The monofilament test is recognized as a diagnostic tool for leprosy neuropathy ( Frade et al., 2021 ), being straightforward, practical, cost-efficient, and demonstrating high accuracy in diagnosing clinical Leprosy ( Frade et al., 2022 ); in Indonesia, the monofilament test is also used to diagnose leprosy-related neuropathy. 95.2% of patients reported experiencing neuropathy symptoms, with 52.4% having symptoms for one year or less and 52.4% exhibiting neuropathy primarily in the lower bilateral extremities ( Dalimunthe et al., 2023 ). Unfortunately, monofilament tests are not yet widely available in Indonesia, which may contribute to delays in diagnosing leprosy-related neuropathy. Nevertheless, the IpTT examination can serve as an alternative for diagnosing neuropathy ( Basir et al., 2020 ) when the monofilament test is unavailable. Healing process In this case, we performed sharp debridement to remove the callus surrounding the ulcer. For infection control, we applied Cadexomer Iodine. Cadexomer iodine, an advanced iodine formulation utilizing microbead technology, offers a unique approach to wound care by effectively managing biofilm and exudate while demonstrating superior desloughing capabilities ( Ruke & Savai, 2019 ). At the end of the second week of treatment, we used a honey-based gel to promote granulation tissue formation. Based on our clinical experience, honey accelerates the growth of granulation tissue. A randomized controlled trial (RCT) is currently investigating the role of honey in ulcer healing in Leprosy ( Udo et al., 2024 ). In this case, the wound healed within 62 days, similar to previous studies. The median healing time for wounds was 75 days for neuropathic ulcers, compared to 136 days for ischemic ulcers and 171 days for neuroischemic ulcers ( Singh et al., 2023 ). Lesson learning An important learning point from this case is the failure to detect Leprosy. The patient had been experiencing neuropathic wounds for six months and had visited four healthcare facilities, yet none recognized the neuropathic wounds as a consequence of Leprosy. This aligns with classic reports that leprosy patients experience a diagnostic delay of approximately 1.8 years (ranging from 0.2 to 15.2 years) ( Lockwood & Reid, 2001 ). Another noteworthy issue is that, according to the patient, none of the four healthcare facilities performed a physical examination, relying only on routine interviews. Several factors contributed to the delayed diagnosis, including a lack of awareness among healthcare workers regarding the symptoms of Leprosy, low clinical suspicion from physicians, and delayed referral to specialist facilities ( Khadilkar et al., 2021 ). The diagnosis of Leprosy was eventually made after the patient was referred to a Private Wound Care Clinic, despite patient have to pay which her own budget, since it uncover by national insurance ( Oe, 2024 ). Current case also highlights that health literacy not only important for patient with chronic disease, but also healthcare professional, to avoid delay in clinical decision ( Kadar, 2024 ). Conclusion This case report provides valuable insights into the delayed diagnosis of leprosy-related neuropathic ulcers across four healthcare settings. It highlights the critical need for heightened clinical awareness and timely diagnosis to prevent prolonged suffering and complications. Accurate diagnosis and appropriate wound management play a pivotal role in promoting the healing process of leprosy-related neuropathic ulcers. Addressing the factors contributing to diagnostic delays can improve patient outcomes and reduce the burden of undiagnosed Leprosy in clinical practice. Consent to publish A written informed consent was obtained from the patient for the publication of this case report. Patient also received a thorough explanation regarding the purpose of her data. Additionally, we adhered to the principles outlined in the Declaration of Helsinki ( https://shorturl.at/2KDfV ). Data availability No data associated with this article. Reporting guidelines Figshare: Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings: A Case Report DOI: https://doi.org/10.6084/m9.figshare.27123441.v1 ( Yusuf, 2024 ). The project contains the following reporting guidelines: • CARE Checklist Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgement We thank the patient for allowing us to publish her case. We also thank to wound care nurses; Sukmawati Kasim, Nuhridatul Aina, and Dian Nurkhalisa who perform wound care in Griya Afiat. 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Publisher Full Text Zhu J, Hu Z, Luo Y, et al. : Diabetic peripheral neuropathy: pathogenetic mechanisms and treatment. Front. Endocrinol. 2024; 14 . PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 11 Oct 2024 ADD YOUR COMMENT Comment Author details Author details Faculty of Nursing, Hasanuddin University, Makassar, Indonesia, 90245, Indonesia Saldy Yusuf Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 12 Sep 2025, 13:1211 https://doi.org/10.12688/f1000research.157023.2 version 1 Published: 11 Oct 2024, 13:1211 https://doi.org/10.12688/f1000research.157023.1 Copyright © 2024 Yusuf S. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Yusuf S. Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 13 :1211 ( https://doi.org/10.12688/f1000research.157023.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 11 Oct 2024 Views 0 Cite How to cite this report: Malik RA. Reviewer Report For: Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 13 :1211 ( https://doi.org/10.5256/f1000research.172417.r379894 ) The direct URL for this report is: https://f1000research.com/articles/13-1211/v1#referee-response-379894 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 03 May 2025 Rayaz Ahmed Malik , Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Qatar Approved VIEWS 0 https://doi.org/10.5256/f1000research.172417.r379894 This is an instructive case report with important learning outcomes on the missed diagnosis of leprosy related foot ulceration despite multiple visits to different health centres. Use of the monofilament for evaluating diabetic neuropathy was ... Continue reading READ ALL This is an instructive case report with important learning outcomes on the missed diagnosis of leprosy related foot ulceration despite multiple visits to different health centres. Use of the monofilament for evaluating diabetic neuropathy was in fact originally adopted from its use in evaluating sensory loss in patients with leprosy in India. It is insufficient to simply state the 'The patient returned to the health clinic (fourth visit) with results from the dermatological center, confirming Leprosy diagnosis'. What tests were undertake, what were the outcomes? In the discussion:The absence of pain in the neuropathic wounds is consistent with the characteristics of Leprosy-related neuropathic ulcers ( Khadilkar et al., 2021 ). and the monofilament test was negative. The sentence on monofilament is out of place. Did the patient have any neuropathic symptoms? Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Diagnosis of peripheral neuropathy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Malik RA. Reviewer Report For: Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 13 :1211 ( https://doi.org/10.5256/f1000research.172417.r379894 ) The direct URL for this report is: https://f1000research.com/articles/13-1211/v1#referee-response-379894 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Tsaku PA. Reviewer Report For: Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 13 :1211 ( https://doi.org/10.5256/f1000research.172417.r345552 ) The direct URL for this report is: https://f1000research.com/articles/13-1211/v1#referee-response-345552 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 26 Dec 2024 Paul Alumbugu Tsaku , The Leprosy Mission Nigeria, Abuja, Nigeria Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.172417.r345552 This is a well-written case study. However, I have some comments for the author to address: 1. The abstract should mention that the case was misdiagnosed at three previous centers before the current diagnosis and management. ... Continue reading READ ALL This is a well-written case study. However, I have some comments for the author to address: 1. The abstract should mention that the case was misdiagnosed at three previous centers before the current diagnosis and management. 2. The author places significant emphasis on differentiating between diabetic mellitus (DM) ulcers and leprosy-related ulcers. However, other previous misdiagnoses, such as gout, should also be discussed in the literature review. 3. It is more appropriate to refer to the Minimum Data Set (MDS) rather than the Minimum Data 'Sheet.' 4. In the wound evaluation section, please further describe how the DMIST tool was used for assessing the wound. 5. Although the author indicated that consent was obtained from the patient in accordance with the Helsinki Declaration, there is no mention of whether ethical clearance was obtained or a justification for why it was not needed. 6. In the acknowledgment section, the author uses the word "we" to acknowledge contributors, but since there is only one author, it would be more appropriate to use the singular form. Thank you for considering these suggestions. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Public Health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Tsaku PA. Reviewer Report For: Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 13 :1211 ( https://doi.org/10.5256/f1000research.172417.r345552 ) The direct URL for this report is: https://f1000research.com/articles/13-1211/v1#referee-response-345552 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 12 Sep 2025 Saldy Yusuf , Faculty of Nursing, Hasanuddin University, Makassar, 90245, Indonesia 12 Sep 2025 Author Response Thank you for the reviewers’ valuable feedback. We have addressed the comments as follows: Abstract: We have revised the abstract to emphasize that the uniqueness of this case lies ... Continue reading Thank you for the reviewers’ valuable feedback. We have addressed the comments as follows: Abstract: We have revised the abstract to emphasize that the uniqueness of this case lies in the fact that the wound status was misdiagnosed at three different healthcare facilities before the correct diagnosis and management were established. Background: We have added clarification that, in clinical practice, neuropathic ulcers caused by leprosy can be mistaken for other conditions, such as gout-related ulcers, thereby highlighting the importance of accurate diagnosis. Methods: We have included information regarding the ethical clearance obtained for this study and provided a detailed description of how the DMIST tool was applied by a certified wound care nurse to assess the wound. Terminology: We have revised the term Minimum Data Sheet to Minimum Data Set for accuracy. Acknowledgment: We have corrected the wording by replacing we with I to appropriately reflect the single authorship. Thank you for the reviewers’ valuable feedback. We have addressed the comments as follows: Abstract: We have revised the abstract to emphasize that the uniqueness of this case lies in the fact that the wound status was misdiagnosed at three different healthcare facilities before the correct diagnosis and management were established. Background: We have added clarification that, in clinical practice, neuropathic ulcers caused by leprosy can be mistaken for other conditions, such as gout-related ulcers, thereby highlighting the importance of accurate diagnosis. Methods: We have included information regarding the ethical clearance obtained for this study and provided a detailed description of how the DMIST tool was applied by a certified wound care nurse to assess the wound. Terminology: We have revised the term Minimum Data Sheet to Minimum Data Set for accuracy. Acknowledgment: We have corrected the wording by replacing we with I to appropriately reflect the single authorship. Competing Interests: nothing Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 12 Sep 2025 Saldy Yusuf , Faculty of Nursing, Hasanuddin University, Makassar, 90245, Indonesia 12 Sep 2025 Author Response Thank you for the reviewers’ valuable feedback. We have addressed the comments as follows: Abstract: We have revised the abstract to emphasize that the uniqueness of this case lies ... Continue reading Thank you for the reviewers’ valuable feedback. We have addressed the comments as follows: Abstract: We have revised the abstract to emphasize that the uniqueness of this case lies in the fact that the wound status was misdiagnosed at three different healthcare facilities before the correct diagnosis and management were established. Background: We have added clarification that, in clinical practice, neuropathic ulcers caused by leprosy can be mistaken for other conditions, such as gout-related ulcers, thereby highlighting the importance of accurate diagnosis. Methods: We have included information regarding the ethical clearance obtained for this study and provided a detailed description of how the DMIST tool was applied by a certified wound care nurse to assess the wound. Terminology: We have revised the term Minimum Data Sheet to Minimum Data Set for accuracy. Acknowledgment: We have corrected the wording by replacing we with I to appropriately reflect the single authorship. Thank you for the reviewers’ valuable feedback. We have addressed the comments as follows: Abstract: We have revised the abstract to emphasize that the uniqueness of this case lies in the fact that the wound status was misdiagnosed at three different healthcare facilities before the correct diagnosis and management were established. Background: We have added clarification that, in clinical practice, neuropathic ulcers caused by leprosy can be mistaken for other conditions, such as gout-related ulcers, thereby highlighting the importance of accurate diagnosis. Methods: We have included information regarding the ethical clearance obtained for this study and provided a detailed description of how the DMIST tool was applied by a certified wound care nurse to assess the wound. Terminology: We have revised the term Minimum Data Sheet to Minimum Data Set for accuracy. Acknowledgment: We have corrected the wording by replacing we with I to appropriately reflect the single authorship. Competing Interests: nothing Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 11 Oct 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 12 Sep 25 read Version 1 11 Oct 24 read read Paul Alumbugu Tsaku , The Leprosy Mission Nigeria, Abuja, Nigeria Rayaz Ahmed Malik , Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Qatar Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Tsaku P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 07 Oct 2025 | for Version 2 Paul Alumbugu Tsaku , The Leprosy Mission Nigeria, Abuja, Nigeria 0 Views copyright © 2025 Tsaku P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I have no further comments. Competing Interests No competing interests were disclosed. Reviewer Expertise Public Health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Tsaku PA. Peer Review Report For: Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 13 :1211 ( https://doi.org/10.5256/f1000research.187888.r413765) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1211/v2#referee-response-413765 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Malik R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 03 May 2025 | for Version 1 Rayaz Ahmed Malik , Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Qatar 0 Views copyright © 2025 Malik R. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is an instructive case report with important learning outcomes on the missed diagnosis of leprosy related foot ulceration despite multiple visits to different health centres. Use of the monofilament for evaluating diabetic neuropathy was in fact originally adopted from its use in evaluating sensory loss in patients with leprosy in India. It is insufficient to simply state the 'The patient returned to the health clinic (fourth visit) with results from the dermatological center, confirming Leprosy diagnosis'. What tests were undertake, what were the outcomes? In the discussion:The absence of pain in the neuropathic wounds is consistent with the characteristics of Leprosy-related neuropathic ulcers ( Khadilkar et al., 2021 ). and the monofilament test was negative. The sentence on monofilament is out of place. Did the patient have any neuropathic symptoms? Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Diagnosis of peripheral neuropathy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Malik RA. Peer Review Report For: Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 13 :1211 ( https://doi.org/10.5256/f1000research.172417.r379894) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1211/v1#referee-response-379894 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Tsaku P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 26 Dec 2024 | for Version 1 Paul Alumbugu Tsaku , The Leprosy Mission Nigeria, Abuja, Nigeria 0 Views copyright © 2024 Tsaku P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is a well-written case study. However, I have some comments for the author to address: 1. The abstract should mention that the case was misdiagnosed at three previous centers before the current diagnosis and management. 2. The author places significant emphasis on differentiating between diabetic mellitus (DM) ulcers and leprosy-related ulcers. However, other previous misdiagnoses, such as gout, should also be discussed in the literature review. 3. It is more appropriate to refer to the Minimum Data Set (MDS) rather than the Minimum Data 'Sheet.' 4. In the wound evaluation section, please further describe how the DMIST tool was used for assessing the wound. 5. Although the author indicated that consent was obtained from the patient in accordance with the Helsinki Declaration, there is no mention of whether ethical clearance was obtained or a justification for why it was not needed. 6. In the acknowledgment section, the author uses the word "we" to acknowledge contributors, but since there is only one author, it would be more appropriate to use the singular form. Thank you for considering these suggestions. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Public Health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 12 Sep 2025 Saldy Yusuf, Faculty of Nursing, Hasanuddin University, Makassar, 90245, Indonesia Thank you for the reviewers’ valuable feedback. We have addressed the comments as follows: Abstract: We have revised the abstract to emphasize that the uniqueness of this case lies in the fact that the wound status was misdiagnosed at three different healthcare facilities before the correct diagnosis and management were established. Background: We have added clarification that, in clinical practice, neuropathic ulcers caused by leprosy can be mistaken for other conditions, such as gout-related ulcers, thereby highlighting the importance of accurate diagnosis. Methods: We have included information regarding the ethical clearance obtained for this study and provided a detailed description of how the DMIST tool was applied by a certified wound care nurse to assess the wound. Terminology: We have revised the term Minimum Data Sheet to Minimum Data Set for accuracy. Acknowledgment: We have corrected the wording by replacing we with I to appropriately reflect the single authorship. View more View less Competing Interests nothing reply Respond Report a concern Tsaku PA. Peer Review Report For: Case Report: Delayed Diagnosis of Leprosy-Related Neuropathic Ulcer, Insights from a Case of Delay to Diagnose across Four Clinical Settings [version 1; peer review: 1 approved, 1 approved with reservations] . F1000Research 2024, 13 :1211 ( https://doi.org/10.5256/f1000research.172417.r345552) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-1211/v1#referee-response-345552 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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