Leprosy, a neglected tropical disease, remains a global health challenge despite effective treatments. Delayed diagnosis causes complications, often disabilities, with India among the highest-burden countries [1]. Kashmir’s low prevalence creates social and clinical challenges [2]. No leprosy studies exist for Anantnag due to limited infrastructure and stigma, despite IDSP monitoring [3]. This first Anantnag case series addresses diagnostic challenges in a low-prevalence, high-stigma region. It supports WHO’s 2021–2030 strategy for early detection and stigma reduction [4].

This retrospective chart review studied suspected leprosy cases at Government Medical College, Anantnag, India (July 2024–June 2025), with ethics approval. Patients with suspected leprosy (e.g., nerve thickening, sensory loss) were included, excluding incomplete records or non-leprosy diagnoses. Two investigators collected demographics, clinical signs, and slit-skin smear data. Smears came from multiple sites (e.g., earlobes) per patient and were Wade-Fite stained [5]. A pathologist analyzed smears for AFB, calculating BI and MI per WHO guidelines, with only AFB-positive MB cases analyzed [6]. Descriptive statistics (means, percentages) and age differences (t-test, p<0.05) were calculated for AFB-positive vs. negative cases. Case Series Case 1: A 35-year-old male from Anantnag had hypopigmented macules (4 months). Smears from lesion and earlobe were AFB-positive (BI 4+, MI 42.6%). Right ulnar nerve thickened; MB-MDT began. At 6 months, lesions regressed, sensation improved. Case 2: A 40-year-old female migrant had an anesthetic thigh plaque (3 months). Smears from lesion and earlobe were AFB-positive (BI 2, MI 15%). Peroneal nerve thickened; MB-MDT began. At 3 months, plaque faded, sensation partially recovered. Case 3: A 40-year-old male from Anantnag had papulo-nodules (>10). Smears from earlobe and lesion were AFB-positive (BI 4, MI 55%). Ulnar/peroneal nerves thickened; MB-MDT began. At 4 months, lesions resolved, AFB load reduced. Case 4: An 18-year-old male from Anantnag had five anesthetic plaques (2 months). Smears from leg and earlobes were AFB-positive (BI 5, MI 60%). Bilateral ulnar nerves thickened; MB-MDT began. At 3 months, plaques regressed. Case 5: A 30-year-old female from Anantnag had an anesthetic forearm patch (5 months). Smears from lesion and earlobe were AFB-positive (3+). Right ulnar nerve thickened; MB-MDT began. At 3 months, lesions improved. No cases had contact exposure, leprosy reactions, grade-2 disabilities, or comorbidities; all were HIV-negative.

Of 19 suspected cases, 5 (26.3%) were AFB-positive, confirming multibacillary leprosy (MB), lower than mainland India’s 55–63% [7]. Positive cases were aged 18–50 years (mean 32.6 ± 9.4 years, median 40 years), mostly younger adults (18–40 years). They were younger than negatives (mean 32.6 vs. 45.2 years, t-test, p=0.034; Figure 1), suggesting active transmission despite Kashmir’s low-endemic status [7]. Figure 1: Age comparison of AFB-positive vs. negative cases (mean 32.6 vs. 45.2 years, p=0.034), indicating younger age in positives. Bacteriological Index (BI) ranged from 2+ to 5+ (mean 3.6 ± 1.1; Figure 2), with Case 4 highest (BI 5+, MI 60%). Figure 2: Bacteriological Index distribution for five MB cases (mean 3.6 ± 1.1), showing varied bacillary loads. All cases had peripheral nerve involvement, primarily ulnar (4/5 cases). Table 1 summarizes demographics, lesions, nerve involvement, BI, MI, and outcomes. No grade-2 disabilities were noted, consistent with early detection. All showed sensory improvement and lesion regression within 2–6 months of MB-MDT, with no leprosy reactions or complications. Figure 3 shows characteristic globi in a smear, confirming high bacterial load. Figure 3: Wade-Fite-stained slit-skin smear (1000×) from Case 1 showing intracellular globi, confirming multibacillary leprosy with high bacterial load. Table 1: Clinical and Demographic Profile of MB Leprosy Cases Case Age Sex Lesions (n, size) Nerve Involvement BI MI (%) Follow-Up Outcome (Months) 1 35 M 6 (2–5 cm) Ulnar 4+ 42.6 Lesion regression, sensory gain (6) 2 40 F 1 (10×8 cm) Peroneal 2+ 15 Plaque fading, partial sensory gain (3) 3 40 M >10 (5–10 mm) Ulnar, Peroneal 4+ 55 Lesion resolution, reduced AFB (4) 4 18 M 5 (not stated) Bilateral Ulnar 5+ 60 Plaque regression (3) 5 30 F 1 (8×6 cm) Ulnar 3+ 45 Lesion improvement (3)

The present case series highlights the occurrence of multibacillary (MB) leprosy in South Kashmir, a region traditionally regarded as epidemiologically silent for Hansen’s disease. Among 19 clinically suspected cases, only 26.3% were confirmed as AFB-positive MB leprosy, a proportion considerably lower than the 55–63% MB prevalence reported from mainland India [7]. This difference likely reflects sustained low endemicity, reduced background transmission, and possibly earlier clinical suspicion and referral in this setting. However, the detection of confirmed MB cases itself underscores that leprosy transmission persists, albeit at a low level, even in regions considered near elimination. A notable finding in this series is the significantly younger age of AFB-positive patients compared with smear-negative cases. The mean age of MB cases was 32.6 years, with most patients clustered between 18 and 40 years, and significantly younger than smear-negative individuals (p = 0.034). This age distribution is epidemiologically important, as MB leprosy in younger adults suggests ongoing or relatively recent transmission rather than residual disease in older populations. Similar observations have been interpreted as markers of active transmission in low-endemic or post-elimination settings, where new cases tend to cluster in younger age groups despite an overall decline in prevalence [7]. The bacteriological profile further supports true multibacillary disease rather than borderline or early presentations. The bacteriological index ranged from 2+ to 5+, with a mean BI of 3.6, indicating moderate to high bacillary loads [6]. One patient demonstrated a BI of 5+ with a high morphological index (60%), reflecting a substantial proportion of viable bacilli and reinforcing the potential of such cases to sustain transmission if undetected. The presence of characteristic intracellular globi on Wade–Fite staining provides unequivocal microbiological confirmation and highlights the continued relevance of slit-skin smear examination in endemic surveillance, particularly in atypical or low-prevalence regions [7]. Peripheral nerve involvement was universal in this series, with the ulnar nerve being the most frequently affected. This pattern is consistent with classical descriptions of MB leprosy, where symmetrical or multiple nerve involvement is common. Importantly, none of the patients had grade 2 disability at diagnosis. This finding suggests relatively early clinical detection, despite the presence of significant bacillary loads. Early diagnosis in MB leprosy is crucial, as nerve damage can progress silently and result in irreversible disability if treatment is delayed [3,7]. All patients responded favorably to standard multibacillary multidrug therapy (MB-MDT), with improvement in sensory function and regression of skin lesions within 2–6 months of follow-up. The absence of lepra reactions or treatment-related complications in this small cohort may reflect early disease stage, prompt initiation of therapy, and close clinical monitoring. These outcomes reinforce the effectiveness of MDT even in patients with high bacterial indices when diagnosed before advanced nerve damage occurs. From a public health perspective, the identification of MB leprosy cases in an epidemiologically silent region has important implications. MB cases are the principal reservoir for Mycobacterium leprae transmission. Even a small number of such cases can maintain low-level transmission within communities, particularly when awareness among healthcare providers and the public is limited due to the perceived rarity of the disease. The younger age of affected individuals in this series further emphasizes the need for sustained surveillance, continued training of clinicians, and a low threshold for considering leprosy in patients presenting with compatible dermatological and neurological features, even in low-endemic areas.

This first Anantnag study reveals leprosy patterns in low-endemic regions. High BI (mean 3.6) and young age (mean 32.6 years) suggest active transmission . Smears confirmed MB cases; nerve exam and BI aided diagnosis. A migrant case from high-endemic India suggests imported transmission, needing surveillance. Stigma delays diagnosis, requiring community engagement and better clinical training. MB-MDT improved all cases, with lesions regressing (mean 3.6 months) and no reactions or disabilities. This supports WHO’s 2021–2030 early detection and stigma reduction goals. Future work should explore molecular diagnostics to aid India’s 2027 zero-leprosy goal.

1. World Health Organization. Weekly epidemiological record. 2024;99(37):497-522. Available from:https://iris.who.int/handle/10665/378893 2. Jammu and Kashmir Health Department. Annual leprosy report 2023-24. Jammu and Kashmir: Jammu and Kashmir Health Department; 2024. 3. Kadri SM, Rehman SU, Rehana K, Benetou DR, Ahmad DF, Abdullah A. Ten years of disease surveillance in Kashmir, India under integrated disease surveillance programme (IDSP) during 2006-2016. Ann Med Health Sci Res. 2018;8:19-23. 4. World Health Organization. Ending the neglect to attain the sustainable development goals: a road map for neglected tropical diseases 2021-2030. Geneva: World Health Organization; 2021. Available from:https://www.who.int/publications/i/item/9789240010352. 5. Fite GL. The staining of acid-fast bacilli in paraffin sections. Am J Pathol. 1938;14(4):491-507. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1964977/ 6. World Health Organization. Guidelines for the diagnosis, treatment and prevention of leprosy. New Delhi: WHO Regional Office for South-East Asia; 2017. Available from: https://apps.who.int/iris/handle/10665/274127 7. World Health Organization. Weekly epidemiological record. 2024;99(37):497-522. Available from: https://iris.who.int/handle/10665/378893