Thursday, August 16, 2018

(LML) Single-dose rifampicin chemoprophylaxis

Leprosy Mailing List – August 16,  2018

Ref.:  (LML) Single-dose rifampicin chemoprophylaxis 

From:  Michael Waters, Radlett, UK


Dear Pieter,

 

Referring to the discussion between Anuj Tiwari, Wim van Brakel and Joel Almeida (LML, July 2018) regarding the article by Anuj Tiwari, Steaven Dandel, Rita Djupuri, Liesbeth Mieras and Jan Hendrik Richardus. Population-wide administration of single dose rifampicin for leprosy prevention in isolated communities: a three-year follow-up feasibility study in Indonesia. BMC Infectious Diseases 2018.18:324

https://doi.org/10.1186/s12879-018-3233-3

 

It should surely not be surprising that, in the first two years of follow-up in this trial, more new cases of leprosy were detected in the SDR group than in the non-SDR group.

 

Around 1960, in the days of dapsone monotherapy, when all newly-diagnosed cases of leprosy in Malaya were automatically admitted to a leprosarium, and when as a newcomer, I was being taught clinical classification by Dr D S Ridley's superb reports on the skin biopsies that I had been invited to send him, I well remember examining a new female patient. This lady gave the history that, around six weeks after a straight-forward delivery, and when she was feeling fully recovered from her pregnancy and delivery, she had developed a small number of skin lesions. Clinically and histolo-gically these were tuberculoid leprosy.  We assumed, in our old-fashioned way, that during her pregnancy, due to the associated mild depression in immunological function, there had been a slight spread of  leprosy bacilli which hitherto had not caused any clinical signs or symptoms. Around six weeks after giving birth, when her immunological function had returned to normal, these new bacilli or their products were 'recognised', with the result that tuberculoid lesions appeared.

 

Might not a single dose of rifampicin, given to someone incubating or suppressing a limited subclinical infection with M.leprae, have a similar effect?     Were all the new patients, who developed clinical lesions in the first year after receiving the single dose of chemoprophylaxis, accurately classified, and are their data available?  

 

Kind regards,

 

Michael Waters


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 

 

 

Wednesday, August 15, 2018

(LML) Manifest Against the Implementation of U-MDT

 

Leprosy Mailing List – August 15,  2018

Ref.:    (LML) Manifest Against the Implementation of U-MDT

From:  Lisa Venida, Manila, Philippines


 

Dear all,

 

 

Thanks to Dr. Francesca Gajete for sending me the message of Dr. Robert Gelber, LML July 26, 2018.

 

I would encourage use of U-MDT for PB patients. In my clinical experience, we rarely use PB MDT, at JRRMMC Dermatology (Manila, Philippines), because only few of our patients falls under PB category. In the Philippines, PB cases are < 10% of all new patients and our PB MDT supplies are oftentimes not used up. 

 

The beauty of MDT MB given to clinically PB Leprosy patients shows in one or two months the extent of clinical infection / affliction of our patients because of the darkened spots of the lesions on the skin area.

 

If SSS is done on clinically apparent lesions and turns out +, there is no more need to reclassify, just continue treatment for 12 months. If SSS is (-) on subsequent checking, then you just need to give treatment for 6 months and this brings comfort and alleviate patient fears of inappropriate treatment.

 

Lisa Venida
JRRMMC Dermatology


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

Tuesday, August 14, 2018

(LML) Manifest against the implementation of U-MDT

 

Leprosy Mailing List – August 14,  2018

Ref.:    (LML) Manifest against the implementation of U-MDT

From: David Scollard, Baton Rouge, USA


 

Dear Pieter,

 

Dr. Shetty's comments (LML Aug 7,2018) have raised the question of the relative merits of elliptical vs punch biopsies for the diagnosis of HD.  The elliptical biopsy will often be larger and thus provide more material for histopathological review.  This would be preferable if all other factors were equal. 

 

However, in our experience, physicians and surgeons taking an elliptical skin biopsy often angle the blade from the margin of the biopsy at the surface toward the center at the deepest point, so that the specimen is a 'wedge'.  The result is that the extent of the specimen in the deep dermis is small, and this is where cutaneous nerves are most easily found and evaluated. 

 

A punch biopsy, on the other hand, is as wide at full depth as it is at the surface, and gives a proportionally better sample of the deep dermis.  As long as emphasis is maintained on obtaining a full-thickness specimen from an active margin of a lesion, a punch biopsy usually provides a very good sample regardless of the skill and experience of the person who performs it. 

 

In my 25 years of experience at the National Hansen's Disease Programs (USA), we found that 4 mm or 6 mm punch biopsies provided excellent material for histopathological diagnosis. In recent years we also found that these specimens provided sufficient additional material for PCR amplification of M. leprae DNA for genotyping. 

 

Best regards,

 

David Scollard

NHDP (Retired)

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

Sunday, August 12, 2018

(LML) Manifest against the implementation of U-MDT

Leprosy Mailing List – August 12,  2018

Ref.:    (LML) Manifest against the implementation of U-MDT

From: VP Shetty, Mumbai, India


 Dear Pieter,

This is in response to Jose Kawuma's request (LML, August 9, 2018) for further justification on my passing comment that 'punch biopsy is a waste of time and effort in cases with doubtful skin lesions'.

 

Pathological Diagnosis of leprosy is based on three major characteristics features:

1) Granulomatous infiltration;

2) presence of acid fast bacilli and

3) involvement of dermal nerve i.e. infiltration with in and around dermal nerves. 

The last one is most important in case of doubtful lesions.

 

Presence of any two of the above confirms the diagnosis of leprosy.

 

Technically punch biopsy may be an easy option but when it comes to pathological diagnosis particularly in case of doubtful lesions it is important to obtain a deep incision biopsy from the centre of the lesion for 2 reasons:

1) it ensures inclusion of dermal nerves that will help in clinching the diagnosis and

2) to avoid crush artefacts which are fairly common in punch biopsy and which makes it difficult for identification of cell types.

 

In my opinion if done correctly this is an important tool in the diagnosis of leprosy, differential diagnosis and relapse.

 

Best regards,

 

VP Shetty   

 

Note editor: Over the past year we have been blocked by gmail several times. For this reason, we are working on a Google Group formation. The advantage of Google Groups is that there are no limitations to the total number of subscribers and to the numbers of messages sent out daily. Anybody could opt out if they do not agree by leaving the Google Group.

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 

Friday, August 10, 2018

(LML) CEDAW Ethiopia

Leprosy Mailing List – August 10,  2018

Ref.:   (LML) CEDAW Ethiopia

From:  Alice Cruz, Quito, Equator


Dear Pieter,

 

It is my great pleasure to share that CEDAW - Committee on the Elimination of Discrimination against Women - has included, for the first time, a question on persons affected by leprosy and their family members in their review of Ethiopia.

This is one more important landmark in the work with Treaty Bodies and other human rights mechanisms. This good result was made possible by an excellent collaboration between ENAPAL and the UN mandate for the elimination of leprosy related discrimination. Tesfaye Tadesse and ENAPAL worked for sharing relevant information that enabled me to persuade CEDAW to address leprosy in their review of Ethiopia. I wish to personally thank Tesfaye and renew my appeal to all organizations to use my mandate as a bridge for accessing the international human rights system.

Please find below the reference to leprosy and attached all the questions CEDAW asked Ethiopia.

 

With warm regards,

Alice Cruz

 

Attached file: Health

17. In view of the State party's efforts to trial a Community Based Health Insurance (CBHI) and the Social Health Insurance (SHI), please indicate measures taken to ensure the accessibility of health care and family planning services for all women and girls in all regions, including for unemployed women, as well as for women working in the informal and in the private sectors. In the light of the Committee's previous recommendation (CEDAW/C/ETH/CO/6-7, para. 35 (e)), please inform on the outcomes of the National Adolescent and Youth Reproductive Health Strategy (2007-2015), including with regards to the provision of age-appropriate and gender-sensitive sexual and reproductive health care services and the promotion of teenage girls' access to contraception. Please also inform on measures taken to strengthen the allocation of financial resources to the Health Extension Programme, which is the primary health care service delivery mechanism at community, and to eliminate discrimination against persons affected by leprosy and their family members.


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

Thursday, August 9, 2018

(LML) Manifest against the implementation of U-MDT

Leprosy Mailing List – August 9,  2018

Ref.:    (LML) Manifest against the implementation of U-MDT

From: Joseph Kawuma, Kampala, Uganda


 

Dear Pieter,

 

In response to the submission by Dr. Ajit P (LML July 26, 2018), Dr. Shetty V P (LML Aug 7,2018) has mentioned (in passing), that a punch biopsy is a " waste of time and effort in cases with doubtful skin lesions...".

 

I suspect that world-wide some people must be still using this "tool" to obtain biopsy material for the diagnosis of leprosy (new or relapse). Some further justification of this statement would be appreciated as indeed reliability of diagnoses of leprosy and leprosy-relapses is core element of the on-going discussion on U-MDT.

 

 

H Joseph Kawuma

Clara Skin Clinic, Kampala, Uganda 

 


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 

 

Tuesday, August 7, 2018

(LML) Manifest against the implementation of U-MDT

Leprosy Mailing List – August 7,  2018

Ref.:    (LML) Manifest against the implementation of U-MDT

From:  VP Shetty, Mumbai, India


Dear Pieter,

 

Dr Ajit  P (LML, July 26, 2018)  has put some hypothetical questions to LML readers  -  if you or your family member gets leprosy then???  I would like to respond to some of the questions.

 

The questions raised by him are important regardless of who the effected person is.

First and foremost, leprosy is not a simple disease of the skin and our treatment approach cannot be casual and over simplistic. If I were a doctor treating leprosy patient I would like to equip my self fully before I take on the responsibility.

 

My responsibilities as a doctor include

1) having a confirmed diagnosis; I must do whatever I need to do (Slit skin smear, Biopsy if situation demands and Nerve function assessments);  

2) talk and listen to the patient carefully. Council the patient and keep the patient fully informed and not to take them for granted;

3) examine and carefully record all the clinical presentations;

4) look for and be warned of all risk factors for Lepra reaction, drug reaction, nerve function impairments and co-morbidity if any; 

5)  choose a drug regime which is time tested;

6) closely monitor the treatment response as well as signs of reaction if any. Timely action in managing the reaction or any other problems go a long way;

7) I would do slit skin smear test on all the patients at baseline and mark the smear positive cases as a high-risk group;

8) Only in smear positive cases I would repeat it at 3 or 6 monthly intervals. This will help monitor the treatment response;

9) I would go for a good deep incision skin biopsy (not a punch biopsy it is a waste of  time and effort) in cases with doubtful skin lesions and in Pure Neural cases biopsy of an involved sensory nerve and do a Fite faraco stain  to ascertain diagnosis before initiating treatment;     

10) As I have said before I would use a time tested regime for treatment.  Half hazard use of antibiotic can do more harm than any good;

11) We have seen relapses in cases who were smear negative at baseline who had received three drug combination. WHO-MDT regimen is not free of relapse but it is the best available.

 

Lastly, we need to make a positive move towards identifying a better treatment regime that would take care of persisters (dormant) bacilli in leprosy.

 

Dr VP Shetty

FMR


LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com