Leprosy Mailing List, December 11th, 2008
Ref.: Community-based Rehabilitation (CBR) Congress, Bangkok, Feb. 2009
From: Deepak S
Dear friends,
This is to inform you that the new dates for the Community-based Rehabilitation (CBR) Congress and the different workshops including the workshop on "CBR and Leprosy" have been decided as follows:
13-14 February 2009 Pre-congress workshop on CBR and Mental Health
16-17 February 2009 Pre-congress workshop on CBR and UN Convention
18-20 February 2009 Asia Pacific CBR Congress
21-22 February 2009 Post-congress workshop on CBR and Leprosy
All the different events, congress and workshops, will take place at Prince Palace Hotel, Bangkok. Updated information about the workshops including back ground documents, draft programmes and registration forms are available from the following AIFO Italy webpage:
<http://www.aifo.it/english/resources/announcements/2008/bangkok_cbr_workshops08.htm>
Thank you in advance for your collaboration. With best wishes,
Dr Sunil Deepak
AIFO, Italy
Thursday, December 11, 2008
Consultation on “Elimination of discrimination against persons affected by leprosy and their family members”. Geneva, 15 January 2009
Leprosy Mailing List, December 10th, 2008
Ref.: Consultation on “Elimination of discrimination against persons affected by leprosy and their family members”. Geneva, 15 January 2009
From: Soutar D., London, UK
<<Information Note -15 01 09 leprosy-related discrimination (2).doc>>
Dear Salvatore,
Please can you post the attached information on an important consultation being held in Geneva on 15th January? I should also note that the Nippon Foundation/Sasakawa Memorial Health Foundation are also sponsoring a second day of informal consultation in the same place on the 16th January. I hope all those who are interested to ensure that there is contribution from people affected by leprosy will do all they can to facilitate their participation.
Regards,
Douglas Soutar
Mr Douglas Soutar
General Secretary
International Federation of Anti-Leprosy Associations
doug.soutar (at) ilep.org.uk
http://www.ilep.org.uk/
Tel: + 44 (0)20 7602 6925
Ref.: Consultation on “Elimination of discrimination against persons affected by leprosy and their family members”. Geneva, 15 January 2009
From: Soutar D., London, UK
<<Information Note -15 01 09 leprosy-related discrimination (2).doc>>
Dear Salvatore,
Please can you post the attached information on an important consultation being held in Geneva on 15th January? I should also note that the Nippon Foundation/Sasakawa Memorial Health Foundation are also sponsoring a second day of informal consultation in the same place on the 16th January. I hope all those who are interested to ensure that there is contribution from people affected by leprosy will do all they can to facilitate their participation.
Regards,
Douglas Soutar
Mr Douglas Soutar
General Secretary
International Federation of Anti-Leprosy Associations
doug.soutar (at) ilep.org.uk
http://www.ilep.org.uk/
Tel: + 44 (0)20 7602 6925
Referral or consultation facility to improve the quality of patient management in leprosy
Leprosy Mailing List, December 10th, 2008
Ref.: Referral or consultation facility to improve the quality of patient management in leprosy.
From: Vijayakumaran, P., Chennai, India
Dear Salvatore,
Greetings from Damien Foundation India Trust. I would like to comment on the debate about the use of steroids for management of reactions in leprosy.
All the experts agree that dose of steroid and duration of therapy may be decided on individual patient basis. This is possible in specialised institutions. What about the field situation ? Where:
- management is mainly by non-medical personnel trained in leprosy;
- specialised referral centres are not available.
Even a medical person in general health care system may not be able to assess the needs in many situations. They need a simple straight forward steroid regimen. That is what many agencies including WHO have done.
This argument will never end. Experts in this field need to help those in need. The problem in the current scenario has been well recognised by the statement in the communication: << "there is a threat that field staff with good clinical knowledge of leprosy are tending to extinction; there is in addition an on-going debate regarding the threat of not having dedicated training facilities!" >> (Kawuma J, LML Dec. 8th, 2008). I would also add that it is not possible to clone Naafs and Kar!
Let us try to establish referral facility or consultation facility to improve the quality of patient management in leprosy.
Dr. P. Vijayakumaran
Director (Prog)
Damien Foundation India Trust
Chennai 600031, India
Ref.: Referral or consultation facility to improve the quality of patient management in leprosy.
From: Vijayakumaran, P., Chennai, India
Dear Salvatore,
Greetings from Damien Foundation India Trust. I would like to comment on the debate about the use of steroids for management of reactions in leprosy.
All the experts agree that dose of steroid and duration of therapy may be decided on individual patient basis. This is possible in specialised institutions. What about the field situation ? Where:
- management is mainly by non-medical personnel trained in leprosy;
- specialised referral centres are not available.
Even a medical person in general health care system may not be able to assess the needs in many situations. They need a simple straight forward steroid regimen. That is what many agencies including WHO have done.
This argument will never end. Experts in this field need to help those in need. The problem in the current scenario has been well recognised by the statement in the communication: << "there is a threat that field staff with good clinical knowledge of leprosy are tending to extinction; there is in addition an on-going debate regarding the threat of not having dedicated training facilities!" >> (Kawuma J, LML Dec. 8th, 2008). I would also add that it is not possible to clone Naafs and Kar!
Let us try to establish referral facility or consultation facility to improve the quality of patient management in leprosy.
Dr. P. Vijayakumaran
Director (Prog)
Damien Foundation India Trust
Chennai 600031, India
Thalidomide for the treatment of ENL reaction
Leprosy Mailing List, December 10th, 2008
Ref.: Thalidomide for the treatment of ENL reaction
From: de Koning P., Würzburg , Germany
Dear Salvatore,
I am amazed that nobody even mentions the benefits of thalidomide. In my view it has been discarded too easily, and patients such as the one described by Dr. Uwyse (LML Nov. 1st , 2008) suffer the consequences.
Greetings,
Pieter de Koning
Dr. Pieter de Koning, MD, MPH
Medical Advisor
Deutsche Lepra- und Tuberkulosehilfe e.V (DAHW)
Mariannhillstraße 1c, 97074 Würzburg
Telefon: ++49 (0)931 7948-113, Fax: -160
pieter.de-koning (at) dahw.de
Ref.: Thalidomide for the treatment of ENL reaction
From: de Koning P., Würzburg , Germany
Dear Salvatore,
I am amazed that nobody even mentions the benefits of thalidomide. In my view it has been discarded too easily, and patients such as the one described by Dr. Uwyse (LML Nov. 1st , 2008) suffer the consequences.
Greetings,
Pieter de Koning
Dr. Pieter de Koning, MD, MPH
Medical Advisor
Deutsche Lepra- und Tuberkulosehilfe e.V (DAHW)
Mariannhillstraße 1c, 97074 Würzburg
Telefon: ++49 (0)931 7948-113, Fax: -160
pieter.de-koning (at) dahw.de
Steroid therapy in leprosy should be individualised
Leprosy Mailing List, December 8th, 2008
Ref.: Steroid therapy in leprosy should be individualised.
From: Nunzi E., Genoa, Italy
Dear Salvatore,
Leprosy is a bacterial disease where the immune system is strongly involved. This is particularly true in the hyperergic forms of the disease. We use MDT against the bacteria and steroids to control the immunologic hyper-reactivity (reaction) that may damage peripheral nerves and, in type two reaction also eyes, testes, kidneys and so on.
In each patient there is a unique relationship between the bacterial load and the immunologic reaction. The latter tends to increase following the decreasing, with therapy, of the bacterial load. Therefore there is no rational for a standard protocol of treatment for all patients. Naafs and Kar in their messages have correctly pointed out respectively, that leprosy is a disease with a “spectrum” and its treatment should be individualised.
Enrico Nunzi
Ref.: Steroid therapy in leprosy should be individualised.
From: Nunzi E., Genoa, Italy
Dear Salvatore,
Leprosy is a bacterial disease where the immune system is strongly involved. This is particularly true in the hyperergic forms of the disease. We use MDT against the bacteria and steroids to control the immunologic hyper-reactivity (reaction) that may damage peripheral nerves and, in type two reaction also eyes, testes, kidneys and so on.
In each patient there is a unique relationship between the bacterial load and the immunologic reaction. The latter tends to increase following the decreasing, with therapy, of the bacterial load. Therefore there is no rational for a standard protocol of treatment for all patients. Naafs and Kar in their messages have correctly pointed out respectively, that leprosy is a disease with a “spectrum” and its treatment should be individualised.
Enrico Nunzi
Steroid therapy in the management of reactions in leprosy
Leprosy Mailing List, December 8th, 2008
Ref.: Steroid therapy in the management of reactions in leprosy
From: Kawuma J., Kampala, Uganda
Dear Salvatore,
Basing on the various responses on this subject it is clear that something must be done about the current guidelines.
Those needing to prompt change should not only be the WHO Experts but also other opinion leaders in the leprosy world. The circulating issues of the ILEP Learning Guides One and Two also describe standard 12 week regimens for Type 1 reactions in PB patients.
Whatever the new guidelines are, they should take serious consideration of the current status of leprosy control programmes in Africa; there is a threat that field staff with good clnical knowledge of leprosy are tending to extinction; there is in addition an on-going debate regarding the threat of not having dedicated training facilities!
Joseph Kawuma
GLRA, Uganda
Ref.: Steroid therapy in the management of reactions in leprosy
From: Kawuma J., Kampala, Uganda
Dear Salvatore,
Basing on the various responses on this subject it is clear that something must be done about the current guidelines.
Those needing to prompt change should not only be the WHO Experts but also other opinion leaders in the leprosy world. The circulating issues of the ILEP Learning Guides One and Two also describe standard 12 week regimens for Type 1 reactions in PB patients.
Whatever the new guidelines are, they should take serious consideration of the current status of leprosy control programmes in Africa; there is a threat that field staff with good clnical knowledge of leprosy are tending to extinction; there is in addition an on-going debate regarding the threat of not having dedicated training facilities!
Joseph Kawuma
GLRA, Uganda
In Reactions the therapy has to be tailored according to the clinical response
Leprosy Mailing List, December 7th, 2008
Ref.: In Reactions the therapy has to be tailored according to the clinical response
From: Palande Dinkar D., Kurichikuppam, Pondicherry, India
Dear Dr. Noto,
I fully endorse what Ben Naafs says (LML Dec. 2nd, 2008). In Reactions and nerve involvement, even though operationally difficult, the therapy HAS to be tailored according to the clinical response and it is not uncommon to find it necessary to continue steroids more than 3 months. Of course all care has to be taken to prevent steroid induced complications and often one had to add additional measures like increasing the dose of Lamprene in Type 2 reactions.
Warm regards,
Dinkar D Palande
Ref.: In Reactions the therapy has to be tailored according to the clinical response
From: Palande Dinkar D., Kurichikuppam, Pondicherry, India
Dear Dr. Noto,
I fully endorse what Ben Naafs says (LML Dec. 2nd, 2008). In Reactions and nerve involvement, even though operationally difficult, the therapy HAS to be tailored according to the clinical response and it is not uncommon to find it necessary to continue steroids more than 3 months. Of course all care has to be taken to prevent steroid induced complications and often one had to add additional measures like increasing the dose of Lamprene in Type 2 reactions.
Warm regards,
Dinkar D Palande
Tuesday, December 2, 2008
Steroid therapy in the management of reactions in leprosy
Leprosy Mailing List, December 2nd, 2008
Ref.: Steroid therapy in the management of reactions in leprosy.
From: van Brakel W. H., Amsterdam, The Netherlands
Dear Salvatore,
I would like to respond to Prof. Kar's plea (LML Nov. 30th, 2008) for a multi-centre trial to determine an optimal steroid regimen. I fully agree. In fact, a proposal for such a study, called the TENLEP Trials (Treatment of Early Neuropathy in Leprosy), was submitted to four funding organisations in August. This collaborative project combines the efforts of some 10 research centres in 6 countries. The study combines two trials, one to test to prognostic benefit of treating sub-clinical neuropathy detected a diagnosis and the other to find an optimal duration and dosage for steroid treatment of clinical nerve damage of recent onset occurring as part of a Type 1 or 2 reaction or silent neuropathy.
Unfortunately, it appears that the urgency for such a study is not acknowledged everywhere. We have not been able to find sufficient funds to start these trials in 2009. If anyone knows of other funding sources interested to support this research, we would be very happy to hear from them!
With friendly greetings,
Wim van Brakel
Reply email address: w.v.brakel (at) kit.nl
Wim H. van Brakel
KIT Leprosy Unit
Wibautstraat 137 J
1097DN Amsterdam
Netherlands
+3120 6939297
http://www.kit.nl/
Ref.: Steroid therapy in the management of reactions in leprosy.
From: van Brakel W. H., Amsterdam, The Netherlands
Dear Salvatore,
I would like to respond to Prof. Kar's plea (LML Nov. 30th, 2008) for a multi-centre trial to determine an optimal steroid regimen. I fully agree. In fact, a proposal for such a study, called the TENLEP Trials (Treatment of Early Neuropathy in Leprosy), was submitted to four funding organisations in August. This collaborative project combines the efforts of some 10 research centres in 6 countries. The study combines two trials, one to test to prognostic benefit of treating sub-clinical neuropathy detected a diagnosis and the other to find an optimal duration and dosage for steroid treatment of clinical nerve damage of recent onset occurring as part of a Type 1 or 2 reaction or silent neuropathy.
Unfortunately, it appears that the urgency for such a study is not acknowledged everywhere. We have not been able to find sufficient funds to start these trials in 2009. If anyone knows of other funding sources interested to support this research, we would be very happy to hear from them!
With friendly greetings,
Wim van Brakel
Reply email address: w.v.brakel (at) kit.nl
Wim H. van Brakel
KIT Leprosy Unit
Wibautstraat 137 J
1097DN Amsterdam
Netherlands
+3120 6939297
http://www.kit.nl/
Steroid therapy in the management of reactions in leprosy
Leprosy Mailing List, December 2nd, 2008
Ref.: Steroid therapy in the management of reactions in leprosy.
From: de Koning P., Würzburg, Germany
Dear colleagues,
The guidelines for treatment of leprosy reactions urgently need to be reviewed. For treatment in the field 12 weeks of prednisolone (in blister packs) is recommended by WHO for both type I and type II reactions. Evidence suggests that this is either not long enough (for type I) or too long and with an insufficiently high starting dose (type II).
For “severe reaction“ the recommendation is that a patient should be referred to experts and treated for “3-6 months“. However, these experts are becoming increasingly rare, and most health workers at grass root level follow the 12-week guideline, which is probably as good as doing nothing at all.
Kind regards,
Dr. Pieter de Koning
Medical Advisor
DAHW, Würzburg, Germany
Ref.: Steroid therapy in the management of reactions in leprosy.
From: de Koning P., Würzburg, Germany
Dear colleagues,
The guidelines for treatment of leprosy reactions urgently need to be reviewed. For treatment in the field 12 weeks of prednisolone (in blister packs) is recommended by WHO for both type I and type II reactions. Evidence suggests that this is either not long enough (for type I) or too long and with an insufficiently high starting dose (type II).
For “severe reaction“ the recommendation is that a patient should be referred to experts and treated for “3-6 months“. However, these experts are becoming increasingly rare, and most health workers at grass root level follow the 12-week guideline, which is probably as good as doing nothing at all.
Kind regards,
Dr. Pieter de Koning
Medical Advisor
DAHW, Würzburg, Germany
Steroid therapy in the management of reactions in leprosy
Leprosy Mailing List, December 2nd, 2008
Ref.: Steroid therapy in the management of reactions in leprosy (see attachment 1 & attachment 2)
From: Naafs B., Bauru, SP, Brazil
Dear Salvatore,
I agree fully with you (LML Nov. 30th, 2008) that there is NO EVIDENCE at all, for the 3-month steroid treatment. It is too short for quite a number of patients. Many patients deteriorate after the cessation of the 3 month treatment. Unluckily for them often the damage is silent. I had hoped that after my papers, which are enclosed (attachment 1, attachment 2 - in PDF), people would come to their senses. I am of the opinion that to continue the 3 month advice is unscientific and would not hold in any court.
I think it is near criminal to neglect the accumulated evidence against only 3 month of treatment in Type I reaction, where it invites problems when you use it in Type 2 reactions.
Why do WHO "experts" not listen to patients and their doctors and do not realise that leprosy is a spectral disease and moreover that leprosy in one geographical area is not that in another and that just looking at the Bangladesh trials is short-sighted and biased.Greetings from Brazil,
Ben Naafs
Ref.: Steroid therapy in the management of reactions in leprosy (see attachment 1 & attachment 2)
From: Naafs B., Bauru, SP, Brazil
Dear Salvatore,
I agree fully with you (LML Nov. 30th, 2008) that there is NO EVIDENCE at all, for the 3-month steroid treatment. It is too short for quite a number of patients. Many patients deteriorate after the cessation of the 3 month treatment. Unluckily for them often the damage is silent. I had hoped that after my papers, which are enclosed (attachment 1, attachment 2 - in PDF), people would come to their senses. I am of the opinion that to continue the 3 month advice is unscientific and would not hold in any court.
I think it is near criminal to neglect the accumulated evidence against only 3 month of treatment in Type I reaction, where it invites problems when you use it in Type 2 reactions.
Why do WHO "experts" not listen to patients and their doctors and do not realise that leprosy is a spectral disease and moreover that leprosy in one geographical area is not that in another and that just looking at the Bangladesh trials is short-sighted and biased.Greetings from Brazil,
Ben Naafs
Revue de presse: "The associated diseases with leprosy"
Leprosy Mailing List, November 30th, 2008
Ref.: Revue de presse: "The associated diseases with leprosy"
From: Al Aboud K., Mecca, Saudi Arabia
Dear Dr Noto,
Greetings,
Sometimes ago, I saw a leprosy patient with extensive pediculosis. I thought this might be due to neuropathy, therefore the patient will not have itch caused by lice. On reviewing the MEDLINE, I could find that many diseases might be encountered with leprosy patients, like scabies, Tineas, pediculosis and others. Theses are listed in this reference:-
Singh M, Kaur S, Kumar B, Kaur I, Sharma VK. The associated diseases with leprosy. Indian J Lepr. 1987 Jul-Sep;59(3):315-21.
I just would like to remind the LML members with a known fact that, detailed examination is important in leprosy patient. Specially scalp examination, which in many countries is covered by scarf.
Yours sincerely,
Dr Khalid Al Aboud
Medical Director and Consultant Dermatologist
King Faisal Hospital ,
P.O Box 5592
Makkah
Saudi Arabia
Tel 0096625566411 ext 6666
Fax: 0096625563523
E-mail alaboudkhalid (at) yahoo.ca
This is the link
1987 Jul-Sep;59(3):315-21, The associated diseases with leprosy Singh M, Kaur S, Kumar B, Kaur I, Sharma VK. Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh.
”The prevalence of cutaneous, medical and surgical disorders was studied in 846 leprosy patients. Common cutaneous disorders among leprosy patients were pityriasis versicolor, tinea, pyodermas, warts, acquired ichthyosis, scabies, pediculosis and callosities. Only pityriasis versicolor had higher incidence when compared to general population. Common medical diseases were tuberculosis, infective hepatitis and diabetes mellitus. The epidemiological importance of their co-existence with leprosy is discussed and relevant literature of other diseases found to be frequently associated with leprosy is reviewed.”
Ref.: Revue de presse: "The associated diseases with leprosy"
From: Al Aboud K., Mecca, Saudi Arabia
Dear Dr Noto,
Greetings,
Sometimes ago, I saw a leprosy patient with extensive pediculosis. I thought this might be due to neuropathy, therefore the patient will not have itch caused by lice. On reviewing the MEDLINE, I could find that many diseases might be encountered with leprosy patients, like scabies, Tineas, pediculosis and others. Theses are listed in this reference:-
Singh M, Kaur S, Kumar B, Kaur I, Sharma VK. The associated diseases with leprosy. Indian J Lepr. 1987 Jul-Sep;59(3):315-21.
I just would like to remind the LML members with a known fact that, detailed examination is important in leprosy patient. Specially scalp examination, which in many countries is covered by scarf.
Yours sincerely,
Dr Khalid Al Aboud
Medical Director and Consultant Dermatologist
King Faisal Hospital ,
P.O Box 5592
Makkah
Saudi Arabia
Tel 0096625566411 ext 6666
Fax: 0096625563523
E-mail alaboudkhalid (at) yahoo.ca
This is the link
1987 Jul-Sep;59(3):315-21, The associated diseases with leprosy Singh M, Kaur S, Kumar B, Kaur I, Sharma VK. Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh.
”The prevalence of cutaneous, medical and surgical disorders was studied in 846 leprosy patients. Common cutaneous disorders among leprosy patients were pityriasis versicolor, tinea, pyodermas, warts, acquired ichthyosis, scabies, pediculosis and callosities. Only pityriasis versicolor had higher incidence when compared to general population. Common medical diseases were tuberculosis, infective hepatitis and diabetes mellitus. The epidemiological importance of their co-existence with leprosy is discussed and relevant literature of other diseases found to be frequently associated with leprosy is reviewed.”
Steroid therapy in the management of reactions in leprosy
Leprosy Mailing List, November 30th, 2008
Ref.: Steroid therapy in the management of reactions in leprosy.
From: Noto S., Genoa, Italy
Dear Prof Smith,
Thank you very much for your LML message dated Nov. 22nd, 2008.
I would like to comment that there is no evidence in favour of treating severe leprosy reactions in highly positive slit-skin smear positive patients with only a three-month course of steroids.
With regards,
S. Noto
Ref.: Steroid therapy in the management of reactions in leprosy.
From: Noto S., Genoa, Italy
Dear Prof Smith,
Thank you very much for your LML message dated Nov. 22nd, 2008.
I would like to comment that there is no evidence in favour of treating severe leprosy reactions in highly positive slit-skin smear positive patients with only a three-month course of steroids.
With regards,
S. Noto
Steroid therapy in management of reactions in leprosy
Leprosy Mailing List, November 30th, 2008
Ref.: Steroid therapy in management of reactions in leprosy.
From: Kar H. K., New Delhi, India
Dear Dr Noto,
I refer to Dr A. Diefenhardt’s LML message from Wurzburg dated Nov. 21st, 2008.
I fully agree with him regarding the duration of steroid therapy for management of reactions in leprosy. It is individualised depending on the type of reaction, severity, frequency of recurrence, therapy and so many other factors. However, there is urgent need of a multi-centric trial for development guidelines for management of type 1 and type 2 reactions.
The present recommendation by WHO is not sufficient to deal with this crucial aspect of the management of leprosy. Particularly attention is needed for the duration of steroid therapy in severe cases.
With regards,
Dr (Prof.) H K Kar
MD, MNAMS
Consultant & HOD
Department of Dermatology, STD & Leprosy
PGIMER, Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001
India
Ref.: Steroid therapy in management of reactions in leprosy.
From: Kar H. K., New Delhi, India
Dear Dr Noto,
I refer to Dr A. Diefenhardt’s LML message from Wurzburg dated Nov. 21st, 2008.
I fully agree with him regarding the duration of steroid therapy for management of reactions in leprosy. It is individualised depending on the type of reaction, severity, frequency of recurrence, therapy and so many other factors. However, there is urgent need of a multi-centric trial for development guidelines for management of type 1 and type 2 reactions.
The present recommendation by WHO is not sufficient to deal with this crucial aspect of the management of leprosy. Particularly attention is needed for the duration of steroid therapy in severe cases.
With regards,
Dr (Prof.) H K Kar
MD, MNAMS
Consultant & HOD
Department of Dermatology, STD & Leprosy
PGIMER, Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001
India
Friday, November 28, 2008
The impact of leprosy control on the transmission of M. leprae: is elimination being attained?
Leprosy Mailing List, November 26th, 2008
Ref.: The impact of leprosy control on the transmission of M. leprae: is elimination being attained? (see attachment)
From: Richardus J.H., Rotterdam, The Netherlands
Dear Dr Noto,
I refer to Dr Bendick’s LML message dated Nov. 22nd, 2008. Could you pass the attached article on to him? I have no problem with your request for circulation of the same paper to the LML.
Thanks,
Jan Hendrik Richardus
J.H. Richardus MD, PhDAssociate ProfessorDepartment of Public HealthErasmus MCUniversity Medical Center Rotterdam P.O. Box 2040 3000 CA Rotterdam The Netherlands tel. +31 (0)10 4638473j.richardu at erasmusmc.nl
Ref.: The impact of leprosy control on the transmission of M. leprae: is elimination being attained? (see attachment)
From: Richardus J.H., Rotterdam, The Netherlands
Dear Dr Noto,
I refer to Dr Bendick’s LML message dated Nov. 22nd, 2008. Could you pass the attached article on to him? I have no problem with your request for circulation of the same paper to the LML.
Thanks,
Jan Hendrik Richardus
J.H. Richardus MD, PhDAssociate ProfessorDepartment of Public HealthErasmus MCUniversity Medical Center Rotterdam P.O. Box 2040 3000 CA Rotterdam The Netherlands tel. +31 (0)10 4638473j.richardu at erasmusmc.nl
Monday, November 24, 2008
Elimination of leprosy
Leprosy Mailing List, November 22nd, 2008
Ref.: Elimination of leprosy
From: Bendick C., Phnom Penh, Cambodia
Dear Dr Noto,
There is an abundance of literature on this controversial topic (elimination of leprosy). Would you know two or three relevant publications which give a comprehensive overview over the WHO-decision-making in this matter, the subsequent development of efforts to eliminate leprosy and the current state of affairs?
Thanks a lot for your help.
Dr. med. Christoph BendickUniversity of Health SciencesBP 1006Phnom PenhCambodiaTel. +855 12 914294Fax: +855 23 430129
Ref.: Elimination of leprosy
From: Bendick C., Phnom Penh, Cambodia
Dear Dr Noto,
There is an abundance of literature on this controversial topic (elimination of leprosy). Would you know two or three relevant publications which give a comprehensive overview over the WHO-decision-making in this matter, the subsequent development of efforts to eliminate leprosy and the current state of affairs?
Thanks a lot for your help.
Dr. med. Christoph BendickUniversity of Health SciencesBP 1006Phnom PenhCambodiaTel. +855 12 914294Fax: +855 23 430129
Length of steroid treatment in leprosy reactions?
Leprosy Mailing List, November 22nd, 2008
Ref.: Length of steroid treatment in leprosy reactions?
From: Smith C., Aberdeen, UK
Dear Dr Noto,
I refer to Dr Diefenhardt’s LML message dated Nov. 21st, 2008. The current recommendations on duration of steroid treatment in leprosy reactions are those in the operational guide for the Global Strategy 2006 - 2010. A revision would need to be based on evidence, so if you and others can collate evidence to support a revision that would be very helpful,
With best wishes,
Cairns Smith
Ref.: Length of steroid treatment in leprosy reactions?
From: Smith C., Aberdeen, UK
Dear Dr Noto,
I refer to Dr Diefenhardt’s LML message dated Nov. 21st, 2008. The current recommendations on duration of steroid treatment in leprosy reactions are those in the operational guide for the Global Strategy 2006 - 2010. A revision would need to be based on evidence, so if you and others can collate evidence to support a revision that would be very helpful,
With best wishes,
Cairns Smith
Length of steroid treatment in leprosy reactions?
Leprosy Mailing List, November 21st, 2008
Ref.: Length of steroid treatment in leprosy reactions?
From: Diefenhardt A., Wurzburg, Germany
Dear colleagues,
Should clinical experience on length of steroid treatment in leprosy reactions not be subject in future TAG meetings as this could be a forum to revise current WHO recommendations that seem to many clinicians insufficient?
Yours,
Dr Adolf Diefenhardt
Ref.: Length of steroid treatment in leprosy reactions?
From: Diefenhardt A., Wurzburg, Germany
Dear colleagues,
Should clinical experience on length of steroid treatment in leprosy reactions not be subject in future TAG meetings as this could be a forum to revise current WHO recommendations that seem to many clinicians insufficient?
Yours,
Dr Adolf Diefenhardt
International Leprosy Symposium, Valencia, Spain, 29-30 January 2009
Leprosy Mailing List, November 21st, 2008
Ref.: International Leprosy Symposium, Valencia, Spain, 29-30 January 2009 (see attachment)
From: Mas V., Fontilles, Spain
Dear Dr. Noto,
Next year Fontilles will celebrate the centenary of its foundation and one of the commemorative acts will be an International Leprosy Symposium. The attached announcement (in PDF) will provide further details. Kindly, could you publish this announcement through LML?
Sincerely,
Veronica Mas
Medical Library
Fontilles, Spain
Ref.: International Leprosy Symposium, Valencia, Spain, 29-30 January 2009 (see attachment)
From: Mas V., Fontilles, Spain
Dear Dr. Noto,
Next year Fontilles will celebrate the centenary of its foundation and one of the commemorative acts will be an International Leprosy Symposium. The attached announcement (in PDF) will provide further details. Kindly, could you publish this announcement through LML?
Sincerely,
Veronica Mas
Medical Library
Fontilles, Spain
Monday, November 10, 2008
Does prednisolone reduce the rate of killing of the bacilli?
Leprosy Mailing List, November 7th, 2008
Ref.: Does prednisolone reduce the rate of killing of the bacilli?
From: Warren G., Sydney, Australia
Dear Dr Salvatore,
Fascinating story, I refer to Dr Ranawaka’s LML message about histoid leprosy dated October 31st, 2008. I would be interested to know the ethnicity of the patient. In my international travels I have seen quite a number of patients with similar problems, but most of them are Chinese or East Asian.
I am glad that Dr Ranawaka does skin smears and the M.I and I assume B.I. The fact that she was still MI 5% after 13 months of blister packs certainly accents teaching I am always giving. In the LL (and many BL) patients the 12 months of blister packs is Not adequate to “kill” all the bacilli. The fact that she has had 3 months of prednisolone in the middle is relevant as the nodules appeared in the month after the prednisolone ceased. My teaching for many years is that Prednisolone while saving nerve function by reducing inflammation and the resultant fibrosis also reduces the Rate of killing of the bacilli. When counting up the months on MDT, I DO NOT count the months in which the patient had prednisolone. Your case accents this. Even after another 3-4 months on MDT her MI was still 5%. I wonder what the BI at the time she started prednisolone was and wonder what the initial BI and MI were, and if any other records were kept of levels during those first 12 months. I would be fascinated to know them.
In Hong Hong (1959-74) we had excellent lab technicians who did B.I. and M.I. on every patient every 3 months. Initial High BI and MI were always carefully recorded. If a patient had a BI of 5-6 and MI of 5-10% we knew it would probably be 5-6 years before they were BI=0. If they were on Prednisolone we observe that the BI did not actually fall during the months on Prednisolone. Dr Ranawaka’s patient I think shows the effect on the prednisolone. I hope he would have other BI and MI readings. I suspect that the BI and MI fell initially, as the Rifampycin killed the bacilli, but while on Prednisolone the bacilli were multiplying again. I would love some figures to show that. MDT did not come in till after that hospital with its excellent facilities had closed and most other places these days do not do BI and MI!
You had the patient on MDT, I suspect that there was no real need to add the ofloxacin. The MI had fallen before the nodules ulcerated. Nodules, described as Histoid are recognised as being due to resistance to the drug being given or to discontinuation of the drugs. This fits in perfectly with the steroids reducing the efficiency of the MDT as stated above. I suspect there is no real indication of resistance especially if the patient was taking the medication correctly; was she?
Of course we must realise she could have caught drug resistance leprosy. Is it common in her home area? In Ethiopia at one time it was found that 50% of all new leprosy patients had DDS resistant bacilli! But that is part of the reason for MDT= 3 drugs. As far as I know No patient has developed Clofazimine resistant leprosy, under treatment even as monotherapy; yes, resistance to dapsone and rifampycin do occur but there is little real evidence of resistance developing under treatment when all three drugs are correctly taken. The fact that the nodules ulcerated does not really signify resistance. Ulceration of nodules is not uncommon and you state the nodules are reducing in number. Good, I would not give more prednisolone it slows healing of the ulcers and encourages secondary infection and is not really going to do much to save nerves which I gather have not yet shown many problems. Those problems will appear in 5-10 years time as the fibrosis that is already in the nerves, due to the severity of the initial infection, squeezes the life out of the nerves causing paraesethesia and slowly increasing muscle weakness. The damage to nerves due to the true LL infection and “normal mild ENL” is not reduced by prednisolone which may delay its clinic symptoms but does not reverse the nerve damage already caused.
Other means of reducing or controlling reaction may in fact reduce other long term problems. No one can prove or disprove that! I find “tranquilisers very good in reaction. Initially it was phenobarb! Later Clofazamine. Now-days Amytriptaline (NOT DIAZAPAM) stops the patient worrying and helps them sleep and some cases of reaction I tracked as being due to “worry etc”.
In your patient, you state she did have Type 1 Reaction, hence your giving Prednisolone was fair enough to reduce the acute effect on the nerves. But I feel that the dangers of long term prednisolone are enough to recommend the benefits of changing onto High dose Clofazimine, especially in the LL/BL patients. In Chinese LL/BL patients admitted in my hospital in severe type 1 reaction I would start therapy with High Clofazimine (200-300mgms daily) and steroids and add the First Rifamycin after 3-4 weeks when the Reaction was more controlled and the clofazimine level was reaching its anti-reaction blood levels. In the 1980s we found that when starting LL/BL patients on MDT, if there was any suggestion of reaction we would start them on high Clofazamine and then a month later add the Rifampycin and dapsone. Rationale= the effective killing of bacilli by RFD leads to a sudden increase in antigen and this may cause signs of reaction. Many patients stated that they got reaction (ENL) days 3-6 after the Rifampycin. But if the patient has the initial month of high Clofazimine its levels in the body help to reduce the antigen-antibody reactions that cause ENL.
For patients developing reaction when already on MDT I would add the high Clofazimine and other anti=reaction drugs and just give 6-12 weeks steroids (if reaction severe enough) and add the extra 3 months onto total duration of MDT. Once the reaction is controlled and after the steroids are stopped the Clofazimine can be slowly reduced say by 1-200mgms per week yes, I said per week, once each month, carefully watching for any signs of reaction. And probably continue the clofazimine for many months after the MDT stopped.
In your patient I would suggest continue normal MDT (Ofloxacin if you wish) for at least 24 months counting without the months on Prednisolone. But I would prefer to keep checking her BI from 6 sites widely spread. The buttock is one of the last areas to become negative in these cases. I would keep her on MDT till smear negative all areas! But as I know many would not agree, so after 24 months MDT, I often continue with Clofazimine alone, 50-100mgms daily.
As I stated, when I was involved in the drug (clofazimine) trial in the 1960/70s we found that monotherapy with Clofazimine was enough to control ENL and prevent bacilli multiplying and eventually “cure the patient”. So I still tend to use it as Mono after an initial blast with MDT so that the Rifampycin can help get rid of the multiplying bugs, but even Rifamypycin does not get all of all the bacilli that hide in the basement membranes.
My Contacts in late 1960s gave me some fascinating information. Patients were given Rifampycin orally under supervision daily, for 5 years, by that time the skin smears were negative. But biopsies of nerves still showed normal bacilli! Once the therapy was stopped these organisms come out and start multiplying again. Yes we are seeing lots of “Relapse” or at least I certainly have seen them in the last 10 years but with the new methods of diagnosis and registration they do not all get listed as relapse, they may be listed as new patients.
I appreciate that many third world countries depend on WHO supplies of MDT so much follow their guide lines which I am sorry to say I cannot really support for patients who have complications.
I am afraid I am unlikely to be convinced that the new shortened MDT is enough treatment for the severe LL patients with high BI and MI initially, especially if they get reaction. Clofazimine is an effective anti-reaction drug. When I got it in the late 1960s I had number of long term LL patients with chronic ENL when were virtually hooked on prednisolone. By careful therapy we were able to get them onto high Clofazimine and then off all steroids. Then their BI started to fall and eventually got them off all anti-reaction medication! If I could use only one drug for leprosy it would be Clofazimine.
Sudden thought: your patient is female, is she menopausal? We found, also in Hong Kong that severity of reaction could be reduced by given pre=menopausal women hormone therapy to prevent ovulation? We thought it helped, why? I do not know.
Well what a mixed medley! The treatment of leprosy is far from straightforward.
All the best.
Grace Warren.
Previously Medical Superintendent Hong Kong leprosy Hospital 1960-1974,
Adviser in leprosy and reconstructive surgery in Asia for the Leprosy Mission 1975-2000.
Ref.: Does prednisolone reduce the rate of killing of the bacilli?
From: Warren G., Sydney, Australia
Dear Dr Salvatore,
Fascinating story, I refer to Dr Ranawaka’s LML message about histoid leprosy dated October 31st, 2008. I would be interested to know the ethnicity of the patient. In my international travels I have seen quite a number of patients with similar problems, but most of them are Chinese or East Asian.
I am glad that Dr Ranawaka does skin smears and the M.I and I assume B.I. The fact that she was still MI 5% after 13 months of blister packs certainly accents teaching I am always giving. In the LL (and many BL) patients the 12 months of blister packs is Not adequate to “kill” all the bacilli. The fact that she has had 3 months of prednisolone in the middle is relevant as the nodules appeared in the month after the prednisolone ceased. My teaching for many years is that Prednisolone while saving nerve function by reducing inflammation and the resultant fibrosis also reduces the Rate of killing of the bacilli. When counting up the months on MDT, I DO NOT count the months in which the patient had prednisolone. Your case accents this. Even after another 3-4 months on MDT her MI was still 5%. I wonder what the BI at the time she started prednisolone was and wonder what the initial BI and MI were, and if any other records were kept of levels during those first 12 months. I would be fascinated to know them.
In Hong Hong (1959-74) we had excellent lab technicians who did B.I. and M.I. on every patient every 3 months. Initial High BI and MI were always carefully recorded. If a patient had a BI of 5-6 and MI of 5-10% we knew it would probably be 5-6 years before they were BI=0. If they were on Prednisolone we observe that the BI did not actually fall during the months on Prednisolone. Dr Ranawaka’s patient I think shows the effect on the prednisolone. I hope he would have other BI and MI readings. I suspect that the BI and MI fell initially, as the Rifampycin killed the bacilli, but while on Prednisolone the bacilli were multiplying again. I would love some figures to show that. MDT did not come in till after that hospital with its excellent facilities had closed and most other places these days do not do BI and MI!
You had the patient on MDT, I suspect that there was no real need to add the ofloxacin. The MI had fallen before the nodules ulcerated. Nodules, described as Histoid are recognised as being due to resistance to the drug being given or to discontinuation of the drugs. This fits in perfectly with the steroids reducing the efficiency of the MDT as stated above. I suspect there is no real indication of resistance especially if the patient was taking the medication correctly; was she?
Of course we must realise she could have caught drug resistance leprosy. Is it common in her home area? In Ethiopia at one time it was found that 50% of all new leprosy patients had DDS resistant bacilli! But that is part of the reason for MDT= 3 drugs. As far as I know No patient has developed Clofazimine resistant leprosy, under treatment even as monotherapy; yes, resistance to dapsone and rifampycin do occur but there is little real evidence of resistance developing under treatment when all three drugs are correctly taken. The fact that the nodules ulcerated does not really signify resistance. Ulceration of nodules is not uncommon and you state the nodules are reducing in number. Good, I would not give more prednisolone it slows healing of the ulcers and encourages secondary infection and is not really going to do much to save nerves which I gather have not yet shown many problems. Those problems will appear in 5-10 years time as the fibrosis that is already in the nerves, due to the severity of the initial infection, squeezes the life out of the nerves causing paraesethesia and slowly increasing muscle weakness. The damage to nerves due to the true LL infection and “normal mild ENL” is not reduced by prednisolone which may delay its clinic symptoms but does not reverse the nerve damage already caused.
Other means of reducing or controlling reaction may in fact reduce other long term problems. No one can prove or disprove that! I find “tranquilisers very good in reaction. Initially it was phenobarb! Later Clofazamine. Now-days Amytriptaline (NOT DIAZAPAM) stops the patient worrying and helps them sleep and some cases of reaction I tracked as being due to “worry etc”.
In your patient, you state she did have Type 1 Reaction, hence your giving Prednisolone was fair enough to reduce the acute effect on the nerves. But I feel that the dangers of long term prednisolone are enough to recommend the benefits of changing onto High dose Clofazimine, especially in the LL/BL patients. In Chinese LL/BL patients admitted in my hospital in severe type 1 reaction I would start therapy with High Clofazimine (200-300mgms daily) and steroids and add the First Rifamycin after 3-4 weeks when the Reaction was more controlled and the clofazimine level was reaching its anti-reaction blood levels. In the 1980s we found that when starting LL/BL patients on MDT, if there was any suggestion of reaction we would start them on high Clofazamine and then a month later add the Rifampycin and dapsone. Rationale= the effective killing of bacilli by RFD leads to a sudden increase in antigen and this may cause signs of reaction. Many patients stated that they got reaction (ENL) days 3-6 after the Rifampycin. But if the patient has the initial month of high Clofazimine its levels in the body help to reduce the antigen-antibody reactions that cause ENL.
For patients developing reaction when already on MDT I would add the high Clofazimine and other anti=reaction drugs and just give 6-12 weeks steroids (if reaction severe enough) and add the extra 3 months onto total duration of MDT. Once the reaction is controlled and after the steroids are stopped the Clofazimine can be slowly reduced say by 1-200mgms per week yes, I said per week, once each month, carefully watching for any signs of reaction. And probably continue the clofazimine for many months after the MDT stopped.
In your patient I would suggest continue normal MDT (Ofloxacin if you wish) for at least 24 months counting without the months on Prednisolone. But I would prefer to keep checking her BI from 6 sites widely spread. The buttock is one of the last areas to become negative in these cases. I would keep her on MDT till smear negative all areas! But as I know many would not agree, so after 24 months MDT, I often continue with Clofazimine alone, 50-100mgms daily.
As I stated, when I was involved in the drug (clofazimine) trial in the 1960/70s we found that monotherapy with Clofazimine was enough to control ENL and prevent bacilli multiplying and eventually “cure the patient”. So I still tend to use it as Mono after an initial blast with MDT so that the Rifampycin can help get rid of the multiplying bugs, but even Rifamypycin does not get all of all the bacilli that hide in the basement membranes.
My Contacts in late 1960s gave me some fascinating information. Patients were given Rifampycin orally under supervision daily, for 5 years, by that time the skin smears were negative. But biopsies of nerves still showed normal bacilli! Once the therapy was stopped these organisms come out and start multiplying again. Yes we are seeing lots of “Relapse” or at least I certainly have seen them in the last 10 years but with the new methods of diagnosis and registration they do not all get listed as relapse, they may be listed as new patients.
I appreciate that many third world countries depend on WHO supplies of MDT so much follow their guide lines which I am sorry to say I cannot really support for patients who have complications.
I am afraid I am unlikely to be convinced that the new shortened MDT is enough treatment for the severe LL patients with high BI and MI initially, especially if they get reaction. Clofazimine is an effective anti-reaction drug. When I got it in the late 1960s I had number of long term LL patients with chronic ENL when were virtually hooked on prednisolone. By careful therapy we were able to get them onto high Clofazimine and then off all steroids. Then their BI started to fall and eventually got them off all anti-reaction medication! If I could use only one drug for leprosy it would be Clofazimine.
Sudden thought: your patient is female, is she menopausal? We found, also in Hong Kong that severity of reaction could be reduced by given pre=menopausal women hormone therapy to prevent ovulation? We thought it helped, why? I do not know.
Well what a mixed medley! The treatment of leprosy is far from straightforward.
All the best.
Grace Warren.
Previously Medical Superintendent Hong Kong leprosy Hospital 1960-1974,
Adviser in leprosy and reconstructive surgery in Asia for the Leprosy Mission 1975-2000.
Histoid leprosy and Granuloma fraction
Leprosy Mailing List, November 7th, 2008
Ref.: Histoid leprosy and Granuloma fraction
From: Faber W. R., Amsterdam, The Netherlands
Dear Dr Ranawaka,
I refer to your LML message dated Oct. 31st, 2008. That is an interesting observation of a patient developing histoid lesions during treatment.
Recently, we treated a patient diagnosed with borderline lepromatous (BL) leprosy who besides the typical BL lesions also had scattered nodular lesions on the extremities: shown by histopathology to be histoid leprosy. As there was a high bacteriological index (BI) we treated him with a long course of multi-drug therapy (MDT). Due to poor compliance we could not definitely state the duration of treatment but we calculated it to be around 24 months. At that time the histoid lesions had flattened, and the BI of the skin biopsy was zero. In this case treatment with standard MDT for around 24 months was effective in curing his (histoid) leprosy.
I would advise you to take biopsies to monitor the result of your treatment by means of BI and Granuloma Fraction *.
With kind regards,
William R. Faber, MD, PhD
Professor of Tropical Dermatology
Academic Medical Center
University of Amsterdam
Meibergdreef 9
1105 AZ Amsterdam
The Netherlands
F: 31 - 20 696 0076
email: w.r.faberatamc.uva.nl
Ref.: Histoid leprosy and Granuloma fraction
From: Faber W. R., Amsterdam, The Netherlands
Dear Dr Ranawaka,
I refer to your LML message dated Oct. 31st, 2008. That is an interesting observation of a patient developing histoid lesions during treatment.
Recently, we treated a patient diagnosed with borderline lepromatous (BL) leprosy who besides the typical BL lesions also had scattered nodular lesions on the extremities: shown by histopathology to be histoid leprosy. As there was a high bacteriological index (BI) we treated him with a long course of multi-drug therapy (MDT). Due to poor compliance we could not definitely state the duration of treatment but we calculated it to be around 24 months. At that time the histoid lesions had flattened, and the BI of the skin biopsy was zero. In this case treatment with standard MDT for around 24 months was effective in curing his (histoid) leprosy.
I would advise you to take biopsies to monitor the result of your treatment by means of BI and Granuloma Fraction *.
With kind regards,
William R. Faber, MD, PhD
Professor of Tropical Dermatology
Academic Medical Center
University of Amsterdam
Meibergdreef 9
1105 AZ Amsterdam
The Netherlands
F: 31 - 20 696 0076
email: w.r.faberatamc.uva.nl
Leprosy in childhood
Leprosy Mailing List, November 2nd, 2008
Ref.: 'Leprosy in childhood'
From: Erlings J., Amsterdam, The Netherlands
Dear Dr Noto,
As there has been quite some interest in 'leprosy in childhood' lately I have now placed a reference list on this subject on the Infolep website:
http://www.ilep.org.uk/library-resources/infolep-information-services/subjectguides/leprosy-in-childhood/The list includes references from 1998-2008 and some links to free full text publications.
I hope to add reference lists on other popular subjects soon. Suggestions for subjects can be e-mailed to infolepatleprastichting.nl
With kind regards,
Jiske Erlings
INFOLEP Leprosy Information Services
Ref.: 'Leprosy in childhood'
From: Erlings J., Amsterdam, The Netherlands
Dear Dr Noto,
As there has been quite some interest in 'leprosy in childhood' lately I have now placed a reference list on this subject on the Infolep website:
http://www.ilep.org.uk/library-resources/infolep-information-services/subjectguides/leprosy-in-childhood/The list includes references from 1998-2008 and some links to free full text publications.
I hope to add reference lists on other popular subjects soon. Suggestions for subjects can be e-mailed to infolepatleprastichting.nl
With kind regards,
Jiske Erlings
INFOLEP Leprosy Information Services
Erythema nodosum leprosum (ENL) reaction
Leprosy Mailing List, November 1st, 2008
Ref.: Erythema nodosum leprosum (ENL) reaction
From: Uwyse S. A., Ampara, Sri Lanka
Dear Noto,
Thanks for your LML service.
When a patient develops ENL reaction after completing the multibacillary (MB) treatment course (12 months according to WHO suggestion), is it necessary to restart MB treatment with oral steroid therapy to treat this condition? Is there any place to treat this condition with chloroquine or cyclophospamide?
Please clarify on this matters as people have various opinions on this issue here. Thank you in advance for your comments.
With best regards,
Dr. S. A. Uwyse
Consultant Dermatologist
General Hospital
Ampara
Sri Lanka
Ref.: Erythema nodosum leprosum (ENL) reaction
From: Uwyse S. A., Ampara, Sri Lanka
Dear Noto,
Thanks for your LML service.
When a patient develops ENL reaction after completing the multibacillary (MB) treatment course (12 months according to WHO suggestion), is it necessary to restart MB treatment with oral steroid therapy to treat this condition? Is there any place to treat this condition with chloroquine or cyclophospamide?
Please clarify on this matters as people have various opinions on this issue here. Thank you in advance for your comments.
With best regards,
Dr. S. A. Uwyse
Consultant Dermatologist
General Hospital
Ampara
Sri Lanka
Histoid leprosy, why ofloxacin?
Leprosy Mailing List, November 1st, 2008
Ref.: Histoid leprosy, why ofloxacin?
From: Kawuma H. J., Kampala, Uganda
Dear Salvatore,
I am reacting to the presentation by Dr. Ranawaka (LML Oct. 31st, 2008).
Atypical ENL reactions in histoid leprosy have been described in the past and so has softening and ulceration of histoid lesions during treatment. The described seems to fit in one or other of the above.
What was the rationale for giving ofloxacin? That may help colleagues to advise on how long it should be continued?
Dr. Ranawaka, thank you for sharing yet another interesting situation!
Yours sincerely,
H Joseph Kawuma
GLRA, Uganda
Ref.: Histoid leprosy, why ofloxacin?
From: Kawuma H. J., Kampala, Uganda
Dear Salvatore,
I am reacting to the presentation by Dr. Ranawaka (LML Oct. 31st, 2008).
Atypical ENL reactions in histoid leprosy have been described in the past and so has softening and ulceration of histoid lesions during treatment. The described seems to fit in one or other of the above.
What was the rationale for giving ofloxacin? That may help colleagues to advise on how long it should be continued?
Dr. Ranawaka, thank you for sharing yet another interesting situation!
Yours sincerely,
H Joseph Kawuma
GLRA, Uganda
Russian papers about leprosy in Yemen
Leprosy Mailing List, October 31st, 2008
Ref.: Russian papers about leprosy in Yemen
From: Al Aboud K., Mecca, Saudi Arabia
Dear Dr Noto,
I have historical papers about leprosy in Yemen. A Russian dermatologist, ''Lavrik AU'', has published them (see below):-
Vestn Dermatol Venerol. 1983 Jul;(7):66-70
Vestn Dermatol Venerol. 1983 Apr;(4):46-9
Vestn Dermatol Venerol. 1974 Jun;0(6):70-3
Vestn Dermatol Venerol. 1973 Mar;47(3):57-60
Vestn Dermatol Venerol. 1970 Jun;44(6):56-8
I have collected a copy of these papers and I want to study them to see the situation of leprosy at that time and how people was reacting and dealing with it. Is there anybody in the LML from Russia who can volunteer to translate them in English for me?I look forward to your reply.
With my thanks and regards,
Yours sincerely,
Dr Khalid Al Aboud
Medical Director and Consultant Dermatologist
King Faisal Hospital ,
P.O Box 5592
Makkah
Saudi Arabia
Tel 0096625566411 ext 6666
Fax 0096625563523
E-mail alaboudkhalidatyahoo.ca
Ref.: Russian papers about leprosy in Yemen
From: Al Aboud K., Mecca, Saudi Arabia
Dear Dr Noto,
I have historical papers about leprosy in Yemen. A Russian dermatologist, ''Lavrik AU'', has published them (see below):-
Vestn Dermatol Venerol. 1983 Jul;(7):66-70
Vestn Dermatol Venerol. 1983 Apr;(4):46-9
Vestn Dermatol Venerol. 1974 Jun;0(6):70-3
Vestn Dermatol Venerol. 1973 Mar;47(3):57-60
Vestn Dermatol Venerol. 1970 Jun;44(6):56-8
I have collected a copy of these papers and I want to study them to see the situation of leprosy at that time and how people was reacting and dealing with it. Is there anybody in the LML from Russia who can volunteer to translate them in English for me?I look forward to your reply.
With my thanks and regards,
Yours sincerely,
Dr Khalid Al Aboud
Medical Director and Consultant Dermatologist
King Faisal Hospital ,
P.O Box 5592
Makkah
Saudi Arabia
Tel 0096625566411 ext 6666
Fax 0096625563523
E-mail alaboudkhalidatyahoo.ca
Histoid leprosy
Leprosy Mailing List, October 31st, 2008
Ref.: Histoid leprosy
From: Ranawaka R., Anuradhapura, Sri Lanka
Dear Dr Salvatore,
Thank you very much for the clinical experience given by members of the LML regarding my previous clinical problems (recurrent type I reaction and nerve abscess). I have another patient whom I would like expert's opinion on management.
A 46-year-old woman with borderline lepromatous (BL) leprosy was started on multibacillary multi-drug therapy (MB-MDT) 15 months ago. When she was on her 6th month of therapy she developed type I reaction which we treated with 12-weeks oral prednisolone regime. At the 10th month of MB-MDT she developed painless discrete nodules of 1cm diameter on face and limbs. Skin biopsy revealed “histoid” leprosy.
We completed 12 MB blister packs, but skin nodules persisted; therefore the morphological index (MI) was performed, which was 5%. We continued MB blister packs. After 1 month (13th month) the MI was 0%. But at 14th month these nodules ulcerated. I added ofloxacin 400mg daily with MB therapy. Now ulceration healed and some of the nodules have disappeared.
For how long it would be safe to continue ofloxacin? Until the lesions are fully flattened? My plan is to continue MB treatment for 24 months. How do assess cure in this patient?
Your opinion regarding management of this patient will be greatly appreciated.
Kind regards,
Ranthilaka Ranawaka
Consultant Dermatologist
Teaching Hospital Anuradhapura
Sri Lanka
Ref.: Histoid leprosy
From: Ranawaka R., Anuradhapura, Sri Lanka
Dear Dr Salvatore,
Thank you very much for the clinical experience given by members of the LML regarding my previous clinical problems (recurrent type I reaction and nerve abscess). I have another patient whom I would like expert's opinion on management.
A 46-year-old woman with borderline lepromatous (BL) leprosy was started on multibacillary multi-drug therapy (MB-MDT) 15 months ago. When she was on her 6th month of therapy she developed type I reaction which we treated with 12-weeks oral prednisolone regime. At the 10th month of MB-MDT she developed painless discrete nodules of 1cm diameter on face and limbs. Skin biopsy revealed “histoid” leprosy.
We completed 12 MB blister packs, but skin nodules persisted; therefore the morphological index (MI) was performed, which was 5%. We continued MB blister packs. After 1 month (13th month) the MI was 0%. But at 14th month these nodules ulcerated. I added ofloxacin 400mg daily with MB therapy. Now ulceration healed and some of the nodules have disappeared.
For how long it would be safe to continue ofloxacin? Until the lesions are fully flattened? My plan is to continue MB treatment for 24 months. How do assess cure in this patient?
Your opinion regarding management of this patient will be greatly appreciated.
Kind regards,
Ranthilaka Ranawaka
Consultant Dermatologist
Teaching Hospital Anuradhapura
Sri Lanka
Monday, October 27, 2008
Methaemoglobinaemia and paralysis of the hemi-diaphragm in a leprosy patient
Leprosy Mailing List – October 22nd, 2008
Ref.: Methaemoglobinaemia and paralysis of the hemi-diaphragm in a leprosy patient.
From: Narasimha Rao P., Hyderabad, India.
Dear Salvatore,
This mail is in response to the LML of Dr Satheeka Kamaladasa, from Sri Lanka, dated 18th Oct. 08, regarding ‘Methaemoglobinaemia and paralysis of the hemi-diaphragm in a leprosy patient’.
Methaemoglobinaemia occurring secondary to dapsone ingestion in leprosy patients is known and also been reported in literature. It usually is not a part of dapsone hypersensitivity syndrome. Methaemoglobinaemia occurs when haemoglobin is oxidized at a rate exceeding the normal enzymatic capacity for haemoglobin reduction. Some individuals are more prone to this condition than others.
Methaemoglobinaemia is characterized by cyanosis in the absence of cardiac or pulmonary disease, and refractory to oxygen administration. The p02 of arterial blood is normal while the measured oxygen saturation is decreased.
The frequently recommended dosage regimen of methylene blue as intermittent bolus dose (is useful in the treatment of methaemoglobinaemia when it occurs due to other causes) is often inadequate when methaemoglobinaemia is secondary to dapsone. This is due to the long half-life of dapsone which provides a continuing oxidative stress that can cause a recurrence of clinically significant methaemoglobinaemia. In dapsone induced methaemoglogbinemia methylene blue infusion is effective, and should be supported by repeated doses of activated charcoal to enhance dapsone elimination. (Dawson AH Whyte IM. Med Toxicol Adverse Drug Exp. 1989 Sep-Oct;4(5):387-92). The efficacy of orally administered activated charcoal is fully comparable to that of haemodialysis in increasing the rate of elimination of dapsone and its metabolite monoacetyldapsone. Activated charcoal is cheap, it can be administered anywhere and its administration rarely involves complications. (Neuvonen PJ, Elonen E, Haapanen EJ. Acta Med Scand. 1983;214(3):215-20). Activated charcoal given orally in multiple doses (20 g X 4/day) which shortens the half-life of dapsone to 12.7 +/- 0.7 hours, from 26 hours which is normal.
When methaemoglobinaemia is fully controlled/ reversed, MDT may be restarted in the patient while withholding Dapsone in the regimen.
Leprosy as cause of phrenic nerve paralysis has not been reported to my knowledge nor have I came across one. However some work has been done and published on the involvement of phrenic nerve in leprosy from the Postgraduate Institute of Medical Education and Research, Chandigarh, India. (Int J Lepr Other Mycobact Dis. 1988 Sep;56(3):389-93). The report states that when phrenic nerve conduction was performed bilaterally in 22 MB leprosy and 18 PB leprosy patients, prolonged phrenic nerve conduction time and/or reduced amplitude of diaphragm muscle action potential beyond 2.5 standard deviations of control mean values was observed in 9 BL-LL patients (4 bilateral) and 6 BT-TT patients (all unilateral). However, the report also states that on fluoroscopy, diaphragm movements were normal in all patients. This study only documented sub-clinical phrenic nerve involvement in leprosy.
Although your patient is in a phase of reaction where neuritis is an associated component, it cannot be attributed as a cause of phrenic nerve paralysis in a patient of leprosy based on the present evidence. While there is a theoretical possibility of phrenic nerve involvement in patients of MB leprosy, other causes for its involvement have to be considered and excluded first, which may be the case in your patient.
Hope this information would be useful to you. Thank you very much for sharing this case with us.
Best regards,
P. Narasimha Rao. M.D. PhD.,
Clinical consultant.
Lepra society -Blue peter research centre
Hyderabad, India.
Ref.: Methaemoglobinaemia and paralysis of the hemi-diaphragm in a leprosy patient.
From: Narasimha Rao P., Hyderabad, India.
Dear Salvatore,
This mail is in response to the LML of Dr Satheeka Kamaladasa, from Sri Lanka, dated 18th Oct. 08, regarding ‘Methaemoglobinaemia and paralysis of the hemi-diaphragm in a leprosy patient’.
Methaemoglobinaemia occurring secondary to dapsone ingestion in leprosy patients is known and also been reported in literature. It usually is not a part of dapsone hypersensitivity syndrome. Methaemoglobinaemia occurs when haemoglobin is oxidized at a rate exceeding the normal enzymatic capacity for haemoglobin reduction. Some individuals are more prone to this condition than others.
Methaemoglobinaemia is characterized by cyanosis in the absence of cardiac or pulmonary disease, and refractory to oxygen administration. The p02 of arterial blood is normal while the measured oxygen saturation is decreased.
The frequently recommended dosage regimen of methylene blue as intermittent bolus dose (is useful in the treatment of methaemoglobinaemia when it occurs due to other causes) is often inadequate when methaemoglobinaemia is secondary to dapsone. This is due to the long half-life of dapsone which provides a continuing oxidative stress that can cause a recurrence of clinically significant methaemoglobinaemia. In dapsone induced methaemoglogbinemia methylene blue infusion is effective, and should be supported by repeated doses of activated charcoal to enhance dapsone elimination. (Dawson AH Whyte IM. Med Toxicol Adverse Drug Exp. 1989 Sep-Oct;4(5):387-92). The efficacy of orally administered activated charcoal is fully comparable to that of haemodialysis in increasing the rate of elimination of dapsone and its metabolite monoacetyldapsone. Activated charcoal is cheap, it can be administered anywhere and its administration rarely involves complications. (Neuvonen PJ, Elonen E, Haapanen EJ. Acta Med Scand. 1983;214(3):215-20). Activated charcoal given orally in multiple doses (20 g X 4/day) which shortens the half-life of dapsone to 12.7 +/- 0.7 hours, from 26 hours which is normal.
When methaemoglobinaemia is fully controlled/ reversed, MDT may be restarted in the patient while withholding Dapsone in the regimen.
Leprosy as cause of phrenic nerve paralysis has not been reported to my knowledge nor have I came across one. However some work has been done and published on the involvement of phrenic nerve in leprosy from the Postgraduate Institute of Medical Education and Research, Chandigarh, India. (Int J Lepr Other Mycobact Dis. 1988 Sep;56(3):389-93). The report states that when phrenic nerve conduction was performed bilaterally in 22 MB leprosy and 18 PB leprosy patients, prolonged phrenic nerve conduction time and/or reduced amplitude of diaphragm muscle action potential beyond 2.5 standard deviations of control mean values was observed in 9 BL-LL patients (4 bilateral) and 6 BT-TT patients (all unilateral). However, the report also states that on fluoroscopy, diaphragm movements were normal in all patients. This study only documented sub-clinical phrenic nerve involvement in leprosy.
Although your patient is in a phase of reaction where neuritis is an associated component, it cannot be attributed as a cause of phrenic nerve paralysis in a patient of leprosy based on the present evidence. While there is a theoretical possibility of phrenic nerve involvement in patients of MB leprosy, other causes for its involvement have to be considered and excluded first, which may be the case in your patient.
Hope this information would be useful to you. Thank you very much for sharing this case with us.
Best regards,
P. Narasimha Rao. M.D. PhD.,
Clinical consultant.
Lepra society -Blue peter research centre
Hyderabad, India.
Relapse in leprosy
Leprosy Mailing List – October 19th, 2008
Ref.: Relapse in leprosy
From: Kar H. K., New Delhi, India
Dear Dr Noto,
I refer to Dr Moharani’s LML message dated Oct. 18th, 2008. Relapse is defined as the recurrence of the disease at any time after the completion of a full course of treatment (WHO, OPERATIONAL GUIDELINE\SEA/GLP/2006.2).
Relapse is indicated by the appearance of new skin lesions and in case of multibacillary (MB) relapse, by evidence on a skin smear of an increase in bacteriological index (BI) of two or more units. It is difficult to be certain that a relapse has occurred, as new lesions may appear in late Type 1 leprosy reaction (also called late reversal reaction or LRR) after the patient has been released from treatment (RFT). Usually, the relapse appears after a sufficient time period to allow the left out live bacilli to multiply, may be a period of three years approximately, to produce a clinical new lesion.
Down grading type 1 reaction is no more considered as a separate type of type 1 reaction since this is nothing but a downgradation of the disease process in the spectrum due to delay in starting MDT. However, when ever there is difficulty to differentiate between LRR and relapse a course of oral steroid for a period of 4 to 6 weeks help in confirmation of the LRR which shows remarkable improvement. MB relapse should be investigated by using skin smears and histopathology.
Dr (Prof.) H K Kar
MD, MNAMS,
President, Indian Association of Leprologists,
Consultant & HODDepartment of Dermatology, STD & Leprosy
PGIMER and associated Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001
India
Ref.: Relapse in leprosy
From: Kar H. K., New Delhi, India
Dear Dr Noto,
I refer to Dr Moharani’s LML message dated Oct. 18th, 2008. Relapse is defined as the recurrence of the disease at any time after the completion of a full course of treatment (WHO, OPERATIONAL GUIDELINE\SEA/GLP/2006.2).
Relapse is indicated by the appearance of new skin lesions and in case of multibacillary (MB) relapse, by evidence on a skin smear of an increase in bacteriological index (BI) of two or more units. It is difficult to be certain that a relapse has occurred, as new lesions may appear in late Type 1 leprosy reaction (also called late reversal reaction or LRR) after the patient has been released from treatment (RFT). Usually, the relapse appears after a sufficient time period to allow the left out live bacilli to multiply, may be a period of three years approximately, to produce a clinical new lesion.
Down grading type 1 reaction is no more considered as a separate type of type 1 reaction since this is nothing but a downgradation of the disease process in the spectrum due to delay in starting MDT. However, when ever there is difficulty to differentiate between LRR and relapse a course of oral steroid for a period of 4 to 6 weeks help in confirmation of the LRR which shows remarkable improvement. MB relapse should be investigated by using skin smears and histopathology.
Dr (Prof.) H K Kar
MD, MNAMS,
President, Indian Association of Leprologists,
Consultant & HODDepartment of Dermatology, STD & Leprosy
PGIMER and associated Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001
India
Methaemoglobinaemia and paralysis of the hemi-diaphragm in a leprosy patient
Leprosy Mailing List – October 19th, 2008
Ref.: Methaemoglobinaemia and paralysis of the hemi-diaphragm in a leprosy patient.
From: Bryceson A., London, UK
Dear Salvatore,
Concerning Dr Kamaladasa's case (LML Oct. 18th, 2008), I cannot explain the methaemoglobinaemia but the signs at the right diaphragm and the general clinical picture suggest the possibility of a sub-diaphragmatic abscess, such as an amoebic liver abscess. An ultrasound scan and amoebic serology might be helpful. Steroids might aggravate the situation and mask its seriousness.
Best wishes,
Anthony
Ref.: Methaemoglobinaemia and paralysis of the hemi-diaphragm in a leprosy patient.
From: Bryceson A., London, UK
Dear Salvatore,
Concerning Dr Kamaladasa's case (LML Oct. 18th, 2008), I cannot explain the methaemoglobinaemia but the signs at the right diaphragm and the general clinical picture suggest the possibility of a sub-diaphragmatic abscess, such as an amoebic liver abscess. An ultrasound scan and amoebic serology might be helpful. Steroids might aggravate the situation and mask its seriousness.
Best wishes,
Anthony
Methaemoglobinaemia and paralysis of the hemi-diaphragm in a leprosy patient
Leprosy Mailing List – October 18th, 2008
Ref.: Methaemoglobinaemia and paralysis of the hemi-diaphragm in a leprosy patient.
From: Satheeka Kamaladasa, Sri Lanka
Dear Dr Noto,
Dr Settinayake has kindly given me your e-mail address to discuss about some complications in a patient with lepromatous leprosy.
A 35-year-old patient was admitted to the ward with fever and a macular papular rash of 3 days duration. He was a diagnosed patient with lepromatous leprosy with multiple lesions and had been treated with the multi-drug therapy for multibacillary (MB) patients for 1 month duration.
While in the ward he became dyspnoeic, cyanosed and the arterial blood gases showed hypoxemia. Patient was transferred to the ICU, and MB therapy was stopped suspecting a dapsone hypersensitivity. Patient was noticed to have mild icterus and the air entry on the R base of the lung was reduced. Investigations showed increased retic count, methaemoglobinaemia and elevated liver enzymes.
Chest X-ray showed elevated R hemidiaphgram with hardly any inflammatory shadows. Ultra sound scan showed reduced movement of the R hemidiaphgram. Awaiting Fluroscopy. At this stage diaphgramatic paralysis due to involvement of the phrenic nerve was considered.
Whether this could be explained by a leprosy reaction?
Or can you put all these due to dapsone hypersensitivity syndrome?
Patient is on steroids and anti leprosy therapy has been omitted. I would value expert opinion about the explanation for his of respiratory problem. Whether it is related to a leprosy reaction or its treatment?
Physians & neurologists have seen the patient & have excluded other pulmonary pathologies & nerological causes & cardiac causes.
Thanking.
Yours sincerely,
Dr Satheeka Kamaladasa
Consultant Dermatologist
& Senior Lecturer in Medicine
Dept Of Medicine
Faculty of Medicine
University of Sri Jayawardenapura
Sri Lanka
Ref.: Methaemoglobinaemia and paralysis of the hemi-diaphragm in a leprosy patient.
From: Satheeka Kamaladasa, Sri Lanka
Dear Dr Noto,
Dr Settinayake has kindly given me your e-mail address to discuss about some complications in a patient with lepromatous leprosy.
A 35-year-old patient was admitted to the ward with fever and a macular papular rash of 3 days duration. He was a diagnosed patient with lepromatous leprosy with multiple lesions and had been treated with the multi-drug therapy for multibacillary (MB) patients for 1 month duration.
While in the ward he became dyspnoeic, cyanosed and the arterial blood gases showed hypoxemia. Patient was transferred to the ICU, and MB therapy was stopped suspecting a dapsone hypersensitivity. Patient was noticed to have mild icterus and the air entry on the R base of the lung was reduced. Investigations showed increased retic count, methaemoglobinaemia and elevated liver enzymes.
Chest X-ray showed elevated R hemidiaphgram with hardly any inflammatory shadows. Ultra sound scan showed reduced movement of the R hemidiaphgram. Awaiting Fluroscopy. At this stage diaphgramatic paralysis due to involvement of the phrenic nerve was considered.
Whether this could be explained by a leprosy reaction?
Or can you put all these due to dapsone hypersensitivity syndrome?
Patient is on steroids and anti leprosy therapy has been omitted. I would value expert opinion about the explanation for his of respiratory problem. Whether it is related to a leprosy reaction or its treatment?
Physians & neurologists have seen the patient & have excluded other pulmonary pathologies & nerological causes & cardiac causes.
Thanking.
Yours sincerely,
Dr Satheeka Kamaladasa
Consultant Dermatologist
& Senior Lecturer in Medicine
Dept Of Medicine
Faculty of Medicine
University of Sri Jayawardenapura
Sri Lanka
BIKASH Nepal Training Centre courses announcement
Leprosy Mailing List – October 18th, 2008
Ref.: BIKASH Nepal Training Centre courses announcement (see attachment)
From: Gopal G., Pokhara, Kaski, Nepal
Dear Dr. Noto,
Greetings from Nepal!
BIKASH Nepal Training Centre is organizing 3 international courses in Pokhara in 2009. They are:
1: Training and Communication Skills: 02-13 February 2009 (2 weeks)
2: Rehabilitation and Prevention of Disability: 23 February - 06 March, 2009 (2 weeks)
3: Community Based Rehabilitation (CBR): 09 - 20 March, 2009 (2 weeks)
The attached announcement will provide further details about the courses. Kindly publish these announcements through the Leprosy Mailing List.
Thanking you for your support.
Yours sincerely,
Gopal GurungProgramme ManagerBIKASH NepalGreen Pastures ComplexPO Box: 28PokharaKaski
Nepal
Ref.: BIKASH Nepal Training Centre courses announcement (see attachment)
From: Gopal G., Pokhara, Kaski, Nepal
Dear Dr. Noto,
Greetings from Nepal!
BIKASH Nepal Training Centre is organizing 3 international courses in Pokhara in 2009. They are:
1: Training and Communication Skills: 02-13 February 2009 (2 weeks)
2: Rehabilitation and Prevention of Disability: 23 February - 06 March, 2009 (2 weeks)
3: Community Based Rehabilitation (CBR): 09 - 20 March, 2009 (2 weeks)
The attached announcement will provide further details about the courses. Kindly publish these announcements through the Leprosy Mailing List.
Thanking you for your support.
Yours sincerely,
Gopal GurungProgramme ManagerBIKASH NepalGreen Pastures ComplexPO Box: 28PokharaKaski
Nepal
Relapse of leprosy
Leprosy Mailing List – October 18th, 2008
Ref.: Relapse of leprosy
From: Maharani I., Jakarta, Indonesia.
Dear Dr. Salvatore,
Firstly I would like to introduce myself. My name is Indah Maharani and I am a resident in dermato-venereology at University of Indonesia, Jakarta. Could you please add my email to the mailing list, thank you for your kind assistance.
Furthermore, I am currently writing a paper on relapse of leprosy and there are some questions that I would like to raise, hope you can help to answer.
1.Is there a fixed criteria on relapse of leprosy?
2.Do you have any idea where I can get online source on relapse of leprosy?
3.
Pertaining downgrading, is this clinically similar to relapse?
I appreciate your kind assistance and awaiting your kind response.
Kind Regards,
Dr. Indah Maharani
Resident in dermato-venereology
University of Indonesia
Jakarta, Indonesia
Ref.: Relapse of leprosy
From: Maharani I., Jakarta, Indonesia.
Dear Dr. Salvatore,
Firstly I would like to introduce myself. My name is Indah Maharani and I am a resident in dermato-venereology at University of Indonesia, Jakarta. Could you please add my email to the mailing list, thank you for your kind assistance.
Furthermore, I am currently writing a paper on relapse of leprosy and there are some questions that I would like to raise, hope you can help to answer.
1.Is there a fixed criteria on relapse of leprosy?
2.Do you have any idea where I can get online source on relapse of leprosy?
3.
Pertaining downgrading, is this clinically similar to relapse?
I appreciate your kind assistance and awaiting your kind response.
Kind Regards,
Dr. Indah Maharani
Resident in dermato-venereology
University of Indonesia
Jakarta, Indonesia
Thursday, October 16, 2008
Module on Disability and Development, Amsterdam, The Netherlands, Nov.24th – Dec.12th, 2008
Leprosy Mailing List – October 14th, 2008
Ref.: Module on Disability and Development, Amsterdam, The Netherlands, Nov.24th – Dec.12th, 2008 (see attachment)
From: Cornielje H., Alphen aan den Rijn, The Netherlands
Dear Dr Noto,
Could you please be so kind to circulate the attached announcement on the mailing list?
Thanks and kind regards,
Huib
Huib Cornielje
Enablement
Langenhorst 36
2402PX Alphen aan den Rijn
The Netherlands
Tel: 0031-172-436953
Mobile: 0031-6-28485083
Fax: 0031-172-244976
E-mail: h.cornieljeatenablement.nl
Internet: www.enablement.nl
Ref.: Module on Disability and Development, Amsterdam, The Netherlands, Nov.24th – Dec.12th, 2008 (see attachment)
From: Cornielje H., Alphen aan den Rijn, The Netherlands
Dear Dr Noto,
Could you please be so kind to circulate the attached announcement on the mailing list?
Thanks and kind regards,
Huib
Huib Cornielje
Enablement
Langenhorst 36
2402PX Alphen aan den Rijn
The Netherlands
Tel: 0031-172-436953
Mobile: 0031-6-28485083
Fax: 0031-172-244976
E-mail: h.cornieljeatenablement.nl
Internet: www.enablement.nl
Leprosy in children
Leprosy Mailing List – October 6th, 2008
Ref.: Leprosy in children (see attachment)
From: Naafs B., Munnekeburen, The Netherlands
Dear Salvatore,
Concerning Dr Deepak's request (LML Sept 5th 2008):- I gave a talk over 10 years ago in Jaipur at a Paediatric conference and later published the content of that talk in a Dutch teaching journal Memisa Medisch. Find enclosed the text I hope it may be useful.
At that time I had little experience in leprosy in children in Brazil. There they have a nodular form of leprosy in children. I have looked for a paper on this specific subject, which can be found with Google: “Nodular leprosy of childhood and tuberculoid leprosy: A comparative, morphologic, immunopathologic and quantitative study of skin tissue reaction”. International Journal of Leprosy and Other Mycobacterial Diseases, Sep 2003 by Fakhouri, Ricardo, Sotto, Mirian N, Manini, Marli I P, Margarido, Leontina C
Ben
<< Naafs B 2008 10 04 Leprosy in children >>
Ref.: Leprosy in children (see attachment)
From: Naafs B., Munnekeburen, The Netherlands
Dear Salvatore,
Concerning Dr Deepak's request (LML Sept 5th 2008):- I gave a talk over 10 years ago in Jaipur at a Paediatric conference and later published the content of that talk in a Dutch teaching journal Memisa Medisch. Find enclosed the text I hope it may be useful.
At that time I had little experience in leprosy in children in Brazil. There they have a nodular form of leprosy in children. I have looked for a paper on this specific subject, which can be found with Google: “Nodular leprosy of childhood and tuberculoid leprosy: A comparative, morphologic, immunopathologic and quantitative study of skin tissue reaction”. International Journal of Leprosy and Other Mycobacterial Diseases, Sep 2003 by Fakhouri, Ricardo, Sotto, Mirian N, Manini, Marli I P, Margarido, Leontina C
Ben
<< Naafs B 2008 10 04 Leprosy in children >>
CBR and Leprosy in Asia Pacific
Leprosy Mailing List – October 5th, 2008
Ref.: CBR and Leprosy in Asia Pacific
From: Deepak S., Bologna, Italy
Dear Salvatore,
Disability & Rehabilitation team of World Health Organisation (WHO/DAR) in collaboration with other WHO departments, other UN organisations, international and national federations and NGOs, is organising the Asia Pacific Congress on Community-based rehabilitation (CBR) in Bangkok (Thailand) from 9 to 11 December 2008. More information about the Asia Pacific CBR congress is available from the following website: http://www.cbr-asiapacific.org/
In this occasion, a number of pre and post congress workshops on specific themes are also being organised. One of these workshops will be on "CBR and Leprosy" that is being organised by WHO/DAR, ILEP & IDEA. It is possible that Global Leprosy Programme of WHO (WHO/GLP) and Thailand National Leprosy Programme will also be official partners for this workshop. It will be held from 12 to 13 December 2008 at Prince Palace Mahanak hotel in Bangkok.
More information about the pre and post congress workshops and their registration forms including for the "CBR and Leprosy" workshop are available at the following website: http://www.aifo.it/english/resources/announcements/2008/bangkok_cbr_workshops08.htm
Dr Sunil Deepak
Head, Medical Support Department
AIFO
Via Borselli 4-6
40135 - Bologna
Italy
Tel: +39051 - 4393211 / 4393219 (Direct)
Fax: +39051 - 434046
Email: sunil.deepakataifo.it
Webpage: www.aifo.it/english/
Ref.: CBR and Leprosy in Asia Pacific
From: Deepak S., Bologna, Italy
Dear Salvatore,
Disability & Rehabilitation team of World Health Organisation (WHO/DAR) in collaboration with other WHO departments, other UN organisations, international and national federations and NGOs, is organising the Asia Pacific Congress on Community-based rehabilitation (CBR) in Bangkok (Thailand) from 9 to 11 December 2008. More information about the Asia Pacific CBR congress is available from the following website: http://www.cbr-asiapacific.org/
In this occasion, a number of pre and post congress workshops on specific themes are also being organised. One of these workshops will be on "CBR and Leprosy" that is being organised by WHO/DAR, ILEP & IDEA. It is possible that Global Leprosy Programme of WHO (WHO/GLP) and Thailand National Leprosy Programme will also be official partners for this workshop. It will be held from 12 to 13 December 2008 at Prince Palace Mahanak hotel in Bangkok.
More information about the pre and post congress workshops and their registration forms including for the "CBR and Leprosy" workshop are available at the following website: http://www.aifo.it/english/resources/announcements/2008/bangkok_cbr_workshops08.htm
Dr Sunil Deepak
Head, Medical Support Department
AIFO
Via Borselli 4-6
40135 - Bologna
Italy
Tel: +39051 - 4393211 / 4393219 (Direct)
Fax: +39051 - 434046
Email: sunil.deepakataifo.it
Webpage: www.aifo.it/english/
Elimination of Discrimination Against Persons Affected by Leprosy and their Family Members (2)
Leprosy Mailing List – October 4th, 2008
Ref.: Elimination of Discrimination Against Persons Affected by Leprosy and their Family Members (2) (see attachment)
From: Soutar D., London, UK
London 24 September 2008
<>
Dear Colleagues,
Following my communications with the Office of the High Commission for Human Rights regarding the important Human Rights Council Resolution 8/13 entitled “Elimination of discrimination against persons affected by leprosy and their family members”, the ILEP Secretariat has now received a copy of a formal letter calling for information to assist in the preparation of a report to the Human Rights Advisory Committee.
The letter (see attached link) calls for views and information on the following:
a) Information on measures taken by Governments to eliminate discrimination against persons affected by leprosy and their family members;
b)Studies carried out at a national level, including by civil society organizations and independent research institutions, on the existence and impact of discriminatory policies and practices related to leprosy in the area of human rights;
c)Views on the relationship between obligations arising out of international human rights treaties and de jure or de facto discrimination in relation to leprosy for the persons affected and their family members.
Any responses should be forwarded to the OHCHR (as indicated in their letter, to registry@ohchr.org or jsotomayor@ohchr.org by the 31st October, 2008. I would also appreciate if the ILEP Secretariat could receive copies in order to monitor the extent of the evidence being submitted. I believe this is a real opportunity for ILEP and their partners, especially those from organizations of people affected by leprosy, to provide the evidence which can help bring about real and meaningful achievements in tackling stigma and discrimination. I hope also that many of you will be able to participate in their proposed meeting in Geneva on January 15th 2009.
With best regards,
Douglas Soutar
Mr Douglas Soutar
General Secretary
International Federation of Anti-Leprosy Associations
doug.soutaratilep.org.uk
www.ilep.org.uk
Tel: + 44 (0)20 7602 6925
Ref.: Elimination of Discrimination Against Persons Affected by Leprosy and their Family Members (2) (see attachment)
From: Soutar D., London, UK
London 24 September 2008
<
Dear Colleagues,
Following my communications with the Office of the High Commission for Human Rights regarding the important Human Rights Council Resolution 8/13 entitled “Elimination of discrimination against persons affected by leprosy and their family members”, the ILEP Secretariat has now received a copy of a formal letter calling for information to assist in the preparation of a report to the Human Rights Advisory Committee.
The letter (see attached link) calls for views and information on the following:
a) Information on measures taken by Governments to eliminate discrimination against persons affected by leprosy and their family members;
b)Studies carried out at a national level, including by civil society organizations and independent research institutions, on the existence and impact of discriminatory policies and practices related to leprosy in the area of human rights;
c)Views on the relationship between obligations arising out of international human rights treaties and de jure or de facto discrimination in relation to leprosy for the persons affected and their family members.
Any responses should be forwarded to the OHCHR (as indicated in their letter, to registry@ohchr.org or jsotomayor@ohchr.org by the 31st October, 2008. I would also appreciate if the ILEP Secretariat could receive copies in order to monitor the extent of the evidence being submitted. I believe this is a real opportunity for ILEP and their partners, especially those from organizations of people affected by leprosy, to provide the evidence which can help bring about real and meaningful achievements in tackling stigma and discrimination. I hope also that many of you will be able to participate in their proposed meeting in Geneva on January 15th 2009.
With best regards,
Douglas Soutar
Mr Douglas Soutar
General Secretary
International Federation of Anti-Leprosy Associations
doug.soutaratilep.org.uk
www.ilep.org.uk
Tel: + 44 (0)20 7602 6925
Elimination of Discrimination Against Persons Affected by Leprosy and their Family Members (1)
Leprosy Mailing List – October 4th, 2008
Ref.: Elimination of Discrimination Against Persons Affected by Leprosy and their Family Members (1)
From: Soutar D., London, UK
Dear Salvatore,
I hope this can be posted on the LML.
Regards,
Doug
London 22 September 2008
http://www.nippon-foundation.or.jp/eng/2jcahj000005bps8-att/8f0j6k000000wnel.pdf
Dear colleagues,
I am certain that many of you will have already received and read with interest the latest issue of the Newsletter of the WHO Goodwill Ambassador. The passing of UNHRC resolution (8/13) in June 2008 on “Elimination of discrimination against persons affected by leprosy and their family members” is a very important development and as General Secretary of ILEP I am eager that all those working in, or affected by, leprosy are fully involved in supporting States in taking the necessary steps to fulfill their obligations under this resolution. The article in the newsletter explaining the resolution indicates that governments should already be approaching people affected by leprosy in an information-gathering process and that there will be a meeting in December or January to exchange views among relevant actors.
Among the readership of the leprosy mailing list there are many “relevant actors” and I very much hope that this information-gathering process is seeking their views and, most importantly, those of people affected by leprosy and their associations.
I am trying to find out more information about the proposed meeting and would welcome any feedback you can provide on how the information-gathering process is being undertaken in your local situation.
With best regards,
Douglas Soutar
Mr Douglas Soutar
General Secretary
International Federation of Anti-Leprosy Associations
doug.soutaratilep.org.uk
www.ilep.org.uk
Tel: + 44 (0)20 7602 6925
Ref.: Elimination of Discrimination Against Persons Affected by Leprosy and their Family Members (1)
From: Soutar D., London, UK
Dear Salvatore,
I hope this can be posted on the LML.
Regards,
Doug
London 22 September 2008
http://www.nippon-foundation.or.jp/eng/2jcahj000005bps8-att/8f0j6k000000wnel.pdf
Dear colleagues,
I am certain that many of you will have already received and read with interest the latest issue of the Newsletter of the WHO Goodwill Ambassador. The passing of UNHRC resolution (8/13) in June 2008 on “Elimination of discrimination against persons affected by leprosy and their family members” is a very important development and as General Secretary of ILEP I am eager that all those working in, or affected by, leprosy are fully involved in supporting States in taking the necessary steps to fulfill their obligations under this resolution. The article in the newsletter explaining the resolution indicates that governments should already be approaching people affected by leprosy in an information-gathering process and that there will be a meeting in December or January to exchange views among relevant actors.
Among the readership of the leprosy mailing list there are many “relevant actors” and I very much hope that this information-gathering process is seeking their views and, most importantly, those of people affected by leprosy and their associations.
I am trying to find out more information about the proposed meeting and would welcome any feedback you can provide on how the information-gathering process is being undertaken in your local situation.
With best regards,
Douglas Soutar
Mr Douglas Soutar
General Secretary
International Federation of Anti-Leprosy Associations
doug.soutaratilep.org.uk
www.ilep.org.uk
Tel: + 44 (0)20 7602 6925
Friday, October 3, 2008
Leprosy in children
Leprosy Mailing List - September 23rd, 2008
Ref.: Leprosy in children (see attachment)
From: Erlings J., Amsterdam, The Nethelands
Dear Dr Noto,
I would like to refer to Dr Deepak's message about literature on leprosy in children (LML Sep. 5th, 2008).
Attached to this e-mail you will find the results of a literature search I did earlier this year on this topic. Anyone interested in receiving full text copies of selected articles may contact me by e-mail at <<>infolepatleprastichting.nl >>.
With kind regards,
Jiske Erlings
INFOLEP Leprosy Information Services
Ref.: Leprosy in children (see attachment)
From: Erlings J., Amsterdam, The Nethelands
Dear Dr Noto,
I would like to refer to Dr Deepak's message about literature on leprosy in children (LML Sep. 5th, 2008).
Attached to this e-mail you will find the results of a literature search I did earlier this year on this topic. Anyone interested in receiving full text copies of selected articles may contact me by e-mail at <<>infolepatleprastichting.nl >>.
With kind regards,
Jiske Erlings
INFOLEP Leprosy Information Services
Reversal reaction (RR or Type 1 reaction)
Leprosy Mailing List, September 22nd, 2008
Ref.: Reversal reaction (RR or Type 1 reaction)
From: Saunderson, P., Greenville, SC, USA
Dear Salvatore,
I would like to respond to Dr Ranawaka concerning her second case, the lepromatous patient with a recurrent reversal reaction (LML Aug. 25th, 2008).
I would like to present data from the AMFES study in Ethiopia, published in Leprosy Review in Sept 2000. In those papers, patients were classified as MB or PB, but I’ve looked again at the data to determine figures for LL patients.
Skin manifestations of RR:
It is true that the typical skin signs of a reversal reaction were mainly seen in borderline patients. Of the 594 patients in the study 98 (16%) showed skin signs of RR; of these 56% were BL cases, 35% were BT cases and only 7% were LL (2% were either TT cases or neural leprosy). But there were fewer LL patients, so skin signs appeared in 23% of all BL cases, 11% of BT cases and 7% of LL cases. (Note: for the purposes of this analysis the few BB cases were included with the BL cases).
Neuropathy as a sign of RR (while the underlying pathophysiology of neuropathy remains obscure, it is often linked to a reversal reaction and is treated in the same way, so many clinicians view neuropathy as another manifestation of RR).
Neuropathy is, if anything, slightly more common in LL cases. In the same cohort of 594 patients in Ethiopia, 258 (43%) developed neuropathy at the time of, or after diagnosis; it occurred in 47% of BL cases, 33% of BT cases and in 54% of LL cases. Similarly, in relation to the highest BI at diagnosis, neuropathy was least frequent in those with a BI of 0 (33%), but most frequent in those with a BI of 6 (59%). Thus new nerve function impairment, requiring treatment with steroids, is common in lepromatous leprosy.
Recurrence of the condition is common, occurring in 54% of the neuropathy cases mentioned above, but it is more common in LL cases. When standardized treatment with steroids was being developed in the 1980’s (at ALERT, under the leadership of Dr Marijke Becx), it was noted even then that multibacillary patients were more likely to get recurrent episodes; it has been standard practice at ALERT since the 1980’s to use the 12-week course of steroids for PB cases, but a 24-week course for MB cases with reversal reactions. The so-called Standard 12-week regimen comes from the WHO “Guide to Eliminate Leprosy as a Public Health Problem” (written in 1995 as an internal WHO document, but published in 2000), which aimed at producing safe and straightforward guidelines for field use.
The recently published WHO Operational Guidelines, linked to the Global Strategy for Further Reducing the Leprosy Burden and Sustaining Leprosy Control Activities (2006 – 2010), mentions treatment with a course of steroids, “…usually lasting 3 – 6 months” (page 27). The ILEP Learning Guide “How to Recognise and Manage Leprosy Reactions” suggests a 12 –week course for PB cases and a 24-week course for MB cases. Many individual leprologists prefer to tailor the steroid regimen to the response of the patient, but this can only be advocated in centers with broad experience in managing leprosy reactions and in managing patients on steroids. [ Note that both the Operational Guidelines and the ILEP Learning Guides are available as pdf files on the ILEP web-site: www.ilep.org.uk ]
Thank you for presenting this interesting case for discussion!
Dr Paul Saunderson, MD, MRCP
Medical Director: American Leprosy Missions
Head Office: 1 ALM Way, Greenville, SC 29601, USA
Home address: Østrem, 6013 Ålesund, Norway
Email: psaundersonatleprosy.org
Ref.: Reversal reaction (RR or Type 1 reaction)
From: Saunderson, P., Greenville, SC, USA
Dear Salvatore,
I would like to respond to Dr Ranawaka concerning her second case, the lepromatous patient with a recurrent reversal reaction (LML Aug. 25th, 2008).
I would like to present data from the AMFES study in Ethiopia, published in Leprosy Review in Sept 2000. In those papers, patients were classified as MB or PB, but I’ve looked again at the data to determine figures for LL patients.
Skin manifestations of RR:
It is true that the typical skin signs of a reversal reaction were mainly seen in borderline patients. Of the 594 patients in the study 98 (16%) showed skin signs of RR; of these 56% were BL cases, 35% were BT cases and only 7% were LL (2% were either TT cases or neural leprosy). But there were fewer LL patients, so skin signs appeared in 23% of all BL cases, 11% of BT cases and 7% of LL cases. (Note: for the purposes of this analysis the few BB cases were included with the BL cases).
Neuropathy as a sign of RR (while the underlying pathophysiology of neuropathy remains obscure, it is often linked to a reversal reaction and is treated in the same way, so many clinicians view neuropathy as another manifestation of RR).
Neuropathy is, if anything, slightly more common in LL cases. In the same cohort of 594 patients in Ethiopia, 258 (43%) developed neuropathy at the time of, or after diagnosis; it occurred in 47% of BL cases, 33% of BT cases and in 54% of LL cases. Similarly, in relation to the highest BI at diagnosis, neuropathy was least frequent in those with a BI of 0 (33%), but most frequent in those with a BI of 6 (59%). Thus new nerve function impairment, requiring treatment with steroids, is common in lepromatous leprosy.
Recurrence of the condition is common, occurring in 54% of the neuropathy cases mentioned above, but it is more common in LL cases. When standardized treatment with steroids was being developed in the 1980’s (at ALERT, under the leadership of Dr Marijke Becx), it was noted even then that multibacillary patients were more likely to get recurrent episodes; it has been standard practice at ALERT since the 1980’s to use the 12-week course of steroids for PB cases, but a 24-week course for MB cases with reversal reactions. The so-called Standard 12-week regimen comes from the WHO “Guide to Eliminate Leprosy as a Public Health Problem” (written in 1995 as an internal WHO document, but published in 2000), which aimed at producing safe and straightforward guidelines for field use.
The recently published WHO Operational Guidelines, linked to the Global Strategy for Further Reducing the Leprosy Burden and Sustaining Leprosy Control Activities (2006 – 2010), mentions treatment with a course of steroids, “…usually lasting 3 – 6 months” (page 27). The ILEP Learning Guide “How to Recognise and Manage Leprosy Reactions” suggests a 12 –week course for PB cases and a 24-week course for MB cases. Many individual leprologists prefer to tailor the steroid regimen to the response of the patient, but this can only be advocated in centers with broad experience in managing leprosy reactions and in managing patients on steroids. [ Note that both the Operational Guidelines and the ILEP Learning Guides are available as pdf files on the ILEP web-site: www.ilep.org.uk ]
Thank you for presenting this interesting case for discussion!
Dr Paul Saunderson, MD, MRCP
Medical Director: American Leprosy Missions
Head Office: 1 ALM Way, Greenville, SC 29601, USA
Home address: Østrem, 6013 Ålesund, Norway
Email: psaundersonatleprosy.org
Sonography for assessing nerve thickening in Leprosy
Leprosy Mailing List - September 22nd, 2008
Ref.: Sonography for assessing nerve thickening in Leprosy
From: Salafia A., Mumbai, India
Dear Salvatore,
Referring to assessment of nerve size; in the literature there are already references to "sonography" of nerves to assess consistency and size. It is possible; a sonography instrument is required and, somebody capable of reading it.
Yours sincerely,
Salafia
Ref.: Sonography for assessing nerve thickening in Leprosy
From: Salafia A., Mumbai, India
Dear Salvatore,
Referring to assessment of nerve size; in the literature there are already references to "sonography" of nerves to assess consistency and size. It is possible; a sonography instrument is required and, somebody capable of reading it.
Yours sincerely,
Salafia
Measuring leprosy related stigma
Leprosy Mailing List - September 22nd, 2008
Ref.: Measuring leprosy related stigma (please see attachment)
From: de Pinho Andrade J. E., Rio de Janeiro, RJ, Brazil
Dear Salvatore,
I refer to Mr Singh’s request circulated with the LML dated Sept. 15th, 2008. There is a very good article by Wim van Brakel on the issue of measuring leprosy-related stigma. It’s attached to this e-mail and is available at http://www.leprosyjournal.org/pdfserv/10.1489/1544-581X(2003)71%3C190:MLSPRO%3E2.0.CO;2. Please circulate it in the LML!
Best regards,
José Eduardo de Pinho Andrade, MD, MPH
Associação NLR Brasil
Avenida Marechal Câmara, 350 Sala 1002 – Centro
CEP 20.020-080 – Rio de Janeiro – RJ
Brasil
eduardoathansen.org.br
http://www.hansen.org.br/
Ref.: Measuring leprosy related stigma (please see attachment)
From: de Pinho Andrade J. E., Rio de Janeiro, RJ, Brazil
Dear Salvatore,
I refer to Mr Singh’s request circulated with the LML dated Sept. 15th, 2008. There is a very good article by Wim van Brakel on the issue of measuring leprosy-related stigma. It’s attached to this e-mail and is available at http://www.leprosyjournal.org/pdfserv/10.1489/1544-581X(2003)71%3C190:MLSPRO%3E2.0.CO;2. Please circulate it in the LML!
Best regards,
José Eduardo de Pinho Andrade, MD, MPH
Associação NLR Brasil
Avenida Marechal Câmara, 350 Sala 1002 – Centro
CEP 20.020-080 – Rio de Janeiro – RJ
Brasil
eduardoathansen.org.br
http://www.hansen.org.br/
Nerve thickening standards
Leprosy Mailing List - September 21st, 2008
Note: The tables in this post are not easy to understand on this blog. You can also look at this post on the LML archives for easier understanding.
Ref.: Nerve thickening standards
From: Srinivasan H., Chennai, India
Dear Dr Noto,
This is with reference to the query raised by Dr KV Krishnamurthy about standards and gradation of nerve thickening in leprosy (July 31, 2008). My views on this are as follows.Involvement of peripheral nerves is such an essential feature of leprosy that one will not diagnose leprosy without any evidence for the same. Typical impairments (deformities and disabilities) due to damage to peripheral nerves is are complications of leprosy dreaded by affected persons. We therefore look, during clinical examination, for nerve involvement for two totally different reasons: (a) for help in diagnosing the disease and (b) also for help in assessing the risk of impairments resulting from damage to peripheral nerves.
Peripheral nerve involvement manifests clinically as:
(a) thickening elicited by palpation of the affected nerves;
(b) tenderness (pain elicited by normal palpation);
(c) spontaneous pain in the affected nerves (nerve pain); and
(d) nerve function deficit (NFD – sensori-motor-autonomic deficit).
It will be noticed that we do not have objective measurements for assessing the first three parameters (thickening, tenderness, pain) and that we depend on the subjective judgements, of ourselves or of the affected person. Certain amount of experience in clinical examination is necessary for making these judgements. The fact that these parameters are based on subjective appraisal does not mean that we cannot come to reasonably accurate conclusions like those based on objective measurements. I have used the following scales and found them useful and fairly accurately repeatable.
(a) Nerve thickening: a four-grade scale (0 to 3) is used.
Grade
Degree
Description
0.
No thickening
Nerve undoubtedly feels normal
1
Mild thickening
Probably thickened or doubtful thickening
2
Moderate
Nerve undoubtedly feels thickened
3
Severe
Nerve is grossly thickened
Greater accuracy than what is obtained with this grading does not appear necessary or useful.
(b) Nerve tenderness: a four-grade scale (0 to 3) is used.
You palpate the nerve and watch the subject’s behaviour. If the subject does not indicate that palpation was painful, ask whether feeling the nerve was painful.
Grade
Degree
Description
0
None
Says palpation is not painful even when asked about it.
1
Mild
Says palpation is painful only when asked about it
2
Moderate
Indicates palpation is painful even without asking about it
3
Severe
Is scared of palpation. Jumps, or, tries to withdraw the part. Tries to avoid palpation
I have found the above described four grade system quite adequate for our purposes. It has also been found it repeatable with fairly low inter observer variation.
(c) Nerve pain: A four-degree scale (0 to 3) is used.
Grade
Degree
Description
0
None
Does not complain of nerve pain; says ‘no nerve pain’ even when asked about it
1
Mild
Complains of nerve pain even when not asked about it. But, says ‘it is not severe ‘ when asked about it.
2
Moderate
Says ‘it is severe’ when asked about it. But says it does not interfere with sleep and demonstrates that the movement of the adjoining joint is not restricted by pain.
3
Severe
Says ‘pain is severe, and/or that it interferes with sleep; and/or movement of the adjacent joint is restricted because of pain.
Other recognized methods of grading pain are to ask the subject (a) to locate the level of his/her pain on a pain line (like a number line marked zero at one end and 10 at the other end), or, (b) describe the severity of the pain in terms of monetary units, with one rupee or one dollar as the most severe or intolerable pain.
Though the above are qualitative scales, they are reasonably reliable and accurate and can be used like quantitative scales, provided we do not give the numerical values more than their due (e.g., Gr. 2 is not twice as much as Gr. 4).
Thank you.
H. Srinivasan
Note: The tables in this post are not easy to understand on this blog. You can also look at this post on the LML archives for easier understanding.
Note: The tables in this post are not easy to understand on this blog. You can also look at this post on the LML archives for easier understanding.
Ref.: Nerve thickening standards
From: Srinivasan H., Chennai, India
Dear Dr Noto,
This is with reference to the query raised by Dr KV Krishnamurthy about standards and gradation of nerve thickening in leprosy (July 31, 2008). My views on this are as follows.Involvement of peripheral nerves is such an essential feature of leprosy that one will not diagnose leprosy without any evidence for the same. Typical impairments (deformities and disabilities) due to damage to peripheral nerves is are complications of leprosy dreaded by affected persons. We therefore look, during clinical examination, for nerve involvement for two totally different reasons: (a) for help in diagnosing the disease and (b) also for help in assessing the risk of impairments resulting from damage to peripheral nerves.
Peripheral nerve involvement manifests clinically as:
(a) thickening elicited by palpation of the affected nerves;
(b) tenderness (pain elicited by normal palpation);
(c) spontaneous pain in the affected nerves (nerve pain); and
(d) nerve function deficit (NFD – sensori-motor-autonomic deficit).
It will be noticed that we do not have objective measurements for assessing the first three parameters (thickening, tenderness, pain) and that we depend on the subjective judgements, of ourselves or of the affected person. Certain amount of experience in clinical examination is necessary for making these judgements. The fact that these parameters are based on subjective appraisal does not mean that we cannot come to reasonably accurate conclusions like those based on objective measurements. I have used the following scales and found them useful and fairly accurately repeatable.
(a) Nerve thickening: a four-grade scale (0 to 3) is used.
Grade
Degree
Description
0.
No thickening
Nerve undoubtedly feels normal
1
Mild thickening
Probably thickened or doubtful thickening
2
Moderate
Nerve undoubtedly feels thickened
3
Severe
Nerve is grossly thickened
Greater accuracy than what is obtained with this grading does not appear necessary or useful.
(b) Nerve tenderness: a four-grade scale (0 to 3) is used.
You palpate the nerve and watch the subject’s behaviour. If the subject does not indicate that palpation was painful, ask whether feeling the nerve was painful.
Grade
Degree
Description
0
None
Says palpation is not painful even when asked about it.
1
Mild
Says palpation is painful only when asked about it
2
Moderate
Indicates palpation is painful even without asking about it
3
Severe
Is scared of palpation. Jumps, or, tries to withdraw the part. Tries to avoid palpation
I have found the above described four grade system quite adequate for our purposes. It has also been found it repeatable with fairly low inter observer variation.
(c) Nerve pain: A four-degree scale (0 to 3) is used.
Grade
Degree
Description
0
None
Does not complain of nerve pain; says ‘no nerve pain’ even when asked about it
1
Mild
Complains of nerve pain even when not asked about it. But, says ‘it is not severe ‘ when asked about it.
2
Moderate
Says ‘it is severe’ when asked about it. But says it does not interfere with sleep and demonstrates that the movement of the adjoining joint is not restricted by pain.
3
Severe
Says ‘pain is severe, and/or that it interferes with sleep; and/or movement of the adjacent joint is restricted because of pain.
Other recognized methods of grading pain are to ask the subject (a) to locate the level of his/her pain on a pain line (like a number line marked zero at one end and 10 at the other end), or, (b) describe the severity of the pain in terms of monetary units, with one rupee or one dollar as the most severe or intolerable pain.
Though the above are qualitative scales, they are reasonably reliable and accurate and can be used like quantitative scales, provided we do not give the numerical values more than their due (e.g., Gr. 2 is not twice as much as Gr. 4).
Thank you.
H. Srinivasan
Note: The tables in this post are not easy to understand on this blog. You can also look at this post on the LML archives for easier understanding.
An attempt to standardize nerve enlargement in leprosy
Leprosy Mailing List - September 21st, 2008
Ref.: An attempt to standardize nerve enlargement in leprosy
From: Eggens H., Amsterdam, The Netherlands
Dear Salvatore,
I refer to the important LML message of Dr Krishna Moorthy K. V., Cherlapally, Hyderabad, India, requiring information about graduation of nerve thickening in leprosy and dated July 31st, 2008. I thank him for putting forward this topic.
During my initial training in leprosy (mid-eighties) I came across a learning device (at ALERT?) consisting of a set of about five pieces of rope (10 cm long) of different diameter. During the examination of patients, the size of their nerves were to be compared with the set of ropes to try to make any nerve enlargement objectively verifiable.
I never saw it since then. It was an attempt to standardize nerve enlargements. Anybody has recent experiences?
Henk
Henk Eggens, MD, MPH
Senior Public Health Adviser
Development Policy & Practice
Royal Tropical Institute
P.O.Box 95001, 1090 AH Amsterdam
Phone: +31 (0)20 5688305
Web: www.kit.nl
Ref.: An attempt to standardize nerve enlargement in leprosy
From: Eggens H., Amsterdam, The Netherlands
Dear Salvatore,
I refer to the important LML message of Dr Krishna Moorthy K. V., Cherlapally, Hyderabad, India, requiring information about graduation of nerve thickening in leprosy and dated July 31st, 2008. I thank him for putting forward this topic.
During my initial training in leprosy (mid-eighties) I came across a learning device (at ALERT?) consisting of a set of about five pieces of rope (10 cm long) of different diameter. During the examination of patients, the size of their nerves were to be compared with the set of ropes to try to make any nerve enlargement objectively verifiable.
I never saw it since then. It was an attempt to standardize nerve enlargements. Anybody has recent experiences?
Henk
Henk Eggens, MD, MPH
Senior Public Health Adviser
Development Policy & Practice
Royal Tropical Institute
P.O.Box 95001, 1090 AH Amsterdam
Phone: +31 (0)20 5688305
Web: www.kit.nl
Call for papers for a special issue of Leprosy Review
Leprosy Mailing List, September 21st, 2008
Ref.: Call for papers for a special issue of Leprosy Review (please see attachment)
From: Allen, I., Colchester, Essex, UK.
Dear Salvatore,
It would be possible to put our 'call for papers' on the Leprosy Mailing List please? With many thanks for all your help.
Best wishes,
Irene
Mrs. Irene Allen
Assistant Editor
Leprosy Review
In attachment: << Allen Irene 2008 09 21 call for papers.doc >>
Ref.: Call for papers for a special issue of Leprosy Review (please see attachment)
From: Allen, I., Colchester, Essex, UK.
Dear Salvatore,
It would be possible to put our 'call for papers' on the Leprosy Mailing List please? With many thanks for all your help.
Best wishes,
Irene
Mrs. Irene Allen
Assistant Editor
Leprosy Review
In attachment: << Allen Irene 2008 09 21 call for papers.doc >>
Leprosy, society and stigma
Leprosy Mailing List, September 21st, 2008
Ref.: "Leprosy, society and stigma”.
From: Ryan T, Oxford, UK
Dear Salvatore,
I refer to Dr Singh request about a <<>>. (LML Sept. 15th, 2008).
This request should be easily answered by a Google search or a glance through leprosy journals, but I want to emphasise that the aspect of being unwelcome in society is shared by other skin diseases such as psoriasis, vitiligo, and elephantiasis which are also good models.
It was also found to be a feature of other conditions such as incontinence or even being wheel chair bound so it will do contemporary leprosy studies no favour if the proposed study is confined to leprosy. The Quality of Life movement was much improved by the WHO changes in classification that included participation as a factor requiring measurement. I will post of some reprints to Dr Singh.
Terence Ryan
Ref.: "Leprosy, society and stigma”.
From: Ryan T, Oxford, UK
Dear Salvatore,
I refer to Dr Singh request about a <<>>. (LML Sept. 15th, 2008).
This request should be easily answered by a Google search or a glance through leprosy journals, but I want to emphasise that the aspect of being unwelcome in society is shared by other skin diseases such as psoriasis, vitiligo, and elephantiasis which are also good models.
It was also found to be a feature of other conditions such as incontinence or even being wheel chair bound so it will do contemporary leprosy studies no favour if the proposed study is confined to leprosy. The Quality of Life movement was much improved by the WHO changes in classification that included participation as a factor requiring measurement. I will post of some reprints to Dr Singh.
Terence Ryan
Type 1 (reversal) reaction
Leprosy Mailing List, September 15th, 2008
Ref.: Type 1 (reversal) reaction
From: van Brakel W., Amsterdam, Netherlands
Dear Dr. Ranawaka,
I refer to you paper dated LML Aug. 25th, 2008. Yes, recurrent type 1 reaction (T1R) is well-known in lepromatous leprosy. This is then assumed to be the 'sub-polar' type, but I wouldn't claim I could tell the difference between polar and sub-polar, nor is it relevant to treatment. T1R in multibacillary (MB) leprosy should be treated with a longer course of steroids; 6 months is recommended (see e.g. Becx-Bleumink & Berhe, Int Lep J, 1992 and Rao et al, Leprosy Rev 2006). Recurrence during and just after tapering of steroids is often seen and was also documented in our recent INFIR Cohort Study in India, though we have not published specifically on recurrent reaction yet.
With friendly greetings,
Wim
Wim H. van Brakel
KIT Leprosy Unit
Wibautstraat 137
J1097DN Amsterdam
Netherlands
+3120 6939297
w.v.brakelatkit.nl
www.kit.nl
Ref.: Type 1 (reversal) reaction
From: van Brakel W., Amsterdam, Netherlands
Dear Dr. Ranawaka,
I refer to you paper dated LML Aug. 25th, 2008. Yes, recurrent type 1 reaction (T1R) is well-known in lepromatous leprosy. This is then assumed to be the 'sub-polar' type, but I wouldn't claim I could tell the difference between polar and sub-polar, nor is it relevant to treatment. T1R in multibacillary (MB) leprosy should be treated with a longer course of steroids; 6 months is recommended (see e.g. Becx-Bleumink & Berhe, Int Lep J, 1992 and Rao et al, Leprosy Rev 2006). Recurrence during and just after tapering of steroids is often seen and was also documented in our recent INFIR Cohort Study in India, though we have not published specifically on recurrent reaction yet.
With friendly greetings,
Wim
Wim H. van Brakel
KIT Leprosy Unit
Wibautstraat 137
J1097DN Amsterdam
Netherlands
+3120 6939297
w.v.brakelatkit.nl
www.kit.nl
Request about: "Leprosy, society and stigma: an anthropological study in an urban setting”
Leprosy Mailing List, September 15th, 2008
Ref.: Request about: "Leprosy, society and stigma: an anthropological study in an urban setting”.
From: Sukhbir Singh, Chandigarh, Panjab, India
Respected Sir ,
I am a research scholar in the Department of Anthropology, Panjab University, Chandigarh. I am doing my research work on the topic "Leprosy, society and stigma: an anthropological study in an urban setting”.
Sir I need some favour from you. Sir I need a “model” to study the stigma of leprosy patients (e.g. a theoretical framework or any scale to measure stigma). If you have information about relevant material or references please let me know so that I can use in my research work. They will be correctly acknowledged in the thesis.
Thanking you.
Yours sincerely,
Sukhbir SinghResearch ScholarDepartment of AnthropologyPanjab UniversityChandigarh
India
Postal address:-# B-729, Rathpur Colony, Pinjore,District- Panchkula,Haryana- 134102
Ref.: Request about: "Leprosy, society and stigma: an anthropological study in an urban setting”.
From: Sukhbir Singh, Chandigarh, Panjab, India
Respected Sir ,
I am a research scholar in the Department of Anthropology, Panjab University, Chandigarh. I am doing my research work on the topic "Leprosy, society and stigma: an anthropological study in an urban setting”.
Sir I need some favour from you. Sir I need a “model” to study the stigma of leprosy patients (e.g. a theoretical framework or any scale to measure stigma). If you have information about relevant material or references please let me know so that I can use in my research work. They will be correctly acknowledged in the thesis.
Thanking you.
Yours sincerely,
Sukhbir SinghResearch ScholarDepartment of AnthropologyPanjab UniversityChandigarh
India
Postal address:-# B-729, Rathpur Colony, Pinjore,District- Panchkula,Haryana- 134102
Management of type 1 (reversal) reaction
Leprosy Mailing List, September 15th, 2008
Ref.: Management of type 1 (reversal) reaction
From: Periche Fernandez J., Santo Domingo, Dominican Republic
Dear Salvatore,
This is about the request of information about treatment of type 1 (reversal) reaction from Dr Ranawaka R., from Anuradhapura, Sri Lanka dated Mon, August 25, 2008.
Dr Ranawaka reported a 60 year old woman with lepromatous leprosy (LL) and presenting with type 1 reaction. She was treated with oral prednisolone for 3 months. At the tapering off of prednisolone she developed recurrence of type 1 reaction twice. Dr Ranawaka’s questions are:-
Question 1.
”Is type 1 reaction described in lepromatous leprosy?”
No! type one reactions are seen in borderline (BT, BB, BL) cases, if the reaction is really type 1 then the patient is not LL, but she probably is a BL case. This means a borderline case but close to the LL side on the leprosy spectrum. Alternatively the patient may have sub polar lepromatous leprosy (LLs). On the other hand it might be that the patient is having a type 2 reaction! A carefully look at biopsy taken form the lesions and a new bacteriology, both compared to previous biopsy and bacteriology might give the clue and tell the difference. If there are ENL like nodules this will give diagnosis of the type 2 reaction.
Question 2.
“Is there a recurrent type of type 1 (reversal) reaction?”
Yes. Both types of reactions are recurrent.
Question 3.
“Is the 3 month course of oral prednisolone the standard treatment?”
No. Some patients need longer than that.
There may also be a late reaction; that is to say a reaction after ending MDT. Biopsy and bacteriology are necessary to rule out the presence of live acid fast bacilli (these would indicate the need for prolongation of antibacterial therapy).
Regards,
Dr. Juan Periche Fernandez
Medico-DermatologoDirector Unidad de Lepra del Distrito Nacional
Coordinador Comite de etica interno (Internal review board)
Instituto Dermatologico y Cirugia de PielDr Huberto Bogaert Diaz (IDCP-Dr.HBD)
office (809) 684-3257 ext 234
Fax (809) 681-7687
Apartado postal 1090Corazones Unidos
Dermatologia y Cosmiatria(809) 683-6185mobile (809)815-1060
e mail: jpericheathvtudr.org
Santo Domingo DN, Rep Dominicana
Ref.: Management of type 1 (reversal) reaction
From: Periche Fernandez J., Santo Domingo, Dominican Republic
Dear Salvatore,
This is about the request of information about treatment of type 1 (reversal) reaction from Dr Ranawaka R., from Anuradhapura, Sri Lanka dated Mon, August 25, 2008.
Dr Ranawaka reported a 60 year old woman with lepromatous leprosy (LL) and presenting with type 1 reaction. She was treated with oral prednisolone for 3 months. At the tapering off of prednisolone she developed recurrence of type 1 reaction twice. Dr Ranawaka’s questions are:-
Question 1.
”Is type 1 reaction described in lepromatous leprosy?”
No! type one reactions are seen in borderline (BT, BB, BL) cases, if the reaction is really type 1 then the patient is not LL, but she probably is a BL case. This means a borderline case but close to the LL side on the leprosy spectrum. Alternatively the patient may have sub polar lepromatous leprosy (LLs). On the other hand it might be that the patient is having a type 2 reaction! A carefully look at biopsy taken form the lesions and a new bacteriology, both compared to previous biopsy and bacteriology might give the clue and tell the difference. If there are ENL like nodules this will give diagnosis of the type 2 reaction.
Question 2.
“Is there a recurrent type of type 1 (reversal) reaction?”
Yes. Both types of reactions are recurrent.
Question 3.
“Is the 3 month course of oral prednisolone the standard treatment?”
No. Some patients need longer than that.
There may also be a late reaction; that is to say a reaction after ending MDT. Biopsy and bacteriology are necessary to rule out the presence of live acid fast bacilli (these would indicate the need for prolongation of antibacterial therapy).
Regards,
Dr. Juan Periche Fernandez
Medico-DermatologoDirector Unidad de Lepra del Distrito Nacional
Coordinador Comite de etica interno (Internal review board)
Instituto Dermatologico y Cirugia de PielDr Huberto Bogaert Diaz (IDCP-Dr.HBD)
office (809) 684-3257 ext 234
Fax (809) 681-7687
Apartado postal 1090Corazones Unidos
Dermatologia y Cosmiatria(809) 683-6185mobile (809)815-1060
e mail: jpericheathvtudr.org
Santo Domingo DN, Rep Dominicana
Friday, September 12, 2008
Leprosy Mailing List, September 11th, 2008
Ref.: Leprosy in children and INFOLEP
From: v Brakel W., Amsterdam, The Netherlands
Dear Salvatore,
I refer to Dr Sunil Deepak LML message dated Sept. 5th 2008. I have already written a specific suggestion to Sunil, but would like to remind LML readers that such requests for articles, etc. can also be addressed to the now joint ILEP/NLR resource centre INFOLEP. Requests should be addressed to:
infolep@leprastichting.nl.
More information about INFOLEP and its resources can be found on the new ILEP website: www.ilep.org.uk.
With best wishes,
Wim van Brakel
KIT Leprosy Unit
w.v.brakelatkit.nl
Ref.: Leprosy in children and INFOLEP
From: v Brakel W., Amsterdam, The Netherlands
Dear Salvatore,
I refer to Dr Sunil Deepak LML message dated Sept. 5th 2008. I have already written a specific suggestion to Sunil, but would like to remind LML readers that such requests for articles, etc. can also be addressed to the now joint ILEP/NLR resource centre INFOLEP. Requests should be addressed to:
infolep@leprastichting.nl.
More information about INFOLEP and its resources can be found on the new ILEP website: www.ilep.org.uk.
With best wishes,
Wim van Brakel
KIT Leprosy Unit
w.v.brakelatkit.nl
Leprosy in children
Leprosy Mailing List, September 11th, 2008
Ref.: Leprosy in children
From: Faria Rodrigues C. A., Passos, MG, Brazil
Dear Salvatore,
I think many of us around the world like Dr Sunil Deepak (LML Sep. 5th, 2008) have the same problem with “leprosy in children” and those monographs and articles he asked for, on this theme will be useful to all of us.
Thanks.
With best wishes,
Dr Carlos Alberto Faria Rodrigues
Av. Arouca 660 Sala 1014 – Passos – Minas Gerais – BrazilTel: +55 (35) 3521-7811Email dermorlatpassosnet.com.br Webpage: www.hanseniase2.passosuemg.br
Ref.: Leprosy in children
From: Faria Rodrigues C. A., Passos, MG, Brazil
Dear Salvatore,
I think many of us around the world like Dr Sunil Deepak (LML Sep. 5th, 2008) have the same problem with “leprosy in children” and those monographs and articles he asked for, on this theme will be useful to all of us.
Thanks.
With best wishes,
Dr Carlos Alberto Faria Rodrigues
Av. Arouca 660 Sala 1014 – Passos – Minas Gerais – BrazilTel: +55 (35) 3521-7811Email dermorlatpassosnet.com.br Webpage: www.hanseniase2.passosuemg.br
Leprosy in children
Leprosy Mailing List, September 11th, 2008
Ref.: Leprosy in children
From: Ryan T., Oxford, UK
Dear Salvatore,
I refer to Dr Deepak’s LML message dated Sept. 5th, 2008. Very important to emphasise that anything that switches on repair of the epidermis accelerates its cell turnover and melanisation may not be able to keep up. Mild dermatitis is very common due a range of climate effects, infections and irritants. It results in hypopigmentation, so white patches in children are common (Pityriasis alba) and respond to emollients. Sweating is not pronounced in children and therefore its absence un helpful. The memory of leprosy has to be sown in every medical student and of course the basic skill of sensory testing.
In Children, facial pityriasis alba cannot so easily be distinguished since the facial innervation defects in leprosy white patches in children are difficult to define. One hesitates to biopsy a child's face but persistent white patches else where on the body, not responding to emollients or antifungals should be biopsied. As has been pointed out by Margaret Lockwood in the UK the memory of leprosy is often triggered by the Dermatologists habit of taking a biopsy.
This is a preface to ask you not to focus on this rare disease out of context of the many other causes of skin disease but to emphasise the importance of the skin, its barrier function, communication role, themoregulation, and sensory function and encourage them to avoid the ignorance that prevails world wide on how to manage it.
Most of dermatology's textbooks and Internet are well equipped to answer questions on the diagnosis of skin lesions in Children. Think of leprosy should be the main teaching point.
Terence Ryan
Ref.: Leprosy in children
From: Ryan T., Oxford, UK
Dear Salvatore,
I refer to Dr Deepak’s LML message dated Sept. 5th, 2008. Very important to emphasise that anything that switches on repair of the epidermis accelerates its cell turnover and melanisation may not be able to keep up. Mild dermatitis is very common due a range of climate effects, infections and irritants. It results in hypopigmentation, so white patches in children are common (Pityriasis alba) and respond to emollients. Sweating is not pronounced in children and therefore its absence un helpful. The memory of leprosy has to be sown in every medical student and of course the basic skill of sensory testing.
In Children, facial pityriasis alba cannot so easily be distinguished since the facial innervation defects in leprosy white patches in children are difficult to define. One hesitates to biopsy a child's face but persistent white patches else where on the body, not responding to emollients or antifungals should be biopsied. As has been pointed out by Margaret Lockwood in the UK the memory of leprosy is often triggered by the Dermatologists habit of taking a biopsy.
This is a preface to ask you not to focus on this rare disease out of context of the many other causes of skin disease but to emphasise the importance of the skin, its barrier function, communication role, themoregulation, and sensory function and encourage them to avoid the ignorance that prevails world wide on how to manage it.
Most of dermatology's textbooks and Internet are well equipped to answer questions on the diagnosis of skin lesions in Children. Think of leprosy should be the main teaching point.
Terence Ryan
11th congress of the Brazilian Society of Leprology. Porto Alegre, Brazil, 24-26 November 2008
Leprosy Mailing List, September 11th, 2008
Ref.: 11th congress of the Brazilian Society of Leprology. Porto Alegre, Brazil, 24-26 November 2008
From: Theuvenet W., Apeldoorn, The Netherlands
Dear Salvatore,
Warm regards from the Netherlands!
To visit the 11th congress of the Brazilian Leprology Society (Porto Alegre, Brazil, 24-26 November 2008) sounds like a real learning experience be it that the announcement comes in a bit late for some agendas. Are dates for the 12th congress already set?
Warm regards,
Wim
Ref.: 11th congress of the Brazilian Society of Leprology. Porto Alegre, Brazil, 24-26 November 2008
From: Theuvenet W., Apeldoorn, The Netherlands
Dear Salvatore,
Warm regards from the Netherlands!
To visit the 11th congress of the Brazilian Leprology Society (Porto Alegre, Brazil, 24-26 November 2008) sounds like a real learning experience be it that the announcement comes in a bit late for some agendas. Are dates for the 12th congress already set?
Warm regards,
Wim
20 weeks of Prednisolone are better than 12 weeks in the treatment of reversal reaction (RR)
Leprosy Mailing List, September 11th, 2008
Ref.: 20 weeks of Prednisolone are better than 12 weeks in the treatment of reversal reaction (RR)
From: Kar H. K., New Delhi, India
Dear Dr Salvatore,
Thanks. I refer to Dr. Kawuma’s message (LML, Sept. 8th, 2008) on the treatment of reversal reaction (RR or Type 1 reaction). I agree with him. A short course of prednisolone less than 12 weeks is not sufficient to control RR.
Irrespective of the spectrum of the disease, 5 to 6 months (or even more) course of prednisolone is required to control RR along with MDT. When the inflamed lesion of RR is on the face, it may need more than 6 months of prednisolone therapy. You may need to continue tapering dose of steroid few more weeks after the patient has been released from treatment (RFT) to prevent late RR or to treat late RR.
This is our experience.
Best regards.
Dr (Prof.) H K KarMD, MNAMSConsultant & HODDepartment of Dermatology, STD & LeprosyPGIMER, Dr Ram Manohar Lohia HospitalBaba Kharag Singh MargNew Delhi-110001
India
Ref.: 20 weeks of Prednisolone are better than 12 weeks in the treatment of reversal reaction (RR)
From: Kar H. K., New Delhi, India
Dear Dr Salvatore,
Thanks. I refer to Dr. Kawuma’s message (LML, Sept. 8th, 2008) on the treatment of reversal reaction (RR or Type 1 reaction). I agree with him. A short course of prednisolone less than 12 weeks is not sufficient to control RR.
Irrespective of the spectrum of the disease, 5 to 6 months (or even more) course of prednisolone is required to control RR along with MDT. When the inflamed lesion of RR is on the face, it may need more than 6 months of prednisolone therapy. You may need to continue tapering dose of steroid few more weeks after the patient has been released from treatment (RFT) to prevent late RR or to treat late RR.
This is our experience.
Best regards.
Dr (Prof.) H K KarMD, MNAMSConsultant & HODDepartment of Dermatology, STD & LeprosyPGIMER, Dr Ram Manohar Lohia HospitalBaba Kharag Singh MargNew Delhi-110001
India
20 weeks of Prednisolone are better than 12 weeks in the treatment of type 1 (reversal) reaction
Leprosy Mailing List, September 8th, 2008
Ref.: 20 weeks of Prednisolone are better than 12 weeks in the treatment of type 1 (reversal) reaction
From: Kawuma H. J., Kampala, Uganda
Dear Salvatore,
I refer to the request by Dr. Ranawaka on the treatment of Type 1 (reversal) reaction (Leprosy Mailing List, August 25th, 2008). I wish to share the experience from Uganda.
Polar types of leprosy, both tuberculoid (TT) and lepromatous (LLp), are rare in our region. We have more cases of sub-polar lepromatous leprosy (LLs), lacking classical features of LLp.
The LLs cases were known to develop protracted and recurrent Type 1 reactions but which when well managed gave a very good result in the end for the patient.
We learnt to use more prolonged treatment with Prednisolone and this has been confirmed by good clinical trials. 20 weeks Prednisolone courses are better than 12 weeks courses. Of course we need to keep in mind other factors (already discussed in this forum) that can precipitate recurrent reactions or poor response to treatment.
H Joseph Kawuma
GLRA, Kampala, Uganda
Ref.: 20 weeks of Prednisolone are better than 12 weeks in the treatment of type 1 (reversal) reaction
From: Kawuma H. J., Kampala, Uganda
Dear Salvatore,
I refer to the request by Dr. Ranawaka on the treatment of Type 1 (reversal) reaction (Leprosy Mailing List, August 25th, 2008). I wish to share the experience from Uganda.
Polar types of leprosy, both tuberculoid (TT) and lepromatous (LLp), are rare in our region. We have more cases of sub-polar lepromatous leprosy (LLs), lacking classical features of LLp.
The LLs cases were known to develop protracted and recurrent Type 1 reactions but which when well managed gave a very good result in the end for the patient.
We learnt to use more prolonged treatment with Prednisolone and this has been confirmed by good clinical trials. 20 weeks Prednisolone courses are better than 12 weeks courses. Of course we need to keep in mind other factors (already discussed in this forum) that can precipitate recurrent reactions or poor response to treatment.
H Joseph Kawuma
GLRA, Kampala, Uganda
Management of nerve abscess in leprosy
Leprosy Mailing List, September 8th, 2008
Ref.: Management of nerve abscess in leprosy
From: Salafia A., Mumbai, India
Dear Salvatore,
This has reference to the on-going discussion about nerves and nerve abscess; let me add one more “last” word.
My colleague and I operate in a referral hospital in Mumbai; 95% of the patients referred to us have been treated elsewhere before coming to us and they are referred because the treatment given has not worked.
After few years of trial and error (because nobody in India used to teach about nerve surgery, as the Indian School (unlike the French School) was against surgery of nerves, in 1990 we formulated our protocol which is still valid. Let me add the we have been seen about 650 neuritis cases a year, out of which only about 100-150 have been operated; in the last year and this year too the number of referred cases has come down significantly to about 250-300 a year.
The protocol for all types of neuritis;
a)We operate, as soon as possible, in cases of "visible swelling" (I repeat, already treated for months on elsewhere without benefit), discharging sinus, increasing neural loss, intractable pain and/or paresthesia.
b)All other cases are first given a course of steroids (most clinicians use 'homeopathic dosages of steroids). In our book we suggest 1mg. of Prednisolone (or its equivalent) per kilo body wt. Our routine is: I.M. injection of Dexamethasone in tapering dosages: start with 8-12 mgs (as per body wt.) per day for 3 day, followed by 6-10 mgs. for another 3 days, and then 4-8 mgs for another 3 days. At this point the patient is assessed: 1.)If all symptoms have disappeared or at least reduced significantly, we prescribe oral steroids - starting from 20-30 mgs. of Prednisolone and taper it over a period of 3-6 months or more (assessment once a month or so).
2.)If the symptoms have not subsided or have increased, then we explore surgically without further ado.
About the statement made by Dr. Warren (LML Sept. 2nd, 2008), that any stroke of knife may increase neural damage, we had the same doubt when we started; but once our protocol was set, this problem was solved.
How you may ask? I trained in microsurgery in 1983 under Prof. G. Brunelli (a world authority on the field) and Dr. Chauhan trained too in 1990 under the same teacher, here in India. In 1990 the hospital received an operation microscope (Zeiss), and every since, we have been using (in almost all cases) operation microscope and microsurgical techniques; in this way the damage to the nerves is nil or almost.
Naked-eye surgery (as it is was done in the past and is even done today by some) is not without risks as mentioned in our book, besides we are against all those dubious procedures like stripping the epineurium, ante position of the ulnar etc.. for reasons clearly stated in our book*.
While dealing with nerve abscess, we have been guilty a few times (if guilty is the right word) of being too cautious; let me explain. We have three cases who came to us with large abscesses of the ulnar and total neural loss; we carried out a surgical toilet, the nerve looked totally necrotic yet we refrained ourselves from removing the 'empty shell' which was the epineurium, in the hope that some nerve fibres might be still viable.
Well, one patient, in whom we did a successful claw-hand repair, come exactly after 10 years with a small abscess in the 'empty shell'; and this point the patient insisted that we explore the nerve and remove whatever there was to remove (we explained to him what had happened). We had no other choice but excise the 'empty shell'. The same has happened in another two cases, both coming to us after 8-10 years from the first surgery. Experience and the operation microscope have taught us when to stop and where... To our students (every year we have a training programme for young surgeons) we teach and show (in the O.T.) what to do and what not to do.
I believe this is enough. Thanks for your patience.
Antonio Salafia
Head of dept. or reconstructive surgery
Vimala hospital
Mumbai
India
*Treatment of Neuritis in Leprosy. Medical and Surgical”. A. Salafia, G. Chauhan, 1997.
Ref.: Management of nerve abscess in leprosy
From: Salafia A., Mumbai, India
Dear Salvatore,
This has reference to the on-going discussion about nerves and nerve abscess; let me add one more “last” word.
My colleague and I operate in a referral hospital in Mumbai; 95% of the patients referred to us have been treated elsewhere before coming to us and they are referred because the treatment given has not worked.
After few years of trial and error (because nobody in India used to teach about nerve surgery, as the Indian School (unlike the French School) was against surgery of nerves, in 1990 we formulated our protocol which is still valid. Let me add the we have been seen about 650 neuritis cases a year, out of which only about 100-150 have been operated; in the last year and this year too the number of referred cases has come down significantly to about 250-300 a year.
The protocol for all types of neuritis;
a)We operate, as soon as possible, in cases of "visible swelling" (I repeat, already treated for months on elsewhere without benefit), discharging sinus, increasing neural loss, intractable pain and/or paresthesia.
b)All other cases are first given a course of steroids (most clinicians use 'homeopathic dosages of steroids). In our book we suggest 1mg. of Prednisolone (or its equivalent) per kilo body wt. Our routine is: I.M. injection of Dexamethasone in tapering dosages: start with 8-12 mgs (as per body wt.) per day for 3 day, followed by 6-10 mgs. for another 3 days, and then 4-8 mgs for another 3 days. At this point the patient is assessed: 1.)If all symptoms have disappeared or at least reduced significantly, we prescribe oral steroids - starting from 20-30 mgs. of Prednisolone and taper it over a period of 3-6 months or more (assessment once a month or so).
2.)If the symptoms have not subsided or have increased, then we explore surgically without further ado.
About the statement made by Dr. Warren (LML Sept. 2nd, 2008), that any stroke of knife may increase neural damage, we had the same doubt when we started; but once our protocol was set, this problem was solved.
How you may ask? I trained in microsurgery in 1983 under Prof. G. Brunelli (a world authority on the field) and Dr. Chauhan trained too in 1990 under the same teacher, here in India. In 1990 the hospital received an operation microscope (Zeiss), and every since, we have been using (in almost all cases) operation microscope and microsurgical techniques; in this way the damage to the nerves is nil or almost.
Naked-eye surgery (as it is was done in the past and is even done today by some) is not without risks as mentioned in our book, besides we are against all those dubious procedures like stripping the epineurium, ante position of the ulnar etc.. for reasons clearly stated in our book*.
While dealing with nerve abscess, we have been guilty a few times (if guilty is the right word) of being too cautious; let me explain. We have three cases who came to us with large abscesses of the ulnar and total neural loss; we carried out a surgical toilet, the nerve looked totally necrotic yet we refrained ourselves from removing the 'empty shell' which was the epineurium, in the hope that some nerve fibres might be still viable.
Well, one patient, in whom we did a successful claw-hand repair, come exactly after 10 years with a small abscess in the 'empty shell'; and this point the patient insisted that we explore the nerve and remove whatever there was to remove (we explained to him what had happened). We had no other choice but excise the 'empty shell'. The same has happened in another two cases, both coming to us after 8-10 years from the first surgery. Experience and the operation microscope have taught us when to stop and where... To our students (every year we have a training programme for young surgeons) we teach and show (in the O.T.) what to do and what not to do.
I believe this is enough. Thanks for your patience.
Antonio Salafia
Head of dept. or reconstructive surgery
Vimala hospital
Mumbai
India
*Treatment of Neuritis in Leprosy. Medical and Surgical”. A. Salafia, G. Chauhan, 1997.
“eMedicine”
Leprosy Mailing List, September 8th, 2008
Ref.: “eMedicine”
From: Frankel R. I., Hawaii, USA
Dear Dr. Noto,
With all due respect, I must take issue with Dr. Compostella's statement "eMedicine is the leading provider of clinical medical information for medical professionals and consumers." (LML Sept. 6th, 2008). It is but one of many sources of clinical medical information, and I certainly do not consider it the leading provider.
I am sure many readers of your list will disagree with statements in this article, such as "The fluid is placed on a glass slide and stained by using the Ziehl-Neelsen acid-fast method or the Fite method to look for organisms." One should certainly avoid the Ziehl-Neelsen stain because of the risk of a false negative result. One can take issue with other statements, but I am writing less to criticize this paper than to caution readers regarding Dr. Compostella's statement.
The lead author of this eMedicine paper is a resident. I have great respect for residents and spent most of my career actively teaching them. I served as Program Director and Deputy Program of the University of Hawai'i Internal Medicine Residency Program. Yet resident are learning and gaining experience and generally have very limited clinical experience and a limited perspective. I was very surprised in the early days of eMedicine when one of my residents told me that she had written a chapter for eMedicine. Residents can certainly do extensive reviews of the literature, yet that does not generally suffice for broad expertise that includes knowledge of more obscure literature, knowledge of data that has been presented but not published, and clinical and research experience.
Thank you.
Richard I. Frankel, M.D., M.P.H., F.A.C.P.Emeritus Professor of MedicineUniversity of Hawai'i
Ref.: “eMedicine”
From: Frankel R. I., Hawaii, USA
Dear Dr. Noto,
With all due respect, I must take issue with Dr. Compostella's statement "eMedicine is the leading provider of clinical medical information for medical professionals and consumers." (LML Sept. 6th, 2008). It is but one of many sources of clinical medical information, and I certainly do not consider it the leading provider.
I am sure many readers of your list will disagree with statements in this article, such as "The fluid is placed on a glass slide and stained by using the Ziehl-Neelsen acid-fast method or the Fite method to look for organisms." One should certainly avoid the Ziehl-Neelsen stain because of the risk of a false negative result. One can take issue with other statements, but I am writing less to criticize this paper than to caution readers regarding Dr. Compostella's statement.
The lead author of this eMedicine paper is a resident. I have great respect for residents and spent most of my career actively teaching them. I served as Program Director and Deputy Program of the University of Hawai'i Internal Medicine Residency Program. Yet resident are learning and gaining experience and generally have very limited clinical experience and a limited perspective. I was very surprised in the early days of eMedicine when one of my residents told me that she had written a chapter for eMedicine. Residents can certainly do extensive reviews of the literature, yet that does not generally suffice for broad expertise that includes knowledge of more obscure literature, knowledge of data that has been presented but not published, and clinical and research experience.
Thank you.
Richard I. Frankel, M.D., M.P.H., F.A.C.P.Emeritus Professor of MedicineUniversity of Hawai'i
Paper on leprosy from “eMedicine”
Leprosy Mailing List, September 6th, 2008
Ref.: Paper on leprosy from “eMedicine”
From: Compostella L., Cortina d'Ampezzo, Belluno, Italy
Dear Salvatore,
I thought you might be interested in this article from eMedicine. You may either click on the following link or copy and paste it into your browser:-http://www.emedicine.com/derm/TOPIC223.HTM
eMedicine is the leading provider of clinical medical information for medical professionals and consumers. To explore eMedicine today, visit http://www.emedicine.com
Best regards,
Leonida
Ref.: Paper on leprosy from “eMedicine”
From: Compostella L., Cortina d'Ampezzo, Belluno, Italy
Dear Salvatore,
I thought you might be interested in this article from eMedicine. You may either click on the following link or copy and paste it into your browser:-http://www.emedicine.com/derm/TOPIC223.HTM
eMedicine is the leading provider of clinical medical information for medical professionals and consumers. To explore eMedicine today, visit http://www.emedicine.com
Best regards,
Leonida
Report of the 9th meeting of the WHO Technical Advisory Group
Leprosy Mailing List, September 6th, 2008
Ref.: Report of the 9th meeting of the WHO Technical Advisory Group
From: Pannikar V., New Delhi, India
Dear Dr Noto,
Please find attached the report of the 9th meeting of the WHO Technical Advisory Group for your kind perusal.
It may also be interest to leprosy discussion list (LML).
Regards,
V. Pannikar
Ref.: Report of the 9th meeting of the WHO Technical Advisory Group
From: Pannikar V., New Delhi, India
Dear Dr Noto,
Please find attached the report of the 9th meeting of the WHO Technical Advisory Group for your kind perusal.
It may also be interest to leprosy discussion list (LML).
Regards,
V. Pannikar
11th Brazilian Congress of Leprology
Leprosy Mailing List, September 5th, 2008
Ref.: 11th Brazilian Congress of Leprology
From: Andrade E., Rio de Janeiro, Brazil
Dear Dr Salvatore,
The Brazilian Leprology Society is organizing its 11th National Congress which will take place in the city of Porto Alegre, RS, Brazil, from November 24th till 26th 2008. It is one of the most scientific happening in the field of hanseniasis in Brazil!
One can get information at www.sbhansenologia.org.br and sbhatilsl.br
Contact by phone: 00-55-14-3103-5984 or fax: 00-55-14-3103-5916.
Please post it at the LML!
Best regards,
Eduardo Andrade
NLR Brasil
Ref.: 11th Brazilian Congress of Leprology
From: Andrade E., Rio de Janeiro, Brazil
Dear Dr Salvatore,
The Brazilian Leprology Society is organizing its 11th National Congress which will take place in the city of Porto Alegre, RS, Brazil, from November 24th till 26th 2008. It is one of the most scientific happening in the field of hanseniasis in Brazil!
One can get information at www.sbhansenologia.org.br and sbhatilsl.br
Contact by phone: 00-55-14-3103-5984 or fax: 00-55-14-3103-5916.
Please post it at the LML!
Best regards,
Eduardo Andrade
NLR Brasil
Leprosy in children
Leprosy Mailing List, September 5th, 2008
Ref.: Leprosy in children
From: Deepak S., Bologna, Italy
Dear Salvatore,
I need to prepare a lesson for medical students on "Leprosy in children". I shall be grateful if we can receive any monographs or articles or bibliography on this theme from the LML readers.
The documents can be sent to LML or directly to my email: sunil.deepakataifo.it
Thanks in advance to all the LML readers who can help us and with best wishes,
Sunil
Dr Sunil Deepak
Head, Medical Support Department
AIFO
Via Borselli 4-6
40135 - Bologna
Italy
Tel: +39051 - 4393211 / 4393219 (Direct)
Fax: +39051 - 434046
Webpage: www.aifo.it/english/
Ref.: Leprosy in children
From: Deepak S., Bologna, Italy
Dear Salvatore,
I need to prepare a lesson for medical students on "Leprosy in children". I shall be grateful if we can receive any monographs or articles or bibliography on this theme from the LML readers.
The documents can be sent to LML or directly to my email: sunil.deepakataifo.it
Thanks in advance to all the LML readers who can help us and with best wishes,
Sunil
Dr Sunil Deepak
Head, Medical Support Department
AIFO
Via Borselli 4-6
40135 - Bologna
Italy
Tel: +39051 - 4393211 / 4393219 (Direct)
Fax: +39051 - 434046
Webpage: www.aifo.it/english/
Wednesday, September 3, 2008
Management of nerve abscess in leprosy. There is no one rule for every occasion.
Leprosy Mailing List, September 2nd, 2008
Ref.: Management of nerve abscess in leprosy. There is no one rule for every occasion.
From: Warren G., Sydney, Australia
Dear Salvatore,
Interested in the comments about nerve abscesses. In leprosy it is essential that we separate the abscess due to the destruction of the nerve from the antibody-antigen- immunity reaction to that which is caused by a secondary bacillary infection. Sure in the latter it may be essential that the abscess be drained and those bacillary abscesses are usually easy to recognize by the heat and swelling in association with the infection. If they are not drained they may well cause other problems as mentioned by Dr Salafia in a letter from Mumbai (in LML) on August 27th.
However, even when the damaged nerve is infected by foreign bacteria it may eventually resolve, spontaneously, without surgery, leaving only a small lump behind and no problems other than the neural deficits that are the direct result of the destroyed nerve fibres. Surgery will not produce recovery in fact there may be an increase in the neural deficit due to the surgeons knife.
However when the active inflammation of the nerve results is caseation of the nerve fibres and there is no complicating secondary infection this is a totally different matter. It may be possible to palpate the swelling on the nerve but it will usually be painless and no obvious heat. There may be motor and obvious sensory abnormality depending on where the nerve is and that neural deficit may have only recently developed.
One frequently sees these small abscesses on the backs of the hands and then it is usually NOT necessary to try and excise them. They cause no disability and are not really unsightly (especially when compared with all the other problems the patient may have). One often finds them at first diagnosis and once the patient starts on MDT there are not likely to be any or certainly not many more develop and the ones that do develop will slowly absorb and disappear. There is no advantage in excising because the nerve fibres destroyed in the development of the abscess will not and cannot recover. Once treatment starts the number of bacilli will rapidly reduce and further increase in the number of abscesses is unlikely after the first few weeks of MDT.
Surgery may well result in damage to nerve fibres that were not initially involved so may make the neural deficit worse. Best advice is chart size and signs of neural deficit regularly every week for first few weeks and then monthly. If the abscess is still increasing after 4-6 months then obviously it is more than just the effects of an acute upgrading reaction producing caseation. And surgical intervention may need to be considered.
In reference to Dr Srinivasan’s letter (LML Aug. 31st, 2008) I would say that an intraneural abscess usually does not need to be opened unless it is very large and causing pressure problems on tissues around the nerve. The damage to the nerve has been done. Rest Protect the limb give full MDT (steroids are Not indicated usually) give antibiotics if suspect infection and watch carefully.
One patient was sent to me for drainage. I wondered if he really had leprosy but he had a very swollen ulnar nerve exactly in the right place; so we explored it to find it a sarcoid! Another had a very red swollen area over the elbow and extending up into the arm that had been there for several years he said, in spite of MDT. On opening we drained 3-400cc of frank pus the grew an interesting collection of bacteria!
In leprosy I have learnt never to say that something never happens. The most unusual things can happen especially if we do not look for problems and if we try to stick to routines like “Open every abscess!”. There is no one rule for every occasion. I hope these thoughts will help some to save nerve function.
Best regards,
Grace Warren
Ref.: Management of nerve abscess in leprosy. There is no one rule for every occasion.
From: Warren G., Sydney, Australia
Dear Salvatore,
Interested in the comments about nerve abscesses. In leprosy it is essential that we separate the abscess due to the destruction of the nerve from the antibody-antigen- immunity reaction to that which is caused by a secondary bacillary infection. Sure in the latter it may be essential that the abscess be drained and those bacillary abscesses are usually easy to recognize by the heat and swelling in association with the infection. If they are not drained they may well cause other problems as mentioned by Dr Salafia in a letter from Mumbai (in LML) on August 27th.
However, even when the damaged nerve is infected by foreign bacteria it may eventually resolve, spontaneously, without surgery, leaving only a small lump behind and no problems other than the neural deficits that are the direct result of the destroyed nerve fibres. Surgery will not produce recovery in fact there may be an increase in the neural deficit due to the surgeons knife.
However when the active inflammation of the nerve results is caseation of the nerve fibres and there is no complicating secondary infection this is a totally different matter. It may be possible to palpate the swelling on the nerve but it will usually be painless and no obvious heat. There may be motor and obvious sensory abnormality depending on where the nerve is and that neural deficit may have only recently developed.
One frequently sees these small abscesses on the backs of the hands and then it is usually NOT necessary to try and excise them. They cause no disability and are not really unsightly (especially when compared with all the other problems the patient may have). One often finds them at first diagnosis and once the patient starts on MDT there are not likely to be any or certainly not many more develop and the ones that do develop will slowly absorb and disappear. There is no advantage in excising because the nerve fibres destroyed in the development of the abscess will not and cannot recover. Once treatment starts the number of bacilli will rapidly reduce and further increase in the number of abscesses is unlikely after the first few weeks of MDT.
Surgery may well result in damage to nerve fibres that were not initially involved so may make the neural deficit worse. Best advice is chart size and signs of neural deficit regularly every week for first few weeks and then monthly. If the abscess is still increasing after 4-6 months then obviously it is more than just the effects of an acute upgrading reaction producing caseation. And surgical intervention may need to be considered.
In reference to Dr Srinivasan’s letter (LML Aug. 31st, 2008) I would say that an intraneural abscess usually does not need to be opened unless it is very large and causing pressure problems on tissues around the nerve. The damage to the nerve has been done. Rest Protect the limb give full MDT (steroids are Not indicated usually) give antibiotics if suspect infection and watch carefully.
One patient was sent to me for drainage. I wondered if he really had leprosy but he had a very swollen ulnar nerve exactly in the right place; so we explored it to find it a sarcoid! Another had a very red swollen area over the elbow and extending up into the arm that had been there for several years he said, in spite of MDT. On opening we drained 3-400cc of frank pus the grew an interesting collection of bacteria!
In leprosy I have learnt never to say that something never happens. The most unusual things can happen especially if we do not look for problems and if we try to stick to routines like “Open every abscess!”. There is no one rule for every occasion. I hope these thoughts will help some to save nerve function.
Best regards,
Grace Warren
RPOD and CBR course announcements
Leprosy Mailing List, September 2nd, 2008
Ref.: RPOD and CBR course announcements (see attachments)
From: Brandsma W., Addis Ababa, Ethiopia
Dear Salvatore,
Please find attached the course announcements for both the RPOD and CBR courses in Nepal (BIKASH) and Ethiopia (ALERT) for 2009.
There are still some seats available for the 2008 RPOD course at ALERT (October 27- 4 weeks).
Please would you be so kind to distribute these announcements to the members of the LML?
With kind regards,
Wim Brandsma ALERT P.O.Box 165Addis Ababa ETHIOPIAhttp://www.wimariet.com/+251-11-3211371
Ref.: RPOD and CBR course announcements (see attachments)
From: Brandsma W., Addis Ababa, Ethiopia
Dear Salvatore,
Please find attached the course announcements for both the RPOD and CBR courses in Nepal (BIKASH) and Ethiopia (ALERT) for 2009.
There are still some seats available for the 2008 RPOD course at ALERT (October 27- 4 weeks).
Please would you be so kind to distribute these announcements to the members of the LML?
With kind regards,
Wim Brandsma ALERT P.O.Box 165Addis Ababa ETHIOPIAhttp://www.wimariet.com/+251-11-3211371
Management of nerve abscess in leprosy
Leprosy Mailing List, August 31st, 2008
Ref.: Management of nerve abscess in leprosy (see attachment)
From: Salafia A., Mumbai, India
Dear Salvatore,
This is with reference to nerve abscess and its treatment.
Let me clarify that the hospital where I work is a referral centre for most NGO's in town and for the Govt. Units too, so the patients who come to us, have been treated previously with steroids and what not; the abscess has not disappeared and that is why the patients are sent to us.
In order to set at rest the mind of the reader, I am sending a few photos. Kindly see the attached paper in PDF format.
Let me elaborate: this patient -19 years boy- was treated elsewhere for leprosy; he developed a large abscess on along the left ulnar nerve, close to the elbow (slide 1).
The abscess was treated conservatively by a Plastic Surgeon for about 4-5 months; the abscess kept on growing; finally the Plastic Surgeon referred the case to me. The first surgery was an extensive one (slides 2-4) because by that time the abscess (which initially was confined to the ulnar nerve at the elbow level, had spread distally) had spread further along the virtual space created by the ante-brachial fascia and the cutis (i.e. the epidermis, the dermis and the subcutis).
Let me clarify that we operate a 'visible' abscess and not a 'possible' one; it is important to understand what I am going to relate. The patient came to us every 2-3 months with new abscesses: one on the left median nerve (slides 5-7) and many cutaneous nerves (slides 8-11). In short, he was operated 8 times for 8 different nerve abscesses which kept on propping up along the arm and the forearm.
With “a posteriori” knowledge we realized that, by waiting 4-5 months, the original abscess had spread slowly and insidiously, to other nerves along the virtual space mentioned above. I am sure that had the patient been operated as soon as the first abscess had appeared, he would not have landed 8 times in the operation theatre; the ninth time was for claw-hand correction.
This proves, if there was a need for it, that nerve abscesses have to be excised as soon as possible, lest they spread by contiguity.
About the sinuses which I mentioned in my previous letter (LML Aug 27th, 2008) I have a number of photos to prove my point. I would like to suggest reading my book on Neuritis, which deals in details with nerve abscess (“Treatment of Neuritis in Leprosy. Medical and Surgical”. A. Salafia, G. Chauhan, 1997).
With warm regards,
Antonio Salafia
Hand surgeon
Head of Reconstructive Surgery
Vimala Hospital
Mumbai
India
Ref.: Management of nerve abscess in leprosy (see attachment)
From: Salafia A., Mumbai, India
Dear Salvatore,
This is with reference to nerve abscess and its treatment.
Let me clarify that the hospital where I work is a referral centre for most NGO's in town and for the Govt. Units too, so the patients who come to us, have been treated previously with steroids and what not; the abscess has not disappeared and that is why the patients are sent to us.
In order to set at rest the mind of the reader, I am sending a few photos. Kindly see the attached paper in PDF format.
Let me elaborate: this patient -19 years boy- was treated elsewhere for leprosy; he developed a large abscess on along the left ulnar nerve, close to the elbow (slide 1).
The abscess was treated conservatively by a Plastic Surgeon for about 4-5 months; the abscess kept on growing; finally the Plastic Surgeon referred the case to me. The first surgery was an extensive one (slides 2-4) because by that time the abscess (which initially was confined to the ulnar nerve at the elbow level, had spread distally) had spread further along the virtual space created by the ante-brachial fascia and the cutis (i.e. the epidermis, the dermis and the subcutis).
Let me clarify that we operate a 'visible' abscess and not a 'possible' one; it is important to understand what I am going to relate. The patient came to us every 2-3 months with new abscesses: one on the left median nerve (slides 5-7) and many cutaneous nerves (slides 8-11). In short, he was operated 8 times for 8 different nerve abscesses which kept on propping up along the arm and the forearm.
With “a posteriori” knowledge we realized that, by waiting 4-5 months, the original abscess had spread slowly and insidiously, to other nerves along the virtual space mentioned above. I am sure that had the patient been operated as soon as the first abscess had appeared, he would not have landed 8 times in the operation theatre; the ninth time was for claw-hand correction.
This proves, if there was a need for it, that nerve abscesses have to be excised as soon as possible, lest they spread by contiguity.
About the sinuses which I mentioned in my previous letter (LML Aug 27th, 2008) I have a number of photos to prove my point. I would like to suggest reading my book on Neuritis, which deals in details with nerve abscess (“Treatment of Neuritis in Leprosy. Medical and Surgical”. A. Salafia, G. Chauhan, 1997).
With warm regards,
Antonio Salafia
Hand surgeon
Head of Reconstructive Surgery
Vimala Hospital
Mumbai
India
Management of nerve abscess (Errata Corrige)
Leprosy Mailing List, August 31st, 2008
Ref.: Management of nerve abscess (Errata Corrige)
From: Srinivasan H., Chennai, India
Dear Dr Noto,
I am sorry that I have made an error while typing the note on nerve abscess (LML communication dated Friday August 29, 2008). The fourth paragraph from the bottom in that communication should read as:
When the abscess is identified as an “intra neural abscess” (fusiform swelling of the nerve, abscess part of the nerve and not separate from it) is dealt with surgically without delay.
Sorry for the mistake.
Regards,
H. Srinivasan
Dr H SrinivasanReconst. Surgeon (Retired)25, First Seaward RoadChennai 600 041India
Ref.: Management of nerve abscess (Errata Corrige)
From: Srinivasan H., Chennai, India
Dear Dr Noto,
I am sorry that I have made an error while typing the note on nerve abscess (LML communication dated Friday August 29, 2008). The fourth paragraph from the bottom in that communication should read as:
When the abscess is identified as an “intra neural abscess” (fusiform swelling of the nerve, abscess part of the nerve and not separate from it) is dealt with surgically without delay.
Sorry for the mistake.
Regards,
H. Srinivasan
Dr H SrinivasanReconst. Surgeon (Retired)25, First Seaward RoadChennai 600 041India
Request of information about availability of leprosy treatment in Ivory Coast
Leprosy Mailing List, August 29th, 2008
Ref.: Request of information about availability of leprosy treatment in Ivory Coast?
From: Wexler R., Jerusalem, Israel
Dear Dr. Noto,
I would appreciate your help in obtaining information about the availability of leprosy treatment\services in The République de Côte d'Ivoire.
Thanks,
Ruth Wexler
Israel Hansen's Disease Center
Jerusalem
Ref.: Request of information about availability of leprosy treatment in Ivory Coast?
From: Wexler R., Jerusalem, Israel
Dear Dr. Noto,
I would appreciate your help in obtaining information about the availability of leprosy treatment\services in The République de Côte d'Ivoire.
Thanks,
Ruth Wexler
Israel Hansen's Disease Center
Jerusalem
Friday, August 29, 2008
Management of nerve abscess
Leprosy Mailing List, August 29th, 2008
Ref.: Management of nerve abscess
From: Srinivasan H., Chennai, India
Dear Dr Noto,
This is with reference to the query of Dr Ranthilaka Ranawaka regarding management of nerve abscess (LML Aug. 25th, 2008). My views on this topic are as follows.
Nerve abscesses in leprosy are usually ‘cold abscesses’ like tubercular cold abscesses. They occur due to caseation followed by colliquative necrosis tuberculoid granuloma in nerve fibres. They are commonly seen in major nerve trunks and cutaneous nerves of persons suffering from tuberculoid types of leprosy. In major nerve trunks the abscess may be truly intraneural due to necrosis of a nerve fascicle (or even a part of a fascicle) within the nerve, with the ‘pus’ collected inside the nerve, or, the pus may track through the epineurium and come out as a collar stud abscess to form a ‘para-neural’ abscess. Sometimes, a nerve bundle in the outer sheath of the nerve is the site of abscess formation and the abscess remains ‘para-neural’ from the beginning. Occasionally, a lymph node adherent to the nerve sheath (e.g., epitrochlear node adherent to the ulnar nerve) develops caseous necrosis in tuberculoid leprosy and forms a para-neural abscess, clinically indistinguishable from a true nerve abscess tracking from inside the nerve.
The size of the abscess ranges from very small (minute micro abscesses) to very large ‘giant’ abscesses, many centimetres long and wide. The presence of the abscess or it growing in size does not indicate disease activity. Left alone, smaller abscesses tend to subside on their own while larger abscesses often do not do so. They may even keep increasing in size.
There are two concerns associated with the nerve abscesses: i) the abscess per se and ii) the effect of the abscess on the function of the affected nerve trunk.
i.)Unlike acute inflammatory ‘hot’ abscesses, cold abscesses are relatively painless or there maybe only mild nerve pain. So pain is not a major consideration in the management of nerve abscesses. Nor is “disease activity” a concern and that is determined based on other parameters and not on the presence or changes in the size of the abscess. A very large abscess is a cosmetic concern. A visible abscess may also be an embarrassment because it invites the curiosity of neighbours as to its cause (with may be serious social consequences).
ii.)The size of the abscess does not indicate the extent of nerve damage caused by it and the resulting nerve function deficit (NFD). Even a small intra neural abscess can be associated with significant NFD, as the abscess may press on the surrounding fascicles and strangulate them (especially when the epineurium is thickened and fibrosed and does not allow expansion) because of increased intra neural tension. This causes conduction blockage (neurapraxia) in even undamaged nerve fascicles and NFD. This danger does not exist when the abscess breaks through the epineurium (with relief of intraneural hypertension) and becomes para-neural. When the abscess is para-neural from the beginning, there is little danger of the abscess giving rise to NFD.
Management of the abscess depends primarily on the state of the nerve affected. The nerve may show, at the time the abscess is noticed or complained of, (a) significant functional deficit by way of anaesthesia in its area of supply and / or paralysis or weakness of the muscles supplied by that nerve, or, (b) no significant functional deficit. When functional deficit is noticed, one should enquire whether is well established (“irrecoverable”) or “recoverable”. If NFD is well established or long standing (like e.g., long ante dating the onset of the abscess, severe muscle atrophy, muscle paralysis of more than six months duration), it may be considered “irrecoverable”. It may also be considered “irrecoverable” if NFD is complete (i.e., complete sensory-motor paralysis with paralysis of all the muscles normally supplied by the nerve in the case of a mixed nerve). When NFD is considered “irrecoverable”, we may ignore this aspect and consider the abscess per se. We can wait and see if it will subside of its own accord in the course of some months. If it does not, and if the patient desires it, it is dealt with surgically. The exception to this advice is when the abscess involves the overlying skin and there is an imminent danger of the abscess bursting through the skin. In that case, the abscess is surgically dealt with straight away.If the NFD is incomplete or recent (some muscles normally supplied by the nerve are not paralysed or acting weakly, muscle atrophy not severe, paralysis/NFD is not long standing – less than six months duration), it may be considered to be “recoverable NFD” and the abscess is surgically dealt with without much delay. When there is no NFD, ascertain by clinical examination whether the abscess is purely intra neural or whether it is a collar stud or a para-neural abscess.When the abscess is identified as an “intraneural abscess” (fusiform swelling of the nerve, abscess part of the nerve and separate from it) it is dealt with surgically without delay.When the abscess is identified as a “collar stud” or a “para-neural abscess” (abscess forming a swelling by the side of and adherent to the nerve), we can wait and see if it will subside of its own accord in the course of some months. If it does not, and if the patient desires it, it is dealt with surgically. The exception to this advice is when the abscess involves the overlying skin and there is an imminent danger of the abscess bursting through the skin. In that case, the abscess is surgically dealt with straight away.The intraneural abscess is evacuated, its walls curetted thoroughly and the necrosed fascicles are excised. The wound is closed without drain. Firm bandaging is done.Para-neural and collar-stud abscesses are excised, in toto if possible. The abscess track into the nerve is traced into the interior of the nerve and the necrosed fascicles are identified to their full extent and excised. The wound is closed without drain. Firm bandaging is done.I hope the above is of some use.
H. Srinivasan
Chennai, India
Ref.: Management of nerve abscess
From: Srinivasan H., Chennai, India
Dear Dr Noto,
This is with reference to the query of Dr Ranthilaka Ranawaka regarding management of nerve abscess (LML Aug. 25th, 2008). My views on this topic are as follows.
Nerve abscesses in leprosy are usually ‘cold abscesses’ like tubercular cold abscesses. They occur due to caseation followed by colliquative necrosis tuberculoid granuloma in nerve fibres. They are commonly seen in major nerve trunks and cutaneous nerves of persons suffering from tuberculoid types of leprosy. In major nerve trunks the abscess may be truly intraneural due to necrosis of a nerve fascicle (or even a part of a fascicle) within the nerve, with the ‘pus’ collected inside the nerve, or, the pus may track through the epineurium and come out as a collar stud abscess to form a ‘para-neural’ abscess. Sometimes, a nerve bundle in the outer sheath of the nerve is the site of abscess formation and the abscess remains ‘para-neural’ from the beginning. Occasionally, a lymph node adherent to the nerve sheath (e.g., epitrochlear node adherent to the ulnar nerve) develops caseous necrosis in tuberculoid leprosy and forms a para-neural abscess, clinically indistinguishable from a true nerve abscess tracking from inside the nerve.
The size of the abscess ranges from very small (minute micro abscesses) to very large ‘giant’ abscesses, many centimetres long and wide. The presence of the abscess or it growing in size does not indicate disease activity. Left alone, smaller abscesses tend to subside on their own while larger abscesses often do not do so. They may even keep increasing in size.
There are two concerns associated with the nerve abscesses: i) the abscess per se and ii) the effect of the abscess on the function of the affected nerve trunk.
i.)Unlike acute inflammatory ‘hot’ abscesses, cold abscesses are relatively painless or there maybe only mild nerve pain. So pain is not a major consideration in the management of nerve abscesses. Nor is “disease activity” a concern and that is determined based on other parameters and not on the presence or changes in the size of the abscess. A very large abscess is a cosmetic concern. A visible abscess may also be an embarrassment because it invites the curiosity of neighbours as to its cause (with may be serious social consequences).
ii.)The size of the abscess does not indicate the extent of nerve damage caused by it and the resulting nerve function deficit (NFD). Even a small intra neural abscess can be associated with significant NFD, as the abscess may press on the surrounding fascicles and strangulate them (especially when the epineurium is thickened and fibrosed and does not allow expansion) because of increased intra neural tension. This causes conduction blockage (neurapraxia) in even undamaged nerve fascicles and NFD. This danger does not exist when the abscess breaks through the epineurium (with relief of intraneural hypertension) and becomes para-neural. When the abscess is para-neural from the beginning, there is little danger of the abscess giving rise to NFD.
Management of the abscess depends primarily on the state of the nerve affected. The nerve may show, at the time the abscess is noticed or complained of, (a) significant functional deficit by way of anaesthesia in its area of supply and / or paralysis or weakness of the muscles supplied by that nerve, or, (b) no significant functional deficit. When functional deficit is noticed, one should enquire whether is well established (“irrecoverable”) or “recoverable”. If NFD is well established or long standing (like e.g., long ante dating the onset of the abscess, severe muscle atrophy, muscle paralysis of more than six months duration), it may be considered “irrecoverable”. It may also be considered “irrecoverable” if NFD is complete (i.e., complete sensory-motor paralysis with paralysis of all the muscles normally supplied by the nerve in the case of a mixed nerve). When NFD is considered “irrecoverable”, we may ignore this aspect and consider the abscess per se. We can wait and see if it will subside of its own accord in the course of some months. If it does not, and if the patient desires it, it is dealt with surgically. The exception to this advice is when the abscess involves the overlying skin and there is an imminent danger of the abscess bursting through the skin. In that case, the abscess is surgically dealt with straight away.If the NFD is incomplete or recent (some muscles normally supplied by the nerve are not paralysed or acting weakly, muscle atrophy not severe, paralysis/NFD is not long standing – less than six months duration), it may be considered to be “recoverable NFD” and the abscess is surgically dealt with without much delay. When there is no NFD, ascertain by clinical examination whether the abscess is purely intra neural or whether it is a collar stud or a para-neural abscess.When the abscess is identified as an “intraneural abscess” (fusiform swelling of the nerve, abscess part of the nerve and separate from it) it is dealt with surgically without delay.When the abscess is identified as a “collar stud” or a “para-neural abscess” (abscess forming a swelling by the side of and adherent to the nerve), we can wait and see if it will subside of its own accord in the course of some months. If it does not, and if the patient desires it, it is dealt with surgically. The exception to this advice is when the abscess involves the overlying skin and there is an imminent danger of the abscess bursting through the skin. In that case, the abscess is surgically dealt with straight away.The intraneural abscess is evacuated, its walls curetted thoroughly and the necrosed fascicles are excised. The wound is closed without drain. Firm bandaging is done.Para-neural and collar-stud abscesses are excised, in toto if possible. The abscess track into the nerve is traced into the interior of the nerve and the necrosed fascicles are identified to their full extent and excised. The wound is closed without drain. Firm bandaging is done.I hope the above is of some use.
H. Srinivasan
Chennai, India
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