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
Friday, August 29, 2008
Weeky epidemiological record, N. 33, 15 August 2008
Leprosy Mailing List, August 28th, 2008
Ref.: Weeky epidemiological record, N. 33, 15 August 2008
From: Pannikar V., New Delhi, India
Dear Dr Noto,
Please, find attached the latest Global Leprosy Situation. I request you to share this with interested colleagues through leprosy discussion list.
Thank you for your support to the Global Leprosy Programme.
Regards,
V. Pannikar
Ref.: Weeky epidemiological record, N. 33, 15 August 2008
From: Pannikar V., New Delhi, India
Dear Dr Noto,
Please, find attached the latest Global Leprosy Situation. I request you to share this with interested colleagues through leprosy discussion list.
Thank you for your support to the Global Leprosy Programme.
Regards,
V. Pannikar
Management of reversal (type 1) reaction
Leprosy Mailing List, August 28th, 2008
Ref.: Management of reversal (type 1) reaction
From: Garbino J. A., Bauru, SP, Brazil
Dear friends,
I refer to Dr Ranawaka’s message about treatment of type 1 reaction (LML Aug. 25th, 2008). I think that type 1 reaction in MB patients takes more time to solve and the 3-month oral prednisolone regimen used was too short. This would explain the relapse when the steroid was tapered off.
I suggest to extend the steroid regimen and, even in smaller doses than at the beginning, the reaction and nerve will continue recovering.
Regards,
José Antônio Garbino
Ref.: Management of reversal (type 1) reaction
From: Garbino J. A., Bauru, SP, Brazil
Dear friends,
I refer to Dr Ranawaka’s message about treatment of type 1 reaction (LML Aug. 25th, 2008). I think that type 1 reaction in MB patients takes more time to solve and the 3-month oral prednisolone regimen used was too short. This would explain the relapse when the steroid was tapered off.
I suggest to extend the steroid regimen and, even in smaller doses than at the beginning, the reaction and nerve will continue recovering.
Regards,
José Antônio Garbino
Management of nerve abscess in leprosy
Leprosy Mailing List, August 27th, 2008
Ref.: Management of nerve abscess in leprosy.
From: Warren G., Sydney, Australia
Dear Salvatore,
I refer to Dr Ranthilaka Ranawaka’s message dated LML Aug. 25th, 2008 about management of multiple nerve abscesses in leprosy.
The fact that the patient has now got abscesses suggests that she has eliminated the infection and her white cells have destroyed the bacilli etc and left the pus. What the writer does not say is if there is any inflammation round the abscess sites. There may be a secondary infection that does need treatment by use of some drawing medication like sugar paste or magnesium sulphate and glycerine paste (BPC>). They rarely need anti-bacterials.
However in many that I have seen the abscesses, if not to large, will eventually absorb in 3-6 months leaving just a little patch of scar in the nerve which is probably non functioning beyond that point anyhow. There is usually no need to remove the abscess; unless it is very large and/or inflamed or causing pain or likely to get traumatised in daily living, etc. I have seen dozens. The only one I remember opening had about 400cc of pus in it, and was just above the elbow and in danger of being ruptured!
I would assume the abscesses are in the original lesion (?) and not further up the nerve. If she was true tuberculoid it is unlikely that there are any other lesions; but her whole body needs to be inspected. Was she in fact really BT? Has she other lesions elsewhere? Is she really multibacillary but started as a TT and has now down graded?
In fact does she need more MDT? I would suspect so and I would in deed give her at least 6 months more to make sure. I do not like relapses!
I do not know the prevalence of DDS resistance in your country. It may be better to give her 6 months of clofazimine which is an effective anti-leprotic and anti-inflammatory and we have not yet seen a patient develop resistance to clofazimine. I often use it alone (as we did in the 1960s in the initial trials) and it is very effective at cleaning up problems, reducing reaction and eliminating bacilli. That also eliminates the risk associated with Rifampycin especially in the elderly who may have liver problems that are aggravated by Rifampycin.
Thank you very much for sharing with us your clinical cases.
Best wishes,
Grace Warren
Ref.: Management of nerve abscess in leprosy.
From: Warren G., Sydney, Australia
Dear Salvatore,
I refer to Dr Ranthilaka Ranawaka’s message dated LML Aug. 25th, 2008 about management of multiple nerve abscesses in leprosy.
The fact that the patient has now got abscesses suggests that she has eliminated the infection and her white cells have destroyed the bacilli etc and left the pus. What the writer does not say is if there is any inflammation round the abscess sites. There may be a secondary infection that does need treatment by use of some drawing medication like sugar paste or magnesium sulphate and glycerine paste (BPC>). They rarely need anti-bacterials.
However in many that I have seen the abscesses, if not to large, will eventually absorb in 3-6 months leaving just a little patch of scar in the nerve which is probably non functioning beyond that point anyhow. There is usually no need to remove the abscess; unless it is very large and/or inflamed or causing pain or likely to get traumatised in daily living, etc. I have seen dozens. The only one I remember opening had about 400cc of pus in it, and was just above the elbow and in danger of being ruptured!
I would assume the abscesses are in the original lesion (?) and not further up the nerve. If she was true tuberculoid it is unlikely that there are any other lesions; but her whole body needs to be inspected. Was she in fact really BT? Has she other lesions elsewhere? Is she really multibacillary but started as a TT and has now down graded?
In fact does she need more MDT? I would suspect so and I would in deed give her at least 6 months more to make sure. I do not like relapses!
I do not know the prevalence of DDS resistance in your country. It may be better to give her 6 months of clofazimine which is an effective anti-leprotic and anti-inflammatory and we have not yet seen a patient develop resistance to clofazimine. I often use it alone (as we did in the 1960s in the initial trials) and it is very effective at cleaning up problems, reducing reaction and eliminating bacilli. That also eliminates the risk associated with Rifampycin especially in the elderly who may have liver problems that are aggravated by Rifampycin.
Thank you very much for sharing with us your clinical cases.
Best wishes,
Grace Warren
Management of nerve abscess in leprosy
Leprosy Mailing List, August 27th, 2008
Ref.: Management of nerve abscess in leprosy.
From: Garbino J. A., Bauru, SP, Brazil
Dear colleagues,
I refer to Dr R Ranawaka’s message (LML 25 Aug. 2008). I understand that the nerve abscesses should be surgically explored.
Best regards,
José Antônio Garbino
Ref.: Management of nerve abscess in leprosy.
From: Garbino J. A., Bauru, SP, Brazil
Dear colleagues,
I refer to Dr R Ranawaka’s message (LML 25 Aug. 2008). I understand that the nerve abscesses should be surgically explored.
Best regards,
José Antônio Garbino
Management of nerve abscess in leprosy
Leprosy Mailing List, August 27th, 2008
Ref.: Management of nerve abscess in leprosy.
From: Salafia A., Mumbai, India
Dear Salvatore,
I refer to Dr Ranthilaka Ranawaka’s message dated LML Aug. 25th, 2008 about management of multiple nerve abscesses in leprosy. This is my view and what I have done in about 2500 nerve explored, out of which more than 500 where nerve abscesses. Multiple nerve abscesses are not rare at all. All nerve abscesses have to be excised. Somebody has even said to leave a nerve abscess alone; now this is contrary to the principles of any good surgery. The fact is: whenever there is an abscess, there is also a certain amount of oedema, so if you give only steroids, the abscess seems to reduce and you are happy about it; but steroids will reduce only the oedema component; the abscess will remain; and if it not excised, two things may happen:
(1) if the abscess is close to the skin, it will lead to a sinus (I have seen quite a few);
(2) if it is deep, it will spread by contiguity to other structures and, sooner or later some more abscesses will appear.
Practically: you can give a brachial block and explore the nerve as far as you can; excise the abscess, taking care not to leave any necrotic tissue behind. I would suggest you take the help of a Hand Surgeon or a Plastic Surgeon as it appears that you need to do an extensive dissection.
Antibiotic treatment is given, for example a good injectable antibiotic like Ceftriazone. Two-three days after surgery, it is advisable to put the patient on high dosages of steroids in order to reduce the inflammatory process which may lead to adhesions.
Good luck.
Antonio Salafia
Hand surgeon
Head of Reconstructive Surgery Vimala Hospital
Mumbai
India
Ref.: Management of nerve abscess in leprosy.
From: Salafia A., Mumbai, India
Dear Salvatore,
I refer to Dr Ranthilaka Ranawaka’s message dated LML Aug. 25th, 2008 about management of multiple nerve abscesses in leprosy. This is my view and what I have done in about 2500 nerve explored, out of which more than 500 where nerve abscesses. Multiple nerve abscesses are not rare at all. All nerve abscesses have to be excised. Somebody has even said to leave a nerve abscess alone; now this is contrary to the principles of any good surgery. The fact is: whenever there is an abscess, there is also a certain amount of oedema, so if you give only steroids, the abscess seems to reduce and you are happy about it; but steroids will reduce only the oedema component; the abscess will remain; and if it not excised, two things may happen:
(1) if the abscess is close to the skin, it will lead to a sinus (I have seen quite a few);
(2) if it is deep, it will spread by contiguity to other structures and, sooner or later some more abscesses will appear.
Practically: you can give a brachial block and explore the nerve as far as you can; excise the abscess, taking care not to leave any necrotic tissue behind. I would suggest you take the help of a Hand Surgeon or a Plastic Surgeon as it appears that you need to do an extensive dissection.
Antibiotic treatment is given, for example a good injectable antibiotic like Ceftriazone. Two-three days after surgery, it is advisable to put the patient on high dosages of steroids in order to reduce the inflammatory process which may lead to adhesions.
Good luck.
Antonio Salafia
Hand surgeon
Head of Reconstructive Surgery Vimala Hospital
Mumbai
India
Monday, August 25, 2008
Request of information about treatment of type 1 (reversal) reaction
Leprosy Mailing List, August 25th, 2008
Ref.: Request of information about treatment of type 1 (reversal) reaction.
From: Ranawaka R., Anuradhapura, Sri Lanka
Dear Dr Salvatore,
I have two clinical problems which I would appreciate others experience in management. Herewith is described the second one. The first case was described in the previous message.
Patient 2; 60 year old women with lepromatous leprosy presented 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.
Is type 1 reaction described in lepromatous leprosy? Is there a recurrent type of this reaction? Is the 3 month course of oral prednisolone the standard treatment? LML collegue's experience in management of this condition will be greatly appreciated.
Kind regards,
Ranthilaka Ranawaka
Consultant Dermatologist
Teaching Hospital Anuradhapura
Sri Lanka
Ref.: Request of information about treatment of type 1 (reversal) reaction.
From: Ranawaka R., Anuradhapura, Sri Lanka
Dear Dr Salvatore,
I have two clinical problems which I would appreciate others experience in management. Herewith is described the second one. The first case was described in the previous message.
Patient 2; 60 year old women with lepromatous leprosy presented 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.
Is type 1 reaction described in lepromatous leprosy? Is there a recurrent type of this reaction? Is the 3 month course of oral prednisolone the standard treatment? LML collegue's experience in management of this condition will be greatly appreciated.
Kind regards,
Ranthilaka Ranawaka
Consultant Dermatologist
Teaching Hospital Anuradhapura
Sri Lanka
Request of information about treatment of nerve abscess in leprosy
Leprosy Mailing List, August 25th, 2008
Ref.: Request of information about treatment of nerve abscess in leprosy.
From: Ranawaka R., Anuradhapura, Sri Lanka
Dear Dr Salvatore,
I have two clinical problems which I would appreciate others experience in management. One is herewith described; the second one will follow with the next message.
Patient 1; 70 year old women had hypo-pigmented anaesthetic patch on right ulnar border, which was treated as tuberculoid leprosy with adult paucibacillary (PB) pack for 6 months. She completed treatment 4 months ago. Now she is presenting with multiple (four) nerve abscesses along the right ulnar nerve.
How do you manage nerve abscess in leprosy? LML collegue's experience in management of this condition will be greatly appreciated.
Kind regards,
Ranthilaka Ranawaka
Consultant Dermatologist
Teaching Hospital Anuradhapura
Sri Lanka
Ref.: Request of information about treatment of nerve abscess in leprosy.
From: Ranawaka R., Anuradhapura, Sri Lanka
Dear Dr Salvatore,
I have two clinical problems which I would appreciate others experience in management. One is herewith described; the second one will follow with the next message.
Patient 1; 70 year old women had hypo-pigmented anaesthetic patch on right ulnar border, which was treated as tuberculoid leprosy with adult paucibacillary (PB) pack for 6 months. She completed treatment 4 months ago. Now she is presenting with multiple (four) nerve abscesses along the right ulnar nerve.
How do you manage nerve abscess in leprosy? LML collegue's experience in management of this condition will be greatly appreciated.
Kind regards,
Ranthilaka Ranawaka
Consultant Dermatologist
Teaching Hospital Anuradhapura
Sri Lanka
Monday, August 4, 2008
Diagnosis of leprosy
Leprosy Mailing List, August 1st, 2008
Ref.: Diagnosis of leprosy
From: Das P. K., Amsterdam, The Netherlands
Dear Salvatore,
I refer to Dr. Khalid’s message: “Mnemonics in leprosy”, LML, June 15th, 2008. I am not sure what he really means with “Mnemonics in leprosy” but, I thank him for introducing the important subject of diagnosis of leprosy and its cardinal signs. I wish to add a few comments.
Together with the first Cardinal Signs of Leprosy (better defined by loss of sensation and hypopigmentation), it is also useful to mention "hypopigmentation and depigmentation". Complete loss of pigment (depigmentation) is not common in leprosy. Depigmentation is seen in vitiligo and, in my experience in India the depigmented patches of vitiligo are sometimes mistaken for leprosy.
In cases of tuberculoid (TT) leprosy and often in of borderline tuberculoid (BT) leprosy, identification of M. leprae by slit-skin smear examination is negative, therefore, the pathology of the biopsy at the margin of the active lesion is an important diagnostic tool.
Also, if possible, simple immunohistology is helpful. Immunohistology is performed using monoclonal antibodies to M. leprae PGL-1 and Lam (Ref.1). Positivity (even minor) will indicate TT leprosy.
Further, where possible, antibody titre to gel purified mycobacterial (not necessarily, M. leprae) 65KD antigen, using 1/400 diluted sera should be carried out and reading of OD value >.50 and can confirm the diagnosis of TT leprosy too (Ref. 2-4).
Hope this information is useful to you.
P. K. Das
Ref. 1. Amer.J.Pathol.(1999), vol . 154, p 1793-18040
Ref. 2. j.clin microbial(1990):`vol 28; p 379-382;
Ref. 3. Acta Leprologica (1989) vol 7(suppl.1)p 117-120;
Ref. 4. USA Patent No: US6,416,962 B1 Jul9,2002.
Ref.: Diagnosis of leprosy
From: Das P. K., Amsterdam, The Netherlands
Dear Salvatore,
I refer to Dr. Khalid’s message: “Mnemonics in leprosy”, LML, June 15th, 2008. I am not sure what he really means with “Mnemonics in leprosy” but, I thank him for introducing the important subject of diagnosis of leprosy and its cardinal signs. I wish to add a few comments.
Together with the first Cardinal Signs of Leprosy (better defined by loss of sensation and hypopigmentation), it is also useful to mention "hypopigmentation and depigmentation". Complete loss of pigment (depigmentation) is not common in leprosy. Depigmentation is seen in vitiligo and, in my experience in India the depigmented patches of vitiligo are sometimes mistaken for leprosy.
In cases of tuberculoid (TT) leprosy and often in of borderline tuberculoid (BT) leprosy, identification of M. leprae by slit-skin smear examination is negative, therefore, the pathology of the biopsy at the margin of the active lesion is an important diagnostic tool.
Also, if possible, simple immunohistology is helpful. Immunohistology is performed using monoclonal antibodies to M. leprae PGL-1 and Lam (Ref.1). Positivity (even minor) will indicate TT leprosy.
Further, where possible, antibody titre to gel purified mycobacterial (not necessarily, M. leprae) 65KD antigen, using 1/400 diluted sera should be carried out and reading of OD value >.50 and can confirm the diagnosis of TT leprosy too (Ref. 2-4).
Hope this information is useful to you.
P. K. Das
Ref. 1. Amer.J.Pathol.(1999), vol . 154, p 1793-18040
Ref. 2. j.clin microbial(1990):`vol 28; p 379-382;
Ref. 3. Acta Leprologica (1989) vol 7(suppl.1)p 117-120;
Ref. 4. USA Patent No: US6,416,962 B1 Jul9,2002.
Friday, August 1, 2008
Leprosy Meeting at Genoa Global Dermatology Congress
Leprosy Mailing List, August 1st, 2008
Ref.: Leprosy Meeting at Genoa Global Dermatology Congress.
From: Deepak S., Bologna, Italy
Dear Salvatore,
I glad to inform that four presentations from the leprosy meeting on 23 April 2008 during the first International Congress on Global Dermatology held in Genoa (Italy) are now available online as follows:
(1) Minimum basic care for leprosy, Terrence Ryan (PDF, 2.2 MB)
http://www.aifo.it/english/resources/online/books/leprosy/leprosy_meeting_genova08/minimum_basic_care_lep_t_ryan.pdf
(2) Treatment of reactions, Ben Naafs (PDF, 6.6 MB)
http://www.aifo.it/english/resources/online/books/leprosy/leprosy_meeting_genova08/treatment_of_reactions_b_naafs.pdf
(3) Early diagnosis of leprosy, Pierre Bobin, (PDF, 2.5 MB)
http://www.aifo.it/english/resources/online/books/leprosy/leprosy_meeting_genova08/early_diagnosis_lep_p_bobin.pdf
(4) Leprosy - control, elimination and eradication, Sunil Deepak (PDF, 255 KB)
http://www.aifo.it/english/resources/online/books/leprosy/leprosy_meeting_genova08/leprosy_control_elim&erad-s_deepak.pdf
If someone has difficulty in downloading any of these files, I can send it by email.
With best wishes,
Dr Sunil Deepak
Head, Medical Support Office
AIFO, Italy
Email: sunil.deepak@aifo.it
Ref.: Leprosy Meeting at Genoa Global Dermatology Congress.
From: Deepak S., Bologna, Italy
Dear Salvatore,
I glad to inform that four presentations from the leprosy meeting on 23 April 2008 during the first International Congress on Global Dermatology held in Genoa (Italy) are now available online as follows:
(1) Minimum basic care for leprosy, Terrence Ryan (PDF, 2.2 MB)
http://www.aifo.it/english/resources/online/books/leprosy/leprosy_meeting_genova08/minimum_basic_care_lep_t_ryan.pdf
(2) Treatment of reactions, Ben Naafs (PDF, 6.6 MB)
http://www.aifo.it/english/resources/online/books/leprosy/leprosy_meeting_genova08/treatment_of_reactions_b_naafs.pdf
(3) Early diagnosis of leprosy, Pierre Bobin, (PDF, 2.5 MB)
http://www.aifo.it/english/resources/online/books/leprosy/leprosy_meeting_genova08/early_diagnosis_lep_p_bobin.pdf
(4) Leprosy - control, elimination and eradication, Sunil Deepak (PDF, 255 KB)
http://www.aifo.it/english/resources/online/books/leprosy/leprosy_meeting_genova08/leprosy_control_elim&erad-s_deepak.pdf
If someone has difficulty in downloading any of these files, I can send it by email.
With best wishes,
Dr Sunil Deepak
Head, Medical Support Office
AIFO, Italy
Email: sunil.deepak@aifo.it
Nerve thickening in leprosy - Are there standards?
Ref.: Nerve thickening in leprosy. Are there standards?
From: Krishna Moorthy K. V., Cherlapally, Hyderabad, India
Dear Dr Noto,
Incidence of leprosy although has come down, still we get cases of leprosy (all types). Some of the cases come with establish deformities of recent origin. We would like to focus in the prevention of deformity formation, for which we wish to undertake suitable measures.
In this connection, assessment of peripheral nerve involvement is a key issue. Anamnesis, palpation, sensory and motor tests are among the modalities used for the evaluation of the peripheral nerve trunks of predilection in leprosy. About the enlargement of the nerves, are there standards to help in assessing this cardinal sign of leprosy?
I shall be highly thankful if you could inform us about gradation of nerve thickening in leprosy with neuritis.
I hope that this information could be obtained from you.
With regards,
Krishna Moorthy
Dr. KV Krishna Moorthy
Head, Clinical & Epidemiology Division
Blue Peter Research Centre, LEPRA SocietyNear TEC Bldg, Cherlapally
Hyderabad – 501 301, AP
IndiaTel. 91 40 27264547, 27261261 Fax: 91 40 27261262Email: bprc@bprcleprasociety.org
From: Krishna Moorthy K. V., Cherlapally, Hyderabad, India
Dear Dr Noto,
Incidence of leprosy although has come down, still we get cases of leprosy (all types). Some of the cases come with establish deformities of recent origin. We would like to focus in the prevention of deformity formation, for which we wish to undertake suitable measures.
In this connection, assessment of peripheral nerve involvement is a key issue. Anamnesis, palpation, sensory and motor tests are among the modalities used for the evaluation of the peripheral nerve trunks of predilection in leprosy. About the enlargement of the nerves, are there standards to help in assessing this cardinal sign of leprosy?
I shall be highly thankful if you could inform us about gradation of nerve thickening in leprosy with neuritis.
I hope that this information could be obtained from you.
With regards,
Krishna Moorthy
Dr. KV Krishna Moorthy
Head, Clinical & Epidemiology Division
Blue Peter Research Centre, LEPRA SocietyNear TEC Bldg, Cherlapally
Hyderabad – 501 301, AP
IndiaTel. 91 40 27264547, 27261261 Fax: 91 40 27261262Email: bprc@bprcleprasociety.org
Rehabilitation: Searching for an appropriate strategy for people affected by leprosy
Ref.: Rehabilitation: Searching for an appropriate strategy for people affected by leprosy.
From: Byamungu D., Almarat, Khartoum, Sudan
Dear Noto,
I am bringing back an issue that I feel was not discussed in depth. In August 2007, Dr Pannikar wrote about "Searching for an appropriate strategy for people affected by leprosy (LML August 28th, 2007). There was some positive comments from Wim Brakel, Gopal and Soutar.
My letter is a call for discussion on how wills our future strategy should look like after the time bound of the current one. We need to start exploring in depth the issues that were raised in the letter of Pannikar like mainstreaming leprosy in the development plan which is far beyond mainstreaming it in disability issues that we are currently working on. How to deal effectively with other issues like leprosy in a war situation, stigma and discrimination and leprosy control in area without health facilities and so on.
We will also need to explore the new partnership for achieving a world without leprosy. I think we need to widen our partnership; this is to open what has been "our baby" to others. In Sudan we worked with many donors and partners and I found that they were more effective in certain field than us like UNDP for development project, FAO for food security and livelihood, Unicef for education of children of people affected by leprosy, WFP for food for training and so on.
Based on that I believe that almost every UN body can have some thing to do with the needs of people affected by leprosy. To make it short I will end here in order to allow other people to bring their input.
Best regard,
Denis Byamungu
Former Country Director of The Leprosy Mission Sudan.
From: Byamungu D., Almarat, Khartoum, Sudan
Dear Noto,
I am bringing back an issue that I feel was not discussed in depth. In August 2007, Dr Pannikar wrote about "Searching for an appropriate strategy for people affected by leprosy (LML August 28th, 2007). There was some positive comments from Wim Brakel, Gopal and Soutar.
My letter is a call for discussion on how wills our future strategy should look like after the time bound of the current one. We need to start exploring in depth the issues that were raised in the letter of Pannikar like mainstreaming leprosy in the development plan which is far beyond mainstreaming it in disability issues that we are currently working on. How to deal effectively with other issues like leprosy in a war situation, stigma and discrimination and leprosy control in area without health facilities and so on.
We will also need to explore the new partnership for achieving a world without leprosy. I think we need to widen our partnership; this is to open what has been "our baby" to others. In Sudan we worked with many donors and partners and I found that they were more effective in certain field than us like UNDP for development project, FAO for food security and livelihood, Unicef for education of children of people affected by leprosy, WFP for food for training and so on.
Based on that I believe that almost every UN body can have some thing to do with the needs of people affected by leprosy. To make it short I will end here in order to allow other people to bring their input.
Best regard,
Denis Byamungu
Former Country Director of The Leprosy Mission Sudan.
Teleleprosy
Ref.: Teleleprosy
From: Grace W., Sidney, Australia
Dear Salvatore I refer to:-
"Accuracy of store-and-forward diagnosis in leprosy"
Bianconcini Trinidade et al
Journal of telemedicine and telecare 2008; 14: 208-210
Grace
Dear Salvatore,
Thanks for your note and for inviting me to publish my comments on the above mentioned paper. So, you do not think I am just nuts and getting too old to be able to understand new concepts; I certainly find it hard to keep up sometimes!
I guess it may be good to spread my comments about it or some of them and I am sure there are many who are confused especially over the sensory impairment and the writers really do not give any indication of what they use to decide the diagnosis. I am interested to see what response we get? For or against [teleleprosy]?; I guess I am basically against in the format in which it is at present presented but “for” when realising that it could be a big help to isolated persons if there was a good protocol as to what should be examined and recorded and photographed to send for a second opinion.
I was intrigued to see the “Teleleprosy” paper come up in LML June 20th, 2008 by Bianconcini Trindade et al, from Sao Paulo, Brazil, as diagnosis and even surgery by television is getting so popular in medical fields. However, I must confess that it has left me “cold”; I just cannot follow the logic and unless a lot of explanation is given I cannot see that will be gained and fear that many patients will be missed because the primary examiners do not really look for leprosy.
A major request that I have for Dr Bianconcini Trindade and collaborators is to get from them more explanation of what they require for diagnosis and how they make a diagnosis? However, when I tried to study the article I got completely left behind. May be I am just too old and do not understand new terminology; but then I got a phone call from someone asking me what it meant and how to make sense from the statistics reported in table 1.
Yes, I can see the usefulness of being able to confirm leprosy by teleleprosy but not many details are supplied as to what is recorded to make a diagnosis. If telemedicine is to be utilised the various clinics need details of exactly what is to be recorded and forwarded and the clinicians must keep leprosy well to the front of their differential diagnosis list.
I think that in this teleleprosy medicine the diagnosis appears not to depend on monofilament type sensory testing as is too often recommended. Too many workers depend on monofilaments and state that if the patient can feel the filament they have no nerve damage and do not have leprosy.
The WHO Guide to “Eliminate leprosy.......” states that “A leprosy patient is someone who has a patch or skin patches with a definite loss of sensation: .......”. If this is so then all patients with leprosy have one or more anaesthetic patch. This is not true. Many patients with severe LL type leprosy do not have obvious skin patches. They just have vague infiltrated lesions without any real edges and certainly no detectable sensory changes for many years. In some of my Chinese patients the skin became grossly thickened after about 10-20 years and only then was there any evidence of altered sensory perception. According to the WHO description in this book these patients do not have leprosy! We are not told what are the signs that Telemedicine accept to make a diagnosis.
I have had a fight for years with the ”specialists” who love using monofilaments and saying that if they [the patients] can feel the monofilaments they are not at risk for traumatising themselves. Monofilaments test pressure, when it is the inability to feel pain or heat which is far more dangerous. WHO keep accenting the loss of sensation being needed in patches to diagnose leprosy. I have seen so many patients with typical ulnar claw hand and easily palpable nerves who have been rejected by WHO Leprosy consultants who say no skin lesions Not leprosy! Some have turned up a couple of year later covered with patches and multiple deformities!
But it was when I started to try and look at the statistics reported in the paper that I really got lost. Table 1. is stated to show the agreement between "in person" diagnosis and "telemedicine" diagnosis. But the first line of the table states telemedicine and beneath that phrase is written Leprosy, Not-leprosy Total. But no numbers are given? Under “In-person diagnosis” there are two lists of numbers stated to be Leprosy and non-leprosy? But are the numbers listed then relevant to the telemedicine three lines? As it appears to me there are no figures given for the telemedicine. What does it mean to list on the left ”Leprosy” and then under “In-person diagnosis” there is leprosy 43 and Non-leprosy 16 total is 59?
Please explain to a novice what this really means. Does it mean that telemedicine diagnosed the total of 59 of which 43 cases were actually leprosy and 16 were non-leprosy? The total of 59.
Sorry I have no answers or explanation to give to younger colleagues. It maybe they have the explanations! I would be interested to hear them. Sorry Salvatore, I just cannot get enthusiastic. I do not know if other ordinary clinicians have given you any reactions; but if someone can give an explanation I would be pleased to read it.
Thanks for the LML,
Grace
From: Grace W., Sidney, Australia
Dear Salvatore I refer to:-
"Accuracy of store-and-forward diagnosis in leprosy"
Bianconcini Trinidade et al
Journal of telemedicine and telecare 2008; 14: 208-210
Grace
Dear Salvatore,
Thanks for your note and for inviting me to publish my comments on the above mentioned paper. So, you do not think I am just nuts and getting too old to be able to understand new concepts; I certainly find it hard to keep up sometimes!
I guess it may be good to spread my comments about it or some of them and I am sure there are many who are confused especially over the sensory impairment and the writers really do not give any indication of what they use to decide the diagnosis. I am interested to see what response we get? For or against [teleleprosy]?; I guess I am basically against in the format in which it is at present presented but “for” when realising that it could be a big help to isolated persons if there was a good protocol as to what should be examined and recorded and photographed to send for a second opinion.
I was intrigued to see the “Teleleprosy” paper come up in LML June 20th, 2008 by Bianconcini Trindade et al, from Sao Paulo, Brazil, as diagnosis and even surgery by television is getting so popular in medical fields. However, I must confess that it has left me “cold”; I just cannot follow the logic and unless a lot of explanation is given I cannot see that will be gained and fear that many patients will be missed because the primary examiners do not really look for leprosy.
A major request that I have for Dr Bianconcini Trindade and collaborators is to get from them more explanation of what they require for diagnosis and how they make a diagnosis? However, when I tried to study the article I got completely left behind. May be I am just too old and do not understand new terminology; but then I got a phone call from someone asking me what it meant and how to make sense from the statistics reported in table 1.
Yes, I can see the usefulness of being able to confirm leprosy by teleleprosy but not many details are supplied as to what is recorded to make a diagnosis. If telemedicine is to be utilised the various clinics need details of exactly what is to be recorded and forwarded and the clinicians must keep leprosy well to the front of their differential diagnosis list.
I think that in this teleleprosy medicine the diagnosis appears not to depend on monofilament type sensory testing as is too often recommended. Too many workers depend on monofilaments and state that if the patient can feel the filament they have no nerve damage and do not have leprosy.
The WHO Guide to “Eliminate leprosy.......” states that “A leprosy patient is someone who has a patch or skin patches with a definite loss of sensation: .......”. If this is so then all patients with leprosy have one or more anaesthetic patch. This is not true. Many patients with severe LL type leprosy do not have obvious skin patches. They just have vague infiltrated lesions without any real edges and certainly no detectable sensory changes for many years. In some of my Chinese patients the skin became grossly thickened after about 10-20 years and only then was there any evidence of altered sensory perception. According to the WHO description in this book these patients do not have leprosy! We are not told what are the signs that Telemedicine accept to make a diagnosis.
I have had a fight for years with the ”specialists” who love using monofilaments and saying that if they [the patients] can feel the monofilaments they are not at risk for traumatising themselves. Monofilaments test pressure, when it is the inability to feel pain or heat which is far more dangerous. WHO keep accenting the loss of sensation being needed in patches to diagnose leprosy. I have seen so many patients with typical ulnar claw hand and easily palpable nerves who have been rejected by WHO Leprosy consultants who say no skin lesions Not leprosy! Some have turned up a couple of year later covered with patches and multiple deformities!
But it was when I started to try and look at the statistics reported in the paper that I really got lost. Table 1. is stated to show the agreement between "in person" diagnosis and "telemedicine" diagnosis. But the first line of the table states telemedicine and beneath that phrase is written Leprosy, Not-leprosy Total. But no numbers are given? Under “In-person diagnosis” there are two lists of numbers stated to be Leprosy and non-leprosy? But are the numbers listed then relevant to the telemedicine three lines? As it appears to me there are no figures given for the telemedicine. What does it mean to list on the left ”Leprosy” and then under “In-person diagnosis” there is leprosy 43 and Non-leprosy 16 total is 59?
Please explain to a novice what this really means. Does it mean that telemedicine diagnosed the total of 59 of which 43 cases were actually leprosy and 16 were non-leprosy? The total of 59.
Sorry I have no answers or explanation to give to younger colleagues. It maybe they have the explanations! I would be interested to hear them. Sorry Salvatore, I just cannot get enthusiastic. I do not know if other ordinary clinicians have given you any reactions; but if someone can give an explanation I would be pleased to read it.
Thanks for the LML,
Grace
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