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:
More information about INFOLEP and its resources can be found on the new ILEP website:

With best wishes,

Wim van Brakel

KIT Leprosy Unit

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.
With best wishes,
Dr Carlos Alberto Faria Rodrigues
Av. Arouca 660 Sala 1014 – Passos – Minas Gerais – BrazilTel: +55 (35) 3521-7811Email Webpage:

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

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,


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

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

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
*Treatment of Neuritis in Leprosy. Medical and Surgical”. A. Salafia, G. Chauhan, 1997.


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

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:-
eMedicine is the leading provider of clinical medical information for medical professionals and consumers. To explore eMedicine today, visit

Best regards,


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).


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 and

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:

Thanks in advance to all the LML readers who can help us and with best wishes,


Dr Sunil Deepak
Head, Medical Support Department
Via Borselli 4-6
40135 - Bologna
Tel: +39051 - 4393211 / 4393219 (Direct)
Fax: +39051 - 434046

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

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 ETHIOPIA

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

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.
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.


Ruth Wexler
Israel Hansen's Disease Center