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