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.
Monday, October 27, 2008
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
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