Monday, May 18, 2009

LML closes from tomorrow to May 18th

Leprosy Mailing List, May 1st, 2009


Ref.:   LML closes from tomorrow to May 18th

From: Noto S., Genoa, Italy



Dear All,


I am sorry to say that the leprosy mailing list closes until May 18th.  I really wish to thank all of you (writers and readers).


Best regards,


S. Noto




Leprosy Mailing List, May 1st, 2009


Ref.:   Itching

From: Ryan T., Oxford, UK



Dear Salvatore,


This has been an interesting series.  Please add that itching being subjective the only objective measurement is of scratching.  Psoriasis was once designated a non itching condition but this has changed since researchers have recognised the varied use of the term itching and the varied objective response.


If there is no sign of scratching it is probably "soreness" or some other "feeling".  If it is scratched it is certainly itchy.


Best regards,


Terence Ryan

Itching as presenting symptom of leprosy and reversal reaction

Leprosy Mailing List, May 1st, 2009


Ref.:   Itching as presenting symptom of leprosy and reversal reaction

FromGilead L, Jerusalem, Israel



Dear Dr. Noto,


I am surprised at the scarcity of responses regarding the association of itching and leprosy, as a presenting sign or as a sign of reversal reaction. You are probably well aware of the small number of patients being treated in the Israeli Hansen DiseaseCenter (200 registered, 5-10 new cases annually).  Nevertheless, in the last 2-3 years we have had at least two cases who presented with itching as their main complaint.


The patients were – a 55 year old male which immigrated from India some 10 years prior to presenting to a dermatology clinic with new (2-3 weeks) itchy plaques on his Lt.>Rt. flanks.  A skin biopsy revealed LL and he was referred to us.  This patient also developed a reversal reaction 1.5 years into his MDT course, which also presented with itchiness in the area of his original plaques. 


The second patient was a 21 year old female, which immigrated from Ethiopia some 5-6 years earlier.  She also presented at a dermatology clinic with itchy plaques, this time on the ventral parts of her thighs.  In her case, again, the biopsy results showed LL and she was referred to us.


In the two cases I report the histology was typical of LL but the clinical picture was less straight forward.  The patients had only a few plaques, distributed asymmetrically.  Smears were AFB positive both from plaques and from apparently uninvolved skin of knees, elbows and earlobes with a +3 - +5 bacillary index.  


I think it safe to say that the first patient was a BL.  The second patient already presented with right hand weakness, toe clawing and significant sensory deficits in both palms and soles and some other areas of her skin in the upper and lower limbs. In her case I think LL is more probable.


Both patients described specifically itching and not paresthesias (both speak and understand Hebrew well) and definitely had no other dermatologically apparent condition which could explain their complaints.


Following these cases we had a discussion regarding the rarity of this presenting symptom and its absence from the textbooks.  I think it might be much more common than presently acknowledged.


All the best,


Dr. Leon Gilead

Head of The Israeli Hansen's Disease Center

24 Strauss St. Jerusalem Israel

Department of Dermatology

Hadassah University Hospital

Mobile 972-50-7874309

Icthyotic changes in leprosy and pruritus

Leprosy Mailing List, April 30th, 2009


Ref.:   Icthyotic changes in leprosy and pruritus

From: Jerajani H R, Mumbai , India



Dear Dr Vijaykumaran,

I appreciate your deliberation on pruritus in leprosy (LML April 28th, 2009).  I would like to add icthyotic changes in leprosy especially those taking clofazimine as one of the common causes of pruritus especially during winter season.

Subsiding leprosy reactions showing icthyotic dry scaly surface too give rise to itching.


Best regards,

Dr H R Jerajani
Professor & Head
Department of Dermatology 
LTM Medical College &
 General Hospital 
Sion, Mumbai-400 022

Itching in leprosy

Leprosy Mailing List, April 30th, 2009


Ref.:   Itching in leprosy

FromManimozhi N., Bangalore , India


Dear Dr. Salvatore Noto,

This is with reference to Dr Pai’s Leprosy Mailing List, April 25th, 2009, Pruritus in BL, LL and smear positive relapse leprosy lesions.

During my tenure at SLR&TC – Department of Epidemiology and leprosy control from 1985 through 2001, we had come across instances where patients reported with pruritus as the main complaint and diagnosis of reactions and relapse was made after examination.  It was noted that it was actually – parasthesia (abnormal sensation) which the patients expressed it to as itching (pruritus) in their own local language and some did mention as burning sensation as well.

Brief case study: Mono- therapy Relapse case presenting with pruritus/rashes as main complaint.

An elderly Anglo-Indian (Mr. Hawkinns – name changed) inmate of Cheshire Home at Virudampet /Vellore, Tamil Nadu, India aged more than 70 years, a know case of Lepromatous leprosy released from treatment. He had an interesting history of treatment started with Hydnocarpus oil injections and Dapsone.  He used to attend the outreach village clinics conducted within the Cheshire Home campus for general complaints along with others.  All the inmates had a separate released from control (RFC) register maintained in which all clinical, treatment details where documented.

It was around 1992 to 1995, there was an anniversary celebrations of Cheshire at UK for which Mr. Hawkinns was invited to attend the function.  The British Airways wanted a certification of fitness and not infectious to others from a specialized institution.  He was very carefully screened by 2 senior specialist and me as well, skin smear examination carried out which was negative and he was declared to be sign free.  Mr. Hawkinns visitedUK , and he could meet all his cousins there spent about more than a month and returned back.  And during our clinic day at the Cheshire Home centre he attended the clinic looking very cheerful, happy but with some complaints of rashes associated with itching, while on examination few micro-papular lesions and plaques where noticed and a skin smear examination was carried out and was positive with BI more than 2+, which ultimately turned out to be a relapse.  Multi-drug therapy MB was initiated and after few months our good friend passed away due to some other general illness.  I am sure Mr. Hawkinns case card is well preserved in the records department (deleted as Expired) to verify in case accurate and or more details is needed.

Lesson learnt from this episode is :

Leprosy is indeed a great imitator.

Presentation of complaints in patients own terminology may be misleading.

Routine sites can show skin smear negativity – While lesions in relapse cases can occur in rare sites which could show skin smear positivity.

It may take a short duration of time (2-3 months in this case) for the disease to express signs of relapse after the last clinical/bacteriological examination.

Dr. N. Manimozhi

Medical Coordination- AIFO

Bangalore, India

Itching in leprosy

Leprosy Mailing List, April 30th, 2009


Ref.:   Itching in leprosy

FromNarasimha Rao P., Hyderabad , India



Dear Salvatore,


This mail is in regard to on going discussion  on itching in leprosy.  Itching is a not a known symptom of leprosy.  However, many itchy conditions can occur as co-dermatosis in leprosy patients.


When leprosy patients are seen in dermatology out patient clinics of developing country like India , it is generally observed that these patients are prone in equal measure to all the dermatological disorders as other patients of their social/peer group.  Hence the occurrence of common dermatological conditions like scabies, dermatophytosis (tinea infection), contact dermatitis, skin eczemas, papular skin reactions to insect bites etc. is quite common in leprosy patients.  All these dermatosis mentioned are itchy conditions and can easily be identified by trained skin specialist.  However, when they occur in a leprosy patient they can be confusing clinically even to a trained eye, as their classical features are modified depending on the extent and type of leprosy.  It is commonly observed that all these itchy conditions when associated with leprosy become /present as less itchy conditions. 


Below mentioned are few commonly associated dermatological itchy conditions modified in leprosy.


Asteatotic leg eczema:  More commonly seen bilaterally in BL or LL patients, more so after treatment with Clofazimine which adds to xerosis of skin. This type eczemas continue to occur many years after patient is made RFT.  Occasionally unilateral leg eczemas are seen in area of anaesthetic/ hypoaesthetic skin lesions of BT  patients.  In these type of eczema, although scaling is profuse, often accompanied by fissuring and secondary infection, itching as a symptom is usually very mild or not reported at all in a patient of leprosy, compared to a non-leprosy patients with similar involvement. 


Papular urticaria:  Papular skin reaction to insect bites commonly observed in tropics is observed to be less symptomatic in BL-LL leprosy patients. Itching is a not a prominent complaint in these patients compared to non leprosy patients with this condition. 


Scabies:  Wide spread crusted type of scabies, also  known as ‘Norwegian scabies, which is known to occur in mentally challenged, paraplegics, immuno-supressed etc, is also reported in leprosy.  Vijaikumar MThappa DM. Crusted (Norwegian) scabies in leprosy. Indian J Lepr..2001 Jan-Mar;73(1):55-8.  Itching which is the principal feature of scabies is absent in this condition.


Tinea corporis:  When tinea corporis lesions co-occur in leprosy patients with type I reactions, they could mimic the patches of type 1 reaction, especially regressing phase of patches when they scale off.  However, differentiating feature is the tinea corporis patches are itchy and when in doubt scraping for fungal filaments on KOH mount would help in the diagnosis.  I have few photographs of this co- infection and would  be happy to forward to those interested to have them.  The case of patient presenting with itching on buttock turning out to be  type 1 reaction on histopathology, (ref: letter from Nunzi E, Italy, Leprosy Mailing List, dated, April 28th, 2009; Itching as presenting symptom of reversal reaction),could be one such instance, as buttock is a common site for tinea infection and it could be a co-infection in this patient.

In summary, it can be stated that itchy dermatological conditions when associated with leprosy patient can be  a) masked (incognito)  b) less inflamed and show modified tissue reaction, c) less itchy,  or d) have normal clinical features.  Hence it is important to consider/rule out associated dermatological conditions as a cause of itching in these patients. Unfortunately , however, it is often  difficult to rule out even common skin conditions such as papular urticaria, insect bite reactions, early scabies etc. by laboratory tests.


In my opinion, when patient of leprosy complains of itching, careful search should be made for (missed) underlying dermatological condition.  The associated conditions could vary depending on the geographical area/ economic/ social status of the patient.  This is necessary because itching is not a known feature of leprosy and there is no accepted scientific or pathological basis for it to be present in either during normal course or during reactions of leprosy.


With best regards,


P. Narasimha Rao

Dr W Nogueira's letter translated in English

Leprosy Mailing List, April 30th, 2009


Ref.:   Dr W Nogueira's letter translated in English (see attachment)

From: Poorman E., Boston , MA , USA


Dear Salvatore,


As requested, I have translated Dr. Nogueira's letter, which I likewise find thought-provoking. Translation is not my vocation, but I have tried to stay as true to the original as possible.



It is not possible to use two different languages with patients and with medical and health professionals

Leprosy Mailing List, April 30th, 2009


Ref.:    It is not possible to use two different languages with patients and with medical and health professionals

From:  Poorman E., Boston , MA , USA


Dear Salvatore,

I much appreciated the discussion of the social aspects of "elimination" for the sick. Please allow me to clarify.  Having spent significant time in the colonies attempting to understand the mind-set of newly diagnosed and those who have spent decades in these strange cities, I feel that I have a responsibility to represent their viewpoints.


As a (very) new member of the medical profession, I understand the terrible tendency to discount other ways of seeing illness besides our own--very important--medical outlook. However, I think that in taking into consideration the words and actions that will be used in attacking a public health problem, the effect on the patient's psyche should be of utmost concern.

It is not possible to use two different languages with patients and with medical and health professionals, as patients are often more well-informed than we about their disease and the actions taken to prevent it.  Moreover, as to the point of "curing" leprosy, from the perspective of the patient, this is clearly a chronic disease, and "cure" is a confusing term at best.

I think that moving towards control is a positive step for Brazil , though here I defer to Dr. Nogueira, Dr. Leide, and colleagues who have spent many more years on this issue. Cadernos Saude Publica published a journal at the end of last year, which I believe foreshadows this change with remarkable astuteness (; Dr. Leide and I both had articles in this issue) I make only one firm claim: the residents of the colonies were for many years the ONLY health professionals for Hansen's patients; they nursed their brothers in disease and watched many of their friends die.  They are truly as neglected as their disease in modern day Brazil . This is a disadvantage for them and for any goal of control, as they are not being utilized in accessible information sources, and their bitterness may even lead them to spread false information.  If it is at all possible to incorporate them in Brazil 's new path, the chances of success and atonement are far greater.


Elisabeth Poorman

Pruritus in BL, LL and smear positive relapse leprosy lesions

Leprosy Mailing List, April 25th, 2009

Ref.:    Pruritus in BL, LL and smear positive relapse leprosy lesions

From:  Pai V. V., Mumbai, India



Dear Dr Noto,


We have observed in some of the new smear positive borderline lepromatous, lepromatous cases and as well as those with smear positive relapse of the disease who reported to the Bombay Leprosy Project Referral centre, itching in the lesions (infiltration, plaques) as a main reporting complaint by the patient which made them report to the clinic.  On careful cutaneous examination and bacteriological examination smears from the lesions were reported to be positive.


We found pruritus as a symptom in such lesions can be misleading in treating other dermatological disorders and therefore can be thought of suspecting multibacillary smear positive leprosy.  This is just our observation.  We would like to know from leprosy mailing list readers about such  experience by others if any.


Dr V V Pai

Bombay Leprosy Project 


On the use of telephone for tracing absentee/defaulter in leprosy?

Leprosy Mailing List, April 25th, 2009

Ref.:    On the use of telephone for tracing absentee/defaulter in leprosy?

From:  Luka E E, Amarat, Khartoum, Sudan


Dear Salvatore,


I am interested in finding out whether anyone has done a study on the use of telephones for tracing absentee and/or defaulter patients of leprosy.  Are there research papers on these? Can anyone help?


Thank you in advance,




Dr Edward Eremugo Luka

TLM Sudan

Dr Nogueira’s paper translation is needed

Leprosy Mailing List, April 25th, 2009

Ref.:    Dr Nogueira’s paper translation is needed.

From:  Lechat M., Brussels , Belgium



Dear Dr. Noto, 


Like Dr Maria Leide (LML April 23rd, 2009), I consider that the excellent and thought-provoking letter by  Dr W. Nogueira (LML April 1st, 2009) should be read by a large audience.


The fact that it is written in Portuguese, though it could prevent some colleagues to open it, will raise no difficulty for its understanding  by French speaking (and speakers of other Latin -derived languages) readers.  But for others, I think it would be highly desirable that it be translated into English.


Thank you again for the most needed services you provide through the LML.


Best regards,


Michel Lechat


Whither Integration?

Leprosy Mailing List, April 24th, 2009

Ref.:    Whither Integration? (see attachment)

From:  Ganapaty R., Mumbai, India



Dear Dr Noto,


We have documented evidence to show that increasing numbers of patients report voluntarily to the Leprosy Referral Centres of Bombay Leprosy Project after integration of leprosy in to general health services (Ganapati R, Pai VV, Nanda A, Pai RR, Can Urban Health Posts manage Leprosy Detection and Treatment after Integration with General Health Services?—A Study in Bombay, Lepr Rev,79, 338-339, 2008).


Observations of a group of dermatologists working in one of the four major teaching medical colleges in the huge metropolis of Mumbai published in the Indian Journal of Dermatology Venereology and Leprology, 75, 190-191, 2009 are extracted in attachment for the benefit of the leprosy mailing list readers.


I believe that the experience of other medical colleges, practicing physicians and NGOs indicates a rising trend of leprosy in this mega city with about 15 million population, though statistics from such sectors remain unrecorded. The situation may not be different in other major cities with population exceeding 10 million.


Though it is clear that over the past five years integration of leprosy has failed, the concerned officials of the government and municipal corporation seem to be quite complacent. 


Dr R Ganapati,

Director Emeritus

Bombay Leprosy Project


Leprosy Mailing List, April 23rd, 2009

Ref.:    Brazil, “Nota Técnica” n. 010/2007 (see attachments in English and Portuguese)

From:  W. de Oliveira M. L., Rio de Janeiro, Brazil

<< “Nota Técnica” n. 010/2007 English >>

<< “Nota Técnica” n. 010/2007 Portuguese >>




Dear Salvatore,

Concerning the latest communications about 
Brazil on the leprosy mailing list, I would like to share some personal comments.  Not because I have been  involved in making National Policy since the introduction of MDT, but especially as a health professional dealing with Hansen´s Disease problems in Brazil , from  patients' assistance to the management programme at different levels, since 1975.

What is the use of the fuss made over leprosy "elimination" versus control inBrazil ?


The Brazilian National Hansen’s Disease Control Programme (Health Surveillance Secretariat of the Federal Ministry of Health) issued technical note nº 10 in 2007, which I have attached for rereading/highlighting the indicators of annual detection of new cases and cases among children as the most appropriate for monitoring the leprosy situation, particularly when trends are analysed over time.  Prevalence, the indicator contemplated in the elimination goal, would be maintained for the purposes of comparison with other countries, but not as a monitoring indicator, given that the public health problem does not end upon reaching a level of less than one case per 10,000 population.   It is important to emphasise that the indicator that most directly affects this outcome is the cure rate, which has been prioritised by the National Hansen’s Disease Control Programme (PNCH) and formally agreed upon by the federal, state and municipal authorities of the Unified Health System (SUS).  In addition, the reduction of cases in children under 15 has been included among the high-priority goals of the Ministry of Health (MoH) as part of the national Programme for Growth Acceleration (PAC).


The technical guideline in question was issued on the basis of analyses of national data conducted by technicians with no political interest in the outcomes, which unequivocally demonstrate the effect that changes in the calculation of the leprosy detection and prevalence indicators had in Brazil from 2004-06, namely an artificial reduction in the number of new cases.  This report was submitted to two technical bodies, one composed of renowned Brazilian epidemiologists and representatives of the Brazilian Association of Post-Graduate Studies in Community Health, as well as to the Evaluation Committee of the National System of Health Surveillance of the MoH, whose president was the former ex-director of PAHO, Dr. Carlyle Guerra.


The technical note was also presented to the Technical Advisory Committee of the PNCH in July 2007, and it was approved by this body, which included the consent of the MORHAN representative. In August 2007, the document was made available on the MoH website as well as during numerous national and international scientific events.  


In all of these cases, there was no opposition to the document on technical grounds put forward by anyone working in the levels of management or execution of the action plans for Hansen’s disease control either in Brazil or abroad.  Neither was any negative manifestation made by the non-governmental organisations (NGOs) that support the state control programmes in Brazil , as was stated in the discussions on the mailing list.


So, why the ruckus now, brought upon by an article in a single Brazilian newspaper?  In light of this, I would like to personally answer some of the affirmations made in that story:

1-To the examples given by MORHAN of elimination of diseases such as rubella and poliomyelitis: It is not necessary to discuss this fact when dealing with immunisable diseases. Why is it, however, that no one has the elimination of tuberculosis as a primary goal when it is a disease with the same intervention/control model as leprosy?

2-To the arguments of Dr. Jarbas Barbosa in reference to the fact that Brazil would eliminate leprosy in three years: according to the evidence presented in the technical note (attached), this could actually have been possible, but only using artificial mechanisms.

3-To Dr. Clovis Lombardi, Brazilian public health physician and retiree of PAHO: I have no comment to make. I have also worked in leprosy for 30 years, with local, regional and national experience. I am not retired, but when I am, I hope to have a good answer to questions like: what was my tangible contribution to the solution of the leprosy PROBLEM in my country?


Lastly, Brazil is a relatively young and extensive country, where leprosy was introduced 500 years ago; where it took three centuries to formulate the first policy of intervention; and where a therapeutic approach to case resolution only appeared 50 years ago, the contingent of infected individuals has still not been exhausted is still being diagnosed. This is due to the characteristics inherent to this disease, such as a long incubation period and the insidious evolution of its multibacillary forms.


In addition to the historical factors and technical/scientific evidence that explain why the number of new cases of leprosy alone does not allow for the achievement of the elimination goal in 2010, there is also the social and political context that interferes with the effectiveness of control measures.  The elimination goal helped to clear the registries, but it has run its course.  The active registry of leprosy patients is now relatively up to date, which is why the prevalence is now nearly exclusively made up of incident cases. Therefore, the stabilisation of the leprosy endemic has already occurred in the most developed regions for over a decade, but is only now starting to appear in the three more impoverished regions, according to recent epidemiological trend studies (


To stir up an unnecessary row and blame federal officials now, simply to create more political pressure, is both a sterile and tiresome discussion. It is even harder to understand when it originates from the local social movement, which would be so much more effective if it were mobilising social interventions in conjunction with local health officials in the most endemic areas in order to intensify control activities and eliminate (yes, eliminate) the focal points of transmission in existence in Brazil.


I recommend the reading of Dr. Wagner Nogueira’s recent contribution to the mailing list (LML April 21st, 2009).  He is a physician that has truly been active in the control of Hansen’s disease in São Paulo state with an important national role over the years and an involvement in the early leadership to found MORHAN.  His missive is particularly salient when he refers to the ambition of some partners to occupy positions of power and the questionable ethical aspect of taking complex technical discussions to the media for wider dissemination.


Maria Leide W. de Oliveira


Professor/Medical School of the Federal University of Rio de Janeiro (UFRJ)

mleide (at)