Ref.: No
Hypopigmented Lesion, No Nerve Thickening, But Its Leprosy!
From: G Warren, Sydney, Australia
From: G Warren, Sydney, Australia
Dear
Dr Noto.,
Thank
you very much to Ms Nathalie Koumans for her message [LML may 22nd,
2012]. I was very pleased to open the new list posted from Infoleps of
leprosy articles, available on line. This article was of particular
interest.
“No Hypopigmented Lesion, No Nerve Thickening, But Its Leprosy!”
Ashish Singh, S Ambujam, and N S Pradeep Kumar
Indian J Dermatol. 2012 Jan-Feb; 57(1): 73–74.
doi: 10.4103/0019-5154.92689
“No Hypopigmented Lesion, No Nerve Thickening, But Its Leprosy!”
Ashish Singh, S Ambujam, and N S Pradeep Kumar
Indian J Dermatol. 2012 Jan-Feb; 57(1): 73–74.
doi: 10.4103/0019-5154.92689
This
is a very timely article based on the general acceptance of the W.H.O.
definition that a patient with leprosy must have a skin patch with a definite
loss of sensation. The writers describe a very common problem in many
countries where the pinkish ENL spot may become and go and may ulcerate and
become infected and may even be uncomfortable but, the quickest way of
checking the diagnosis of leprosy is often by a slit skin smear. Yes, I
am afraid that good reliable technicians able to do a good smear are becoming
more rare, but It is important that general dermatologists and physicians
need to remember that early Lepromatous leprosy may have very vague
lesions or fluctuating ones (as ENL does) that have no loss of
pain or obvious abnormality in touch.
Yes,
“what we do not think about we will never diagnose” and in endemic countries we
need to still be aware that leprosy is present but, we will not diagnose
it if we do not look for it.
Having
worked in eastern Asia for many years I am very familiar with this early LL
type of leprosy in which there are no obvious lesions for many years
though if one palpates carefully one realises that there is some
infiltration. If the positive diagnosis is made at that early stage then
there is often no real problems managing reaction and recovery does occur
relatively rapidly without deformity or disability.
I
vividly remember one middle aged Chinese woman whose face was generally
infiltrated but, she had no obvious edges and no definite lesion.
However on careful examination one could feel the infiltration and appreciate
that the upper lip was not as infiltrated as the rest of the face. The
diagnosis was made because a nodule on her arm was biopsied! In
follow up we found slit skin smears with bacteriological index (BI) of 3+ and 4+ in every site
where we examined even if there was no sign of a definite lesion.
This
is a timely reminder and one wonders how many of these patients are treated for
some other disease or just not treated till the leprosy is definite and that
often means that deformity or disability will result. Also the
patients most likely to have this type of lesion are those at lepromatous end
of spectrum and so most likely to transmit the disease to their contacts;
even if they are not manifesting obvious lesions.
May
we really look for these cases and early treatment will help to keep the
numbers of new cases down.
Yours sincerely,
Grace WarrenYours sincerely,
Previously Med Superintendent of Hong Kong leprosarium 1959-1975.
Adviser in Leprosy and Reconstructive Surgery for the Leprosy Mission Asia 1975-1995.
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