Leprosy Mailing List – June 27th, 2012
Ref: The diagnosis of leprosy.
From: José Augusto da Costa Nery, FIOCRUZ, Rio de Janeiro, Brazil
Dear Noto,
It´s always a pleasure to talk about these matters. Herewith I would like commenting on the papers about the diagnosis of leprosy. This is a very interesting and intriguing subject.
Leprosy can manifest itself initially in 3 different forms: dermatological, neurological and systemic (fever, enlarged lymph nodes, etc). As the patient seeks a doctor, not everyone can correctly diagnose leprosy in its unusual forms. In my opinion this is one of the main causes of a late diagnosis.
Together with Dr Pieter Schreuder we published an article (Hansen's disease in a general hospital: uncommon presentations and delay in diagnosis*) in which we described uncommon leprosy presentations, and the difficulties of making a diagnosis for a general doctor or even for a dermatologist, resulting in late diagnosis. The three cardinal signs of leprosy are very important, but don´t cover all uncommon presentations of leprosy, leading to the maintenance of the epidemiological chain in endemic countries. We need to understand that other leprosy presentations must be given the right attention, for example: patients with a long history of different treatments and presenting cyanosis of the hands and feet, oedema of hands and feet, chronic ulcerations of the lower legs, diffuse infiltration of the body, chronic nasal clogging, erythema nodosum or erythema multifiorme like lesions. In such cases even dermatologists do not always include leprosy in their differential diagnosis, even when peripheral neurological symptoms are present.
The claim that skin lesions always come with sensitive changes is a matter that should be rethought, for we have paucibacillary (PB) patients without any sensitive alterations. Also multibacillary (MB) patients with signs of smooth and bright skin may not present sensitive changes. This group of patients usually has light sensation loss on legs, reduced strength, sharp and acute pain, paraesthesia, among others. The diagnosis is even more complex when they also have diabetes, hypertension, alcoholism, etc.
About thickening of the nerves; two reasons must be thought:
1. Do all professionals know how to search for hypertrophic nerves? Do they have this experience on a daily basis? It´s been years this activity is executed by a physiotherapist, so doctors lost this experience. In most cases, we tend to think of leprosy as only a skin disease.
2. We have many patients without thickening of nerve and, we have to learn the value of the pain on palpation.
Another factor is that not all services offer reliable laboratory tests, which do not rule out leprosy when negative, as is the case in PB. In MB it is important so we can confirm or rule out other diseases, like erythema nodosum from other causes, drug rashes or skin infections common in tropical countries.
We must have a very wide and accurate clinical view in endemic countries as Brazil, so we may raise the chances of early diagnosis, avoiding mutilations and even more dissemination of leprosy.
With best regards,
José Augusto da Costa Nery
*J Eur Acad Dermatol Venereol. 2009 Feb;23(2):150-6. Epub 2008 Sep 10.
LML - S Deepak, B Naafs, S Noto, P Schreuder
LML Archives: http://www.aifo.it/english/resources/online/lml-archives/index.htm
Dr Salvatore Noto
Padiglione Dermatologia Sociale
Az. Ospedaliera Universitaria S. Martino
Largo R. Benzi, 10
16132 Genoa, Italy
Tel: (+39) 010 555 27 83 - Fax: (+39) 010 555 66 41 - E-mail: salvatore.noto@hsanmartino.it
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