Leprosy Mailing List – May 20, 2013
Ref.: (LML) New Case Detection
From: Dr. Jaison Barreto, São Paulo, Brazil
Dear Pieter,
I would like to thank Dr. Kawuma for his reaction (LML May 20, 2013, referring to my letter of May 9, 2013).
Diagnosis of leprosy in children is, in most instances, quite difficult. Especially when there is no history of leprosy in the family. However, the most important problem is the lack of suspicion of leprosy. That is why I agree with the effort of our Health Ministry (search for early leprosy in school children). Although, most likely, this first trial will not result in many new cases.
Why am I thinking this? Because, in Brazil, I have noticed that most physicians, and even dermatologists, do not know how to make the diagnosis based on clinical grounds alone. Almost always, they prefer to take a biopsy, which, unfortunately, is false-negative on almost 70% of cases of Indeterminate leprosy, and is not clear in cases of Tuberculoid leprosy, when there are no bacilli.
Worst, as most physicians do not know how to diagnose leprosy, many times the children undergo a bacilloscopy of ear lobes and knees, which is in 100% of cases is false-negative in indeterminate, initial borderline or tuberculoid leprosy. This is a main reason of household contacts to avoid going to the basic health units.
Why this still occurs? Because leprosy is seen as a rare, and even extinct disease, and is not seen in most Outpatient Departments of universities clinics in Brazil. Dermatologists are not interested in Sanitary Dermatology. Less than 50% of Dermatology Residents in the state of São Paulo (the Brazil's richest state) see regularly leprosy patients while practicing in the Outpatient Department. .
This situation is caused by the declaration of "elimination of leprosy" of our state in 2005. From 2007 to 2011, in Instituto Lauro de Souza Lima (ILSL, where I reside), 64% of newly diagnosed leprosy cases were from São Paulo state, and 26% had already a disability grade 2 on diagnosis. The mean time interval between initial symptoms and the diagnosis here, a National Reference Centre, was 2 years. Patients had to travel up to 400km to be diagnosed. Mean age was 49 years, and 70% a low school education, i.e., less than 8 years in school or analphabet. Among the new cases, 13% were diagnosed only because we invited household contacts for examination. They were not evaluated before.
With DAHW (German Leprosy and TB Relief Association) support, and sometimes also with funds of our Health Ministry, I went to several states of Brazil teaching how to diagnose leprosy. Unfortunately, many times, physicians, mainly in big cities, do not want to learn about leprosy and neglect leprosy patients. It are the nurses who have to solve all problems and care for all programmes (see details on the site www.dahwmt.org.br).
Coming back to the diagnosis of leprosy in children. Thermo-sensibility testing: I use 2 tubes, with warm and cold water. After talking to the child and their relatives, I start showing to the child that the tubes are not harmful, testing it on mother/father/me.
1. Sensitivity testing:
With opened eyes (child), I test the tube on a non affected skin, and I ask if it is warm or cold. Once the answer is trustable, I ask to close the eyes, and after putting an obstacle to the child's sight, as the mother/father hands, I continue to ask "warm or cold". If the child is clearly not sure about the temperature, the diagnosis is confirmed.
If this test is inconclusive I use a fine needle (insulin - 13 x 4,5), that I keep inside the pocket, far from the child's eyes. Never show the needle to a child, or testing will not be possible. Without the child seeing it, I take out the needle from my pocket, and put the needle tip, first inside and then outside the lesion. If there are differences in sensitivity, or no reaction (when testing inside the lesion), the diagnosis is confirmed.
2. Histamine testing:
It is useful if it is no possible to expect a trustable response on sensitivity testing, as in very young children, or when there are associated mental disturbances. A positive control must always be done in normal skin. Histamine is heat sensible, i.e., can be destroyed by heat. A photo of the positive testing, i.e., diagnosis of leprosy, can be seen on the site: www.dahwmt.org.br
Histamine testing can be false-positive in hypochromic vascular naevi, or if the patients are taking antihistamine drugs.
Regards,
Jaison
--
Dr. Jaison A. Barreto, MD, PhD
Chief of the Leprosy Section
Instituto Lauro de Souza Lima
Bauru - SP - Brazil
LML - S Deepak, B Naafs, S Noto and P Schreuder
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