Leprosy Mailing List – January 26, 2015
Ref.: (LML) BT Hansen's Disease and nerve abscesses - surgical intervention or MDT alone?
From: Robert Jerskey, Carlsbad, California, USA
Dear Dr. Pieter,
I enjoyed reading Dr. Sunil D. Ghate’s fascinating case presentation and query early this month, and then most recently, his follow-up report which included the nerve ultrasonography [N.U.] (LML January 22, 2015).
I have also found the posted responses very informative, including of the risks of surgical intervention and possible permanent nerve damage, the importance of monitoring for early nerve function deficit, and the value of crafting a medical regimen in order to best prevent the patient going in to a “full reaction”.
Speaking of Reaction, I am reminded of a retrospective study published over two decades ago re: facial patches, type 1 reaction, and facial nerve damage, by Hogewig, Kiran, and Suneetha. [see below **] Though this case does not fit the criteria at this time, I reference the study because of the new information that has come to the fore: a small facial lesion just lateral to the right eye. Whether the patient is determined to be with PB or MB leprosy, or in Reaction or not, [and as alluded to by Dr. Warren, there are risks for potential Reaction during the course of tx] the fact that there is a facial patch proximal to the eye, though small, and multiple nerve enlargement in the L UE (Left Upper Extrimity), I would aim to carefully monitor the facial and trigeminal nerve function as well.
And, again, with multiple UE nerve involvement there may also be LE nerve enlargement, if only incipient. Incidentally, judging by the N.U. findings, there might be some enlargement in the right radial cutaneous nerve, comparing its diameter vis a vis the median nerve value on the same limb?
Good to read that there is thus far no sensory or motor impairment. However, I am wondering which tool[s] are being used to identify early sensory impairment. I read that the patient is being followed with TST and VMT. Would Dr. Ghate clarify what is “TST”? Likely to be Tactile Sensory Test. [or Temperature?] The tactile test covers quite a repertoire; might be with a pen, cotton, monofilaments, paper clip, etc. I want to re-visit what Dr. Palande emphasized in his recent posting re: this same patient: “…using graded nylons. Unless graded nylons are used one would not know if there is early nerve function deficit.” If these, otherwise known as monofilaments [MF], have not been used, is there access to them in the clinic/hospital. so as to establish a fresh baseline? Any insidious sensory deficits that might have been missed thus far can very likely be identified and measured with the graded MF.
In summary, besides my request for clarification of the sensory testing tool[s], it would be helpful to monitor for any “red flags” at other key structures at risk of morbidity as the focus continues, understandably, on the L UE: to also carefully monitor nerve function in the other extremities and the eyes as well.
Thank you, Dr. Ghate, I look forward to reading of any further developments; your patient is clearly under well-orchestrated care.
Friendly greetings to all LML readers,
Robert Jerskey, LOTR, P.O.D. consultant, based in Carlsbad, California, USA
** See comment in PubMed Commons belowLepr Rev. 1991 Jun;62(2):143-9. The significance of facial patches and type I reaction for the development of facial nerve damage in leprosy. A retrospective study among 1226 paucibacillary leprosy patients.
Hogeweg M1, Kiran KU, Suneetha S.
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
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