Leprosy Mailing List – April 29, 2015
Ref.: (LML) The Missing Millions: A Threat to the Elimination of Leprosy
From: Grace Warren, Sidney, Australia
Interested to read the letter from Dr Shen Jianping regarding the presence of Leprosy today and the stated fall in incidence (LML April 28, 2015). Yes the article Bt Dr Smith was excellent and does raise problems that still need to be solved.
I agree that we would like better means of testing to diagnose if a patient has leprosy and also I would be interested to be able to test a patient who was treated years ago to find out if he still has any viable bacteria and if he is likely to relapse.
The diagnosis of leprosy is not always easy. In fact, when working in Hong Kong I soon discovered that many of the early LL type patients had NO obvious skin lesions and certainly no abnormalities of sensation and so would not be diagnosed as leprosy according to the WHO “diagnostic criteria”. Careful observation often revealed a thickening of the skin but no definite edges so not enough to be called a definite patch, and easily missed. When we did a slit skin smear we got the diagnosis. I well remember one teenaged boy who was put in a psychiatric institution because he complained of anaesthesia of some fingers of the right hand. He was brought to see me for a large lymph node in the neck which on biopsy proved to be leprosy but I found the nerves on the hand were all large. He was typical of so many primary persistent neuritic leprosy patients that I have so often see all round the world, and they are often told, even by WHO consultants, No it is not leprosy because no anaesthetic skin patch!
Over the last 50 plus years I have worked with leprosy patients in over 27 countries and similar problem exist in most. The medical students are literally not taught enough about the disease and its symptomology. As a Medical Student here in Australia, in the 1940/50s, we were taught very little, and as I always tell the students “what you do not look for you will never see” and “what you do not know you will never diagnose”. In the last twenty years I have been seeing patients here in Australia - yes they are here too - some white skinned and born here, some aboriginals - but a number have come from overseas and not previously diagnosed. Though some come with a diagnosis and are on treatment, but have so little to show that the local General Practitioner does not consider it a problem and do not try and follow up. One recent arrival from overseas presented with a partly paralysed hand which was accepted for reconstructive surgery - but fortunately the surgeon took a nerve biopsy and was horrified at the diagnosis of leprosy!!! So he was referred back to us.
Even back in the 1960s I remember working in countries where leprosy was endemic with thousands of patients, but when visiting as a consultant, I was often asked to give a lecture on Leprosy and that was often the first leprosy lecture given in that Medical College. In one college the lecture was the result of having diagnosed a leprosy patient in their outpatients !
Yes, it has been said that Leprosy has been Eliminated, but some leprologists in endemic countries acknowledge that there are thousands of mild early cases, especially child contacts, who have the disease but because it does not fulfil the Who definition they are not included in the Statistics. Treatment is easily available and relatively cheap but unless the medical practitioners look for it they are not going to diagnose it.
A major need is to inform the Medical Practitioners that it is still present and often in forms that are easily hidden. Working in Taiwan in 1970s, I well remember a number of patients with LL disease and positive skin smears who responded well to treatment but stated that No one knew that they had the disease !!! I found that in Chinese LL patients there was often no evidence of sensory abnormalities, let alone anaesthesia for up to twenty years of the disease!!! My query is how can we get the current practitioners to look for a disease that is so clever at remaining hidden!! Can the researchers find some test that will detect the disease early? How can we awaken awareness - teach students, and keep checking the children, and child contacts of those who have had it. I agree it is unlikely that it will ever be completely eliminated, but Hopefully the numbers affected can be much further reduced.
With best wishes to those involved in the research and teaching about the disease and especially the work being done through LML.
Now in Australia. Former adviser in leprosy and reconstructive surgery for The Leprosy Mission in Asia ( 1975-1993).
LML - S Deepak, B Naafs, S Noto and P Schreuder
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