(LML) I was dreaming

Leprosy Mailing List – December 23,  2016

Ref.:    (LML) I was dreaming

From:  Ben Naafs, Munnekesburen, the Netherlands

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Dear readers,

 

I would like to refer to the LML letter of Ben Naafs of November 18, and the reaction to this letter of Arry Pongtiku of December 8, 2016.

 

Best wishes,

 

Pieter AM Schreuder

 

 

 

Dear Arry,

 

My excuses for my late response. It is due to little time this time of the year.

 

First I want to thank you for your response and efforts to make cartoons for explanation. Yes, indeed to translate it in cartoons is a good idea. For type I your drawing is very good. It comes near the real mechanism as I see it. May be there is place for collateral damage. Concerning Type II it is nearby too. Here collateral damage may be even more important.

 

I would try to put in the cartoon the pre-reaction and post-reaction damage. If it is possible to perfectionize your cartoons, please do.  I agree the simpler the better. We can publish them if you are interested.

 

Some remarks to the text:

 

Type I reaction:

It indeed may be that it is directed against M.leprae itself  (foreign body) but it is also possible that it directed against the changes that M.leprae has induced in the host cell. Or due to changes in the immune-system that suddenly considers normal cell constituents as foreign. The CMI indeed brings inflammation which causes oedema. That may give pressure on the nerves when these are in an inelastic “tube” or canal. (bony, fibrous or muscular). Surgery and steroids indeed may diminish this compression.

 

The text under the photo: the swelling on and in the skin may be an indication for similar happenings in the ulnar of other arm.

 

Type II reaction:

The bacilli (antigens) do not need to come in the circulation. There are B cells and plasma cells in the tissues which make the antibodies that bind to the antigens (constituents of M.leprae). This binding of antibody and antigen gives complement activation; thus C3a and C5a giving inflammation and chemotaxis for the neutrophils. It leads to MAC making holes in the antigen containing cell leading to lyses.

 

Here indeed in the acute phase there surgery is not so important because the inflammation last short. But in chronic ENL (type II reaction) the oedema may last due to a compression of the post capillary venulae in the perineurium. Here surgery may help too.

 

Lucio phenomenon:

Your handling of a patient with a most likely Lucio fits in with explanation I cited.

 

I hope that you can adapt the cartoons. Your reaction make me think again and I hope, being like you a clinician, is clear and in the direction of the truth.

 

Greetings

Ben Naafs

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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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