Wednesday, September 4, 2019

(LML) Leprosy Diagnosis and Treatment

Leprosy Mailing List – September 4,  2019

Ref.:  (LML)   Leprosy Diagnosis and Treatment

From:  Robert Gelber, San Francisco, USA

Dear Pieter and colleagues,

Two prominent issues in the last year of the LML received unanimous support: the need to reinstate skin smears and that clofazmine should not be utilized to treat PB patients. Unfortunately, no one stepped forward to argue opposition.  If not here at the Leprosy Congress, we deserve to hear from those who disagree-perhaps the WHO or Novartis, both of whom are to make presentations at plenary sessions.

It is a step forward to the diagnosis of leprosy, that in addition to anaesthetic patches, positive skin smears and nerve enlargement confirm a leprosy diagnosis.   It is not clear, how the BI level will be used to make therapeutic decisions, nor that their general reinstitution is actually advocated.   Most unfortunately from 1995 to the present the classification of leprosy for treatment purposes was determined solely by the counting of anaesthetic patches, and without smears lepromatous leprosy was not even considered leprosy - a serious impediment to the institution of leprosy therapy and control.

Evaluation for nerve enlargement is severely limited by the fact that palpation of nerves is not part of the medical evaluation anywhere.   Also, it is not generally recognized even which nerves are generally palpable and what the size of individual nerves is pathologic.   Even seasoned leprologists will debate whether a particular nerve is enlarged or not.   How then can nerve enlargement be expected to be recognized by the general health services to which leprosy has been regularly relegated.

PB leprosy has been shown to provide a reliable cure using the previous WHO regimen of dapsone and rifampin.   The addition of clofazamiine to that regimen is not only unnecessary but associated with onerous skin discoloration.  

I would like to take this opportunity to invite all of you to attend my congress presentation in the afternoon of 12 September.   There I will review and critically analyze the literature on persisters and relapse frequency in MB leprosy from the dapsone monotherapy era to the present, including MDT.   I will conclude that to date no tested finite therapeutic regimen, including MDT, is capable of eliminating considerable relapse in MB patients, and that lepromatous (BL, LL) patients and those with a high BI require continued treatment, "chemoprophylaxis."

I look forward to seeing you in Manila.

Best wishes.

Robert Gelber

LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link:

Contact: Dr Pieter Schreuder <<

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