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| Jaison Antonio Barreto |
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Re: (1) (LML) Higher risk of relapses in BL/LL with BI 4 or more after MDT-U and MDT 12 dosesInbox x | 
---------- Forwarded message ---------- From: jaison <jaisonbarreto@gmail.com> Date: Sat, Dec 7, 2013 at 9:12 PM Subject: Re: (1) (LML) Higher risk of relapses in BL/LL with BI 4 or more after MDT-U and MDT 12 doses To: Pieter AM Schreuder <editorlml@gmail.com> Dear Pieter and Leprologist colleagues The problems I have seen are occuring every day, whatever in the field or at the national reference I work. Details about situation of the leprosy in the field can be seen at the site of Brazilian DAHW (www.dahwmt.org.br). Physicians do not knows about leprosy, and, many times, do not want to learn about it, because they will have to attend the patients from their municipalities. Of course, there are still goodwill professionals, but they are diminishing in number, mainly because errors in the politics which is used to do on leprosy (neglecting). Ignorance, stigma and prejudice are still the rule, mainly at the Brazilian states where leprosy is said "eliminated". The concept that leprosy is eliminated in a municipality or in a state worses this vicious circle, once health managers do not want to spend money with a disease they believe do not exist. For the few physicians whose are still fighting against leprosy, it is a hard life: we have to fight against the disease, the problems the patients have, and also against the politicians from the local we live and work... And the mistakes on the WHO classification (only the number of lesions, and the number of nerves involved is not important), today on work, also worses this problem. Ridley, 40 years ago, showed that borderline patients tends to downgrading: most BL comes from BT, and most LL comes from BB/BL. Is it right to treat with daily dapson, alone, and only once a month rifampin, a patient with not complete capacity of elimination of M. leprae from the nerves, and who has many bacilli inside nerves and few in the skin? We, clinicians and leprologists, see, today, that many high BI leprosy (LL/BL) patients do not cure with 12 doses. So, what could we say about regimens of 6 month for these patients? The most recent and best cohort study (more than 9 years of follow up) was published by Katoch et al on 2008, when they described that 70 patients with BB, BL and LL leprosy whose were treated with MDT 12 doses plus Ofloxacin and Minocycline, and even though had a relapse rate of 5,7%. Should we expect a best result from normal MDT? On my recent (2011) PhD thesis, in a 11 years cohort study of 46 LL patients, treated with MDT 24 doses, 91% were found clinically healed, but only 27% still had laboratory signs of disease (positive bacilloscopy, serology or bacilli inside the nose). Of course, the household contacts must be evaluated, or the number of doses does not matter. I remember a case I saw, from the state of Mato Grosso: a married woman, treated with 24 doses, who "relapsed" 2 times in 10 years. She said that her husband had no problems: no complains, no patches, no lepromas, no eyebrows, no eyelids and no diagnosis... Why everybody believes that patients with less than 6 lesions have PB leprosy? It is easy to answer, once I see this almost every day: material from lesions are often difficult to collect, and in many instances lesions are not representated in slit skin smears, i.e., only material from ear lobes and knees are collected. The person who collects the material (laboratory technic) is not the same the makes the dematological examination, and, of course, this technic is not allowed to take out the clothes of patient, in order to perform the collection of initial lesions common sites (buttocks, thighs, trunk). Also, often staining of slit skin smears is performed wrongly. I saw this problem in the state of Mato Grosso do Sul 4 years ago. In this Brazilian state, where it was believed to have the best bacilloscopy in Brazil, when we went to the field and made a direct supervision, with the support of DAHW, we saw that 84% of municipalities had problems on the technics (collect, dyes, destaining, interpretation, and others). Other problem I have seen in the field is that many histopathology laboratories perform the staining of M. leprae in biopsies wrongly. They just do not know that the resistance to destaining of carbolfuchsin from M. leprae and other mycobacteria are different. Cell wall of M. leprae is soft, and if when it is performed the deparaffinization in pure xylene, the result is a thin layer to be stained, and when 3% alcohol-acid is used to destain carbolfuchsin, instead 1%, it occurs a catastrophe: even LL leprosy does not show AFB (see differences of the same material showed in microphotos bellow). I personally believe this is the cause of many described cases of neural sarcoidosis in literature... Fortunately, in Brazil, we are working hard, and trying to change this situation, once the make up of statistics, as well as centralization of diagnosis and treatment, used to do in most countries, does not solve the problem. Brazilian Health Ministry is stimulating activities at municipalities, in order to evaluate household contacts locally, and detect the problem in younger ages and early (children with indeterminate leprosy). Best regards Jaison 2013/12/6 Pieter AM Schreuder <editorlml@gmail.com>
Dr. Jaison A. Barreto, MD, PhD Chief of the Leprosy Section Instituto Lauro de Souza Lima Bauru - SP - Brazil
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Chat
| Herman-Joseph Kawuma |
| Jaison Antonio Barreto |
| Salvatore Noto |
| Bernard Naafs |
| grace.warren |
| hk kar |
| Justice, Judith |
| Linda Lehman |
| mariae.alonso |
| undisclosed_recipients |
> < Why this ad? transavia.com - vanaf €49 naar Portugal! - excl. €5 boekingskosten 1024 |
Re: (1) (LML) Higher risk of relapses in BL/LL with BI 4 or more after MDT-U and MDT 12 dosesInbox x | 
---------- Forwarded message ---------- From: jaison <jaisonbarreto@gmail.com> Date: Sat, Dec 7, 2013 at 9:12 PM Subject: Re: (1) (LML) Higher risk of relapses in BL/LL with BI 4 or more after MDT-U and MDT 12 doses To: Pieter AM Schreuder <editorlml@gmail.com> Dear Pieter and Leprologist colleagues The problems I have seen are occuring every day, whatever in the field or at the national reference I work. Details about situation of the leprosy in the field can be seen at the site of Brazilian DAHW (www.dahwmt.org.br). Physicians do not knows about leprosy, and, many times, do not want to learn about it, because they will have to attend the patients from their municipalities. Of course, there are still goodwill professionals, but they are diminishing in number, mainly because errors in the politics which is used to do on leprosy (neglecting). Ignorance, stigma and prejudice are still the rule, mainly at the Brazilian states where leprosy is said "eliminated". The concept that leprosy is eliminated in a municipality or in a state worses this vicious circle, once health managers do not want to spend money with a disease they believe do not exist. For the few physicians whose are still fighting against leprosy, it is a hard life: we have to fight against the disease, the problems the patients have, and also against the politicians from the local we live and work... And the mistakes on the WHO classification (only the number of lesions, and the number of nerves involved is not important), today on work, also worses this problem. Ridley, 40 years ago, showed that borderline patients tends to downgrading: most BL comes from BT, and most LL comes from BB/BL. Is it right to treat with daily dapson, alone, and only once a month rifampin, a patient with not complete capacity of elimination of M. leprae from the nerves, and who has many bacilli inside nerves and few in the skin? We, clinicians and leprologists, see, today, that many high BI leprosy (LL/BL) patients do not cure with 12 doses. So, what could we say about regimens of 6 month for these patients? The most recent and best cohort study (more than 9 years of follow up) was published by Katoch et al on 2008, when they described that 70 patients with BB, BL and LL leprosy whose were treated with MDT 12 doses plus Ofloxacin and Minocycline, and even though had a relapse rate of 5,7%. Should we expect a best result from normal MDT? On my recent (2011) PhD thesis, in a 11 years cohort study of 46 LL patients, treated with MDT 24 doses, 91% were found clinically healed, but only 27% still had laboratory signs of disease (positive bacilloscopy, serology or bacilli inside the nose). Of course, the household contacts must be evaluated, or the number of doses does not matter. I remember a case I saw, from the state of Mato Grosso: a married woman, treated with 24 doses, who "relapsed" 2 times in 10 years. She said that her husband had no problems: no complains, no patches, no lepromas, no eyebrows, no eyelids and no diagnosis... Why everybody believes that patients with less than 6 lesions have PB leprosy? It is easy to answer, once I see this almost every day: material from lesions are often difficult to collect, and in many instances lesions are not representated in slit skin smears, i.e., only material from ear lobes and knees are collected. The person who collects the material (laboratory technic) is not the same the makes the dematological examination, and, of course, this technic is not allowed to take out the clothes of patient, in order to perform the collection of initial lesions common sites (buttocks, thighs, trunk). Also, often staining of slit skin smears is performed wrongly. I saw this problem in the state of Mato Grosso do Sul 4 years ago. In this Brazilian state, where it was believed to have the best bacilloscopy in Brazil, when we went to the field and made a direct supervision, with the support of DAHW, we saw that 84% of municipalities had problems on the technics (collect, dyes, destaining, interpretation, and others). Other problem I have seen in the field is that many histopathology laboratories perform the staining of M. leprae in biopsies wrongly. They just do not know that the resistance to destaining of carbolfuchsin from M. leprae and other mycobacteria are different. Cell wall of M. leprae is soft, and if when it is performed the deparaffinization in pure xylene, the result is a thin layer to be stained, and when 3% alcohol-acid is used to destain carbolfuchsin, instead 1%, it occurs a catastrophe: even LL leprosy does not show AFB (see differences of the same material showed in microphotos bellow). I personally believe this is the cause of many described cases of neural sarcoidosis in literature... Fortunately, in Brazil, we are working hard, and trying to change this situation, once the make up of statistics, as well as centralization of diagnosis and treatment, used to do in most countries, does not solve the problem. Brazilian Health Ministry is stimulating activities at municipalities, in order to evaluate household contacts locally, and detect the problem in younger ages and early (children with indeterminate leprosy). Best regards Jaison 2013/12/6 Pieter AM Schreuder <editorlml@gmail.com>
Dr. Jaison A. Barreto, MD, PhD Chief of the Leprosy Section Instituto Lauro de Souza Lima Bauru - SP - Brazil
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Leprosy Mailing List – December 18, 2013
Ref.: (LML) Taking and processing of Slit Skin Smears and Staining of Biopsies
From: Jaison Barreto, ILSL Bauru, São Paulo, Brazil
Dear Pieter,
Why everybody does believe that a patient with less than 6 lesions has PB leprosy? It is easy to answer. I see problems with taking of skin slit skin smears almost every day. Material from lesions is often difficult to collect, and in many instances lesions are not represented in the slit skin smears, i.e., only material from ear lobes and knees are collected. The person who collects the material (laboratory technician) is not the same one that does the dermatological examination, and, of course, this technician is not allowed to ask the patient to take of the clothes, in order to perform the collection of the lesions; common sites are buttocks, thighs and trunk.
Moreover, often staining of slit skin smears is performed wrongly. I saw this problem in the state of Mato Grosso do Sul 4 years ago. This Brazilian state was believed to have the best bacilloscopy in Brazil. When we went to the field for direct supervision, with the support of DAHW, we saw that 84% of the municipalities had problems with the techniques (collecting, fixing, dying, de-staining, interpretation, and others).
Other problem I saw in the field is that many histopathologal laboratories perform the staining of M. leprae in biopsies wrongly. They just do not know that the resistance to de-staining of carbolfuchsin from M.leprae and other mycobacteria are different. The cell wall of M. leprae is “soft”, and if when the de-paraffinization is performed in pure xylene, the result is a thin layer to be stained, and when 3% alcohol-acid is used to de-stain carbolfuchsin, instead of 1%, a catastrophe occurs: even LL leprosy does not show AFB (see differences of the same material showed in the microphotos enclosed. I personally believe this to have happened in many patients with neural sarcoidosis described in literature.
Best regards,
Jaison
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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