Leprosy Mailing List, May 1st, 2009
Ref.: LML closes from tomorrow to May 18th
From: Noto S., Genoa, Italy
Dear All,
I am sorry to say that the leprosy mailing list closes until May 18th. I really wish to thank all of you (writers and readers).
Best regards,
S. Noto
Leprosy Mailing List, May 1st, 2009
Ref.: Itching
From: Ryan T., Oxford, UK
Dear Salvatore,
This has been an interesting series. Please add that itching being subjective the only objective measurement is of scratching. Psoriasis was once designated a non itching condition but this has changed since researchers have recognised the varied use of the term itching and the varied objective response.
If there is no sign of scratching it is probably "soreness" or some other "feeling". If it is scratched it is certainly itchy.
Best regards,
Terence Ryan
Leprosy Mailing List, May 1st, 2009
Ref.: Itching as presenting symptom of leprosy and reversal reaction
From: Gilead L, Jerusalem, Israel
Dear Dr. Noto,
I am surprised at the scarcity of responses regarding the association of itching and leprosy, as a presenting sign or as a sign of reversal reaction. You are probably well aware of the small number of patients being treated in the
The patients were – a 55 year old male which immigrated from India some 10 years prior to presenting to a dermatology clinic with new (2-3 weeks) itchy plaques on his Lt.>Rt. flanks. A skin biopsy revealed LL and he was referred to us. This patient also developed a reversal reaction 1.5 years into his MDT course, which also presented with itchiness in the area of his original plaques.
The second patient was a 21 year old female, which immigrated from
In the two cases I report the histology was typical of LL but the clinical picture was less straight forward. The patients had only a few plaques, distributed asymmetrically. Smears were AFB positive both from plaques and from apparently uninvolved skin of knees, elbows and earlobes with a +3 - +5 bacillary index.
I think it safe to say that the first patient was a BL. The second patient already presented with right hand weakness, toe clawing and significant sensory deficits in both palms and soles and some other areas of her skin in the upper and lower limbs. In her case I think LL is more probable.
Both patients described specifically itching and not paresthesias (both speak and understand Hebrew well) and definitely had no other dermatologically apparent condition which could explain their complaints.
Following these cases we had a discussion regarding the rarity of this presenting symptom and its absence from the textbooks. I think it might be much more common than presently acknowledged.
All the best,
Dr. Leon Gilead
Head of The Israeli Hansen's Disease Center
Department of Dermatology
Mobile 972-50-7874309
Leprosy Mailing List, April 30th, 2009
Ref.: Icthyotic changes in leprosy and pruritus
From: Jerajani H R,
Dear Dr Vijaykumaran,
I appreciate your deliberation on pruritus in leprosy (LML April 28th, 2009). I would like to add icthyotic changes in leprosy especially those taking clofazimine as one of the common causes of pruritus especially during winter season.
Subsiding leprosy reactions showing icthyotic dry scaly surface too give rise to itching.
Best regards,
Dr H R Jerajani
Professor & Head
Department of
LTM
Sion, Mumbai-400 022
Leprosy Mailing List, April 30th, 2009
Ref.: Itching in leprosy
From: Manimozhi N.,
Dear Dr. Salvatore Noto,
This is with reference to Dr Pai’s Leprosy Mailing List, April 25th, 2009, Pruritus in BL, LL and smear positive relapse leprosy lesions.
During my tenure at SLR&TC – Department of Epidemiology and leprosy control from 1985 through 2001, we had come across instances where patients reported with pruritus as the main complaint and diagnosis of reactions and relapse was made after examination. It was noted that it was actually – parasthesia (abnormal sensation) which the patients expressed it to as itching (pruritus) in their own local language and some did mention as burning sensation as well.
Brief case study: Mono- therapy Relapse case presenting with pruritus/rashes as main complaint.
An elderly Anglo-Indian (Mr. Hawkinns – name changed) inmate of Cheshire Home at Virudampet /Vellore, Tamil Nadu, India aged more than 70 years, a know case of Lepromatous leprosy released from treatment. He had an interesting history of treatment started with Hydnocarpus oil injections and Dapsone. He used to attend the outreach village clinics conducted within the Cheshire Home campus for general complaints along with others. All the inmates had a separate released from control (RFC) register maintained in which all clinical, treatment details where documented.
It was around 1992 to 1995, there was an anniversary celebrations of
Lesson learnt from this episode is :
Leprosy is indeed a great imitator.
Presentation of complaints in patients own terminology may be misleading.
Routine sites can show skin smear negativity – While lesions in relapse cases can occur in rare sites which could show skin smear positivity.
It may take a short duration of time (2-3 months in this case) for the disease to express signs of relapse after the last clinical/bacteriological examination.
Dr. N. Manimozhi
Medical Coordination- AIFO
Bangalore, India
Leprosy Mailing List, April 30th, 2009
Ref.: Itching in leprosy
From: Narasimha Rao P.,
Dear Salvatore,
This mail is in regard to on going discussion on itching in leprosy. Itching is a not a known symptom of leprosy. However, many itchy conditions can occur as co-dermatosis in leprosy patients.
When leprosy patients are seen in dermatology out patient clinics of developing country like
Below mentioned are few commonly associated dermatological itchy conditions modified in leprosy.
Asteatotic leg eczema: More commonly seen bilaterally in BL or LL patients, more so after treatment with Clofazimine which adds to xerosis of skin. This type eczemas continue to occur many years after patient is made RFT. Occasionally unilateral leg eczemas are seen in area of anaesthetic/ hypoaesthetic skin lesions of BT patients. In these type of eczema, although scaling is profuse, often accompanied by fissuring and secondary infection, itching as a symptom is usually very mild or not reported at all in a patient of leprosy, compared to a non-leprosy patients with similar involvement.
Papular urticaria: Papular skin reaction to insect bites commonly observed in tropics is observed to be less symptomatic in BL-LL leprosy patients. Itching is a not a prominent complaint in these patients compared to non leprosy patients with this condition.
Scabies: Wide spread crusted type of scabies, also known as ‘Norwegian scabies, which is known to occur in mentally challenged, paraplegics, immuno-supressed etc, is also reported in leprosy. Vijaikumar M, Thappa DM. Crusted (Norwegian) scabies in leprosy. Indian J Lepr..2001 Jan-Mar;73(1):55-8. Itching which is the principal feature of scabies is absent in this condition.
Tinea corporis: When tinea corporis lesions co-occur in leprosy patients with type I reactions, they could mimic the patches of type 1 reaction, especially regressing phase of patches when they scale off. However, differentiating feature is the tinea corporis patches are itchy and when in doubt scraping for fungal filaments on KOH mount would help in the diagnosis. I have few photographs of this co- infection and would be happy to forward to those interested to have them. The case of patient presenting with itching on buttock turning out to be type 1 reaction on histopathology, (ref: letter from Nunzi E, Italy, Leprosy Mailing List, dated, April 28th, 2009; Itching as presenting symptom of reversal reaction),could be one such instance, as buttock is a common site for tinea infection and it could be a co-infection in this patient.
In summary, it can be stated that itchy dermatological conditions when associated with leprosy patient can be a) masked (incognito) b) less inflamed and show modified tissue reaction, c) less itchy, or d) have normal clinical features. Hence it is important to consider/rule out associated dermatological conditions as a cause of itching in these patients. Unfortunately , however, it is often difficult to rule out even common skin conditions such as papular urticaria, insect bite reactions, early scabies etc. by laboratory tests.
In my opinion, when patient of leprosy complains of itching, careful search should be made for (missed) underlying dermatological condition. The associated conditions could vary depending on the geographical area/ economic/ social status of the patient. This is necessary because itching is not a known feature of leprosy and there is no accepted scientific or pathological basis for it to be present in either during normal course or during reactions of leprosy.
With best regards,
P. Narasimha Rao
Leprosy Mailing List, April 30th, 2009
Ref.: Dr W Nogueira's letter translated in English (see attachment)
From: Poorman E.,
Dear Salvatore,
As requested, I have translated Dr. Nogueira's letter, which I likewise find thought-provoking. Translation is not my vocation, but I have tried to stay as true to the original as possible.
Sincerely,
Elisabeth
