Monday, January 24, 2022

Fw: Ref.: (LML) Median nerve damage in leprosy




From: Leprosy Mailing List <leprosymailinglist@googlegroups.com>
Sent: 24 January 2022 16:14
To: Leprosy Mailing List <leprosymailinglist@googlegroups.com>
Subject: Ref.: (LML) Median nerve damage in leprosy
 

 

 
Leprosy Mailing List – January 24,  2022

 

Ref.:  (LML) Median nerve damage in leprosy

 

From:  Arry Pongtiku, Papua, Indonesia

 

Dear Pieter,

 

The photo from Dr Noto and discussion, I would also say atrophy of the palm muscles, scars from burns of the skin of the fingers, contracture of fingers means it is late and  nerve damaged already and usually poor prognosis. Self Care and prednisolone  treatment may  work effectively to survive the nerves  before 6 months  or during leprosy reaction. Filling POD (Prevention of Disability) form is important for  leprosy health workers to detect the weakness and deformity of nerves.

 

I would  add some photos about weak fingers, hand and self care exercise.

Thank you very much,

 

Best regards,

 

Arry Pongtiku,

Papua- Indonesia

 

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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Tuesday, January 18, 2022

Fw: Ref.: (LML) Median nerve damage in leprosy

 


Leprosy Mailing List – January 18,  2022

 

Ref.:  (LML) Median nerve damage in leprosy

 

From:  Zhauda Umerov, Moscow, Russia

 

 

Dear Pieter,

 

What did I see on the figure from S. Noto. The doctor correctly diagnosed the patient with paucibacillary  leprosy and treated with the WHO suggested MDT and he was ready to be released from treatment, but the accompanying ( untreated ) neuropathy was missed and the deformity continued to develop. Atrophy of the palm muscles, scars from burns of the skin of the fingers indicate the duration of leprosy - at least 3 - 5 years. However, the diagnosis of leprosy was made 6 months ago and what we see is that irreversible nerve changes had happened.

 

The reason is the lack of lab. tests of the early stages of leprosy. It is appropriate to recall that 20 years ago, Stewart Cole's brilliant team deciphered the genome of the leprosy pathogen. Unfortunately, the huge work of researchers has not reached the practical medicine.

 

The patient has been treated with the WHO suggested MDT in which there is no drug for the protection of nerve damage in leprosy. It is probably believed that nerve damage is a complication, but not leprosy itself and there is no need to develop a treatment course. A very strange position of WHO experts.

 

In Russia, it is very popular in such cases to ask two questions: "Who is to blame? and What to do?" Perhaps we should answer these questions as well. Here's what I saw in the photo of S. Noto and I completely agree that clinical skills should be on the forefront for everyone, not only a field doctors and their nurses.

 

Kind regards,

 

Zhauda UMEROV

Moscow and Antalya


 

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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Sunday, January 16, 2022

Fw: Ref.: (LML) Median nerve damage in leprosy

 


Leprosy Mailing List – January 16,  2022

 

Ref.:  (LML) Median nerve damage in leprosy

 

From:  Joel Almeida, London and Mumbai

 

 

Dear Pieter & colleagues,

 

Esteemed colleagues have made important points about protecting HD patients adequately. Those who monitor nerve function regularly set a good example (e.g. the Brazilian national program, Fondation Raoul Follereau personnel, others). Respect for patients prompts adequate medical care, and wider care.

 

It may be helpful to imagine a patient as a family member walking a tightrope from disease to healing. If they fall off that tightrope, they will suffer irreversible damage. We need to provide adequate safety nets. What are the safety nets we would provide to a family member?

 

1) Antimicrobial protection with uninterrupted MDT. If they have LL (lepromatous) HD and live in an endemic area, then they would benefit also from post-treatment prophylaxis to protect them against reinfection. This can be with MDT or with combinations of 3 bactericidal drugs. MIP vaccine often yields rapid clearance of bacilli in even LL patients, making it useful. 

 

2) Nerve function monitoring & prompt intervention when required

 

A pilot survey in two rural communities in India revealed that 15% to 33% of persons who previously received MDT had visible deformity (1). Fewer than 5% of patients in that Indian state had visible deformity at diagnosis. Evidently, most visible deformity in that state arose during or after MDT. A total-population survey among over 100,000 persons in a rural area 100 km from Mumbai (India) revealed a prevalence of visible deformity among previously treated patients of 2308 per million population (2). This suggests that several million people are living with visible deformities that developed during or after MDT treatment.

 

A randomized double-blind clinical trial among persons with mild and recent sensory impairment compared prednisolone, given for 4 months, with placebo.(3) The placebo group had a 158% higher risk of deterioration in sensory scores between the start and end of treatment. Prednisolone works.

 

In South Asia, 85% of nerve damage during MDT was found to be "silent", without signs or symptoms of reaction (4). Even the patients did not suspect anything until they suffered irreversible damage. MB patients showed a greatly multiplied risk of nerve damage compared to PB patients. Therefore, assessment of nerve function in MB patients (correctly classified) needs to be done at diagnosis and at least every quarter thereafter. This needs to continue for 2 years after the start of MDT. Otherwise, patients who newly develop sensory impairment are left without timely prednisolone treatment, allowing permanent nerve damage. That in turn leads to visible deformity, with all its adverse consequences.    

 

Specially trained and skilled health workers provided with transport and covering a wide geographical area have been used for monitoring nerve function in well-run programs (including in exemplary sub-districts of India). NGOs such as Fondation Raoul Follereau, who monitor nerve function regularly and intervene with prednisolone promptly, are showing respect for patients.

 

 

3) Surgical intervention if patients fall through the safety nets 1) and 2) above.

 

All the above are what one would do for one's mother or child (or indeed one might require for oneself if afflicted by HD). HD patients, like others, are entitled to adequate medical care according to the Universal Declaration of Human Rights, article 25. We can keep removing patients from registers and assuring them that they are healed. However, they might not believe us when they are left with visible deformity despite having started MDT without deformity.

 

In 2022 we can improve the quality of care for patients after diagnosis, especially by ensuring

A) Uninterrupted MDT for all, plus post-treatment prophylaxis for LL HD patients in endemic areas

 

B) Quarterly nerve function monitoring, especially for MB patients during the first 2 years after the start of MDT, with prompt prednisolone treatment at the first sign of sensory loss. 

 

C) Availability of surgical interventions for patients who fall through the safety nets above

 

For millennia people with HD have been neglected as if they do not matter, as if they are sub-human in some way or blameworthy. This neglect and ostracism often deprive them of normal relationships, schooling, housing, utilities, income, etc. Denial of adequate medical care need not be added to their deprivations. It seems more humane to monitor nerve function every quarter, as done in the Brazilian national program, and to intervene promptly with prednisolone when required.

 

Best,

 

Joel Almeida

 

References

 

1)      Aggarwal A, Pandey A. Inverse sampling to study disease burden of leprosy. Indian J Med Res 132, October 2010, pp 438-441.

2)      Ganapati R, Pai VV, Tripathi A. Can primary health centres offer care to the leprosy disabled after integration with general health services? - a study in rural India. Lepr Rev 2008, 79:340–341

3)      Van Brakel WH1, Anderson AM, Withington SG, Croft RP, Nicholls PG, Richardus JH, Smith WC. The prognostic importance of detecting mild sensory impairment in leprosy: a randomized controlled trial (TRIPOD 2). Lepr Rev. 2003 Dec;74(4):300-10.

4)      Croft RP, Nicholls PG, Richardus JH, Smith WC. Incidence rates of acute nerve function impairment in leprosy: a prospective cohort analysis after 24 months (The Bangladesh Acute Nerve Damage Study). Lepr Rev. 2000 Mar;71(1):18-33.


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

LML blog link: http://leprosymailinglist.blogspot.it/


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Saturday, January 15, 2022

Fw: Ref.: (LML) Leprosy Research

 

 
Leprosy Mailing List – January 15,  2022

 

Ref.:  (LML) Leprosy Research

 

From:  Pieter Schreuder, Maastricht, the Netherlands

 

 

Dear colleagues,

 

Kindly note the correct Email address for Robert  Machang'u:

machangu@sua.ac.tz


 

Pieter AM Schreuder

Editor LMl



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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Friday, January 14, 2022

Fw: Ref.: (LML) Leprosy Research



 
Leprosy Mailing List – January 14,  2022

 

Ref.:  (LML) Leprosy Research

 

From:  Robert Machang'u, Morogoro, Tanzania

 

Dear Pieter,

 

I would like to know if there are colleagues among us who would be interested to be interested to partner with a Tanzanian team interested in research & outreach in HD hotspots. 

 

Interested people could contact me directly, or through LML

 

Regards,

 

Robert Machang'u

 

Department of Veterinary Microbiology and Parasitology, Sokoine University of Agriculture, Morogoro, Tanzania

machnagu@sua.ac.tz


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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Thursday, January 13, 2022

Fw: Ref.: (LML) Median nerve damage in leprosy

 

 
Leprosy Mailing List – January 13,  2022

 

Ref.:  (LML) Median nerve damage in leprosy

 

From:  Marcos Virmond, Bauru, Brazil

 

Dear Pieter

 

Discussions initiated by Dr. Noto on nerve damage/surgery (Dr. Theuvenet) are most welcome and comments by Dr. De Laguiche quite opportune.

 

Let me say that this issue has direct connection with a post by Dr. B. Naafs some weeks ago, which I dare to resume on the following - monitoring nerve function is an essential step in the follow-up of leprosy cases.

 

In the same line, I dare to say that - correctly indicated, opportune and quality nerve decompression surgery is an essential part of any leprosy control program. It must be available as a choice for cases with progressive nerve function loss non responsive to adequate steroids treatment.

 

With kind regards,

 

Marcos Virmond

School of Medicine-USP,  Bauru


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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Wednesday, January 12, 2022

Fw: Ref.: (LML) Median nerve damage in leprosy

 

 
Leprosy Mailing List – January 12,  2022

 

Ref.:  (LML) Median nerve damage in leprosy

 

From:  Laila de Laquiche, Curitiba, Brazil

 

Dear Pieter,


I thank Dr. Grauwin for his contribution to our discussion on nerve damage (January 10 - LML) which masterfully explained details of upper limb neuritis: Ulnar and Median Nerve, in addition to indications for nerve decompression and treatment. Acting in African territory certainly brings the necessary difference for quality medical care in that region, which I particularly appreciate this effort.


The question I raised is what would be the correct therapeutic approach, since this case under discussion (Dr. Noto - Italia 07 January LML) was diagnosed and treated with a Paucibacillary regimen for 6 months. 

 

Paraesthesia was accidentally diagnosed at the end of treatment due to an accidental injury to the fingers. We do not have data on which initial lesions corroborated this clinical classification and if there was an initial analysis of the sensory and motor function of that limb or even if there was a suspicion of neural damage. But if there were, it would already be indicative of MB treatment according to the WHO guidelines.


The biggest question is: what is the desired therapeutic approach: to face neuritis as an immunological reaction or as a continuation of the neural injury directly caused by the bacillus lodged in the nerve sheaths?


I don't have that answer, but I would certainly like to fully treat patients who suffer from an infectious-immunological disease, at least as far as the infectious part is concerned. Both approaches are not mutually exclusive and we can continue to seek our gold standard in the management of these patients.


Sincerely,

 

Laila de LAGUICHE

Curitiba - Paranรก

 

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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