Leprosy Mailing List – April 10, 2014
Ref.: (LML) Comparing the Clinical and Histological Diagnosis of Leprosy Reactions in the INFIR Cohort of Indian Patients with Multibacillary Leprosy
From: Piet Both, Apeldoorn, the Netherlands
Dear Dr Schreuder,
While preparing a presentation I came across a post at LML of 29 June 2012. Old stuff, 2012, but probably as relevant as ever. It is about: “Comparing the Clinical and Histological Diagnosis of Leprosy Reactions in the INFIR Cohort of Indian Patients with Multibacillary Leprosy” by Lockwood DNJ, Nicholls P, Smith WCS, D a s L, Barkataki P, van Brakel W and, Suneetha S (see attached file).
This very informative mail was posted, but if I understand well it did not receive any questions or comment at LML. The conclusion of this article is that ‘Leprosy reactions may be under-diagnosed by clinicians and increasing biopsy rates would help in the diagnosis of reactions. Future studies should look at T1R and ENL and whether they have impact on clinical outcomes.’ The author says that ‘The public health implication of this work is that leprosy centres need to be supported by pathologists to help with the clinical management of difficult cases.’
In the study in two respected centres in India there were 303 persons enrolled, newly diagnosed with MB leprosy. The study reveals a very significant difference between the clinical and histological diagnosis of leprosy, of Type 1 Reaction and Type 2 Reaction. There is a ‘substantial disparity between clinical and histological diagnosis of reactions’ with ‘reactions are more frequent than is clinically evident.’ (From the table’s in the article it seems that reaction is ‘much more’ frequent than is clinical evident.)
If this is true in the two centres in India the question arises what the reality will be elsewhere, in programmes in which health-workers see far less leprosy and will be less trained in the diagnosis of reaction than in centres where colleagues still see many persons affected by leprosy (and reaction). Increasing biopsy rates would help, but in which countries does that facility exist and what should programmes do when that facility does not exist? Are there examples of countries in which in recent years programmes have lobbied with in-country pathologists or out of country facilities and have acquired this kind of support? Such countries may need to share their success story.
Conclusions and recommendations of this paper:
- The study recommends studies, in order to establish diagnostic criteria that link the diagnosis of clinicians and pathologists more closely. Apparently there are different clinical definitions of T1R as well as for ENL and the ones used for this study are mentioned in the article. It might be important to find out whether in programs the best possible definition is used (and compare the ones used with the definitions in this study).
- It may be that patients with subclinical reactions would benefit from steroid treatment, says the study. But when and how and where will health-workers be able to diagnose subclinical reactions?
- The study also highlights ‘the importance of training doctors and health workers to specifically ask patients with LL and BL type disease about symptoms of ENL, such as new nodular lesions, bone pain, orchitis and fever’. This is probably the easiest recommendation to implement from this study.
- And then there is the conclusion that ‘health workers need to be trained to suspect reaction’. This is and should be possible when leprosy is still ‘high’ endemic, but in other programmes, in the absence of many cases, the health workers may be taught about reaction, but there is little chance to train.
- Finally, in this excellent study there is a call for robust referral systems and for adequate supplies of steroids in field stations and referral centres.
Is this where we are: a position in which still many reactions are not diagnosed, or will be diagnosed late, and in which clinical consequences like nerve impairment may be unavoidable and lives will be damaged because we are unable to diagnose this most important consequence in leprosy? To diagnose reactions early is the very reason, one most important reason, for the maintenance of leprosy control programs.
At the International Leprosy Congress there were a few publications only to support earlier diagnosis of reactions in leprosy. Dr Annamma John presented a paper re early detection by using first 0.2 gms Semmes Weinstein filaments for the palm and 2 gms for the soles before the usual 2 gms for palms and 10 gms for the sole were used. Of the 374 (PB and MB) persons tested 117 had sensory nerve function impairment and 22 of them were picked up by the 0.2 gms (palm) and 2 gms (sole). Does that help to close the gap a little between clinical and histological diagnosis differences in diagnosing reaction T1R? Or is testing with such sensitive filaments possible in referral settings only?
Will the testing of less usually tested nerves, the radial cutaneous and sural nerves help to diagnose more reactions (work presented by Wagenaar, Brandsma, Post and Nicholls at the International Leprosy Congress)?
There has been an extensive exchange of mails at LML about SW Mono-filaments last summer. Dr P. Narasimha Rao reported that a series of workshops were planned to train methods to identify Nerve Function Impairment early. It will be interesting to hear whether those who are trained have become more successful in closing that gap that exists between clinical and histological diagnosis.
And it will be interesting to hear from others, who received the monofilaments at the time of the ILC, whether the skill to diagnose NFI early has been improved.
A few other studies were presented at the ILC, about risk factors. If these factors would be generally known and understood, will this also increase the number of right diagnosis of reaction? The presentations about the risk factor were referring to laboratory investigations, which again are less accessible in many areas in which leprosy control takes place.
Can there be a word of encouragement by some of those who understand these matters better than I do? The reading of the study ‘comparing the clinical and histological diagnosis...’ left me a little in despair because of how much will be missed in diagnosis of this most serious complication of leprosy.
Yours sincerely,
Dr Piet Both
The Leprosy Mission International
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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