(LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy

Leprosy Mailing List – April 29,  2018

Ref.:  (LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy 

From:   Shubhada Pandya, Mumbai, India

---

 

Dear Sir,

 

The ankle jerk is more likely to be absent in diabetic than leprous polyneuropathy.

The questioner has not provided information on the tendon reflexes.

 

Sincerely,

 

Shubhada Pandya 

 

 

---

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

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

Contact: Dr Pieter Schreuder << editorlml@gmail.com

(LML) Invitation to LRI e-survey on Research Priorities

Leprosy Mailing List – April 28,  2018

Ref.:   (LML) Invitation to LRI e-survey on Research Priorities

From:  Nienke Veldhuijzen

---

Dear colleagues,

One and a half week ago I sent an invitation to participate in the LRI e-survey on Research Priorities (LML, April 19, 2018). For those of you who have completed the survey – thank you!

If you have not had a chance to take the survey yet, I'd like to remind you that you can still do so until May 15th.  

Furthermore, I would like to inform everyone that we now have several translations of the LRI e-survey online.

Click here for the English version

Click here for the  French version

Click here for the Hindi version

Click here for the  Portuguese version

Click here for the Bahasa Indonesian version

As indicated earlier – this invitation may be forwarded to others who may not read the LML e-mails but would be important to include.

In case someone experiences difficulties with the online survey they may contact Zahra Khazai to obtain an excel version of the survey (z.khazai@leprosyresearch.org.)

Thank you once again,

Nienke Veldhuijzen  

The Leprosy Research Initiative

 www.leprosyresearch.org

Info@leprosyresearch.org

 

---

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

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

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 

(LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy

Leprosy Mailing List – April 28,  2018

Ref.:  (LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy 

From:  Salvatore Noto, Aosta, Italy

---

 

Dear Pieter,

Thank you very much to Dr Ramesh Sharma for his message dated LML  April 20,  2018 about a patient in Pokhara, Nepal and the differential diagnosis of leprosy and diabetes neuropathies. 

Thank you also to Drs Eric Slim (I did not know that nerve enlargement is seen in diabetes [if it were true, this would cut off a cardinal sign of leprosy]), Willem Theuvenet, Atul Shah  and VP Shetty.

Herewith I try to give some answers and comments to Dr Sharma's questions.  In attachment is a PDF document with 7 slides where are shown clinical pictures of ulnar, median, common peroneal and posterior tibial nerves damaged by leprosy.

My answer to  the 1° question is yes, there is a point in "differentiate between diabetic and pure neural [leprosy] neuropathy" because Dr Sharma's patient has the diagnosis of diabetes but, he still does not have the diagnosis of leprosy.  In acute leprosy neuropathy treatment would be different.

About the 2° question:-  I think we can clinically differentiate the two conditions in those cases where the signs  are fully developed and sequelae have not altered the initial clinical picture, not in other cases. 

Typical ulnar and median nerves deformities are seen in leprosy, kindly see slides 1-5.  Are they seen in diabetes?

Common peroneal nerve damage that leads to a dropped and inverted foot is seen in leprosy and trauma.  The leprosy patient shown in slide 6 is unable of dorsi-flection of the right foot.  Slide 7 is a leprosy patient with severe sensory and autonomic loss on his feet.  Do diabetes cause the same?

Patients with foot ulcers and gross foot deformities are seen in several conditions, leprosy, diabetes, hereditary neuropathies among the others; here clinical diagnosis may be impossible.

About the 3° question please see comments of Dr. VP Shetty.  It may be useful contacting the involved pathologist, before proceeding to the nerve biopsy.

Salvatore Noto

Aosta, Italy

---

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

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

Contact: Dr Pieter Schreuder << editorlml@gmail.com

(LML) Are there any systematic reviews or evaluations of toolkits for challenging stigma?

Leprosy Mailing List – April 26,  2018

Ref.:    (LML)  Are there any systematic reviews or evaluations of toolkits for challenging stigma?

From:  P.K. Das, Birmingham, UK

---

Dear Pieter,

Dr. Ebenso raised  a valid point. Indeed for years long we have been talking about the hindrance factors for controlling the continued leprosy transmiison, one of which  could be the stigma and fear for the patients to come forward to the discovery of the disease. In that regards, we did conduct a student based study in a qualitative manner. I did have a nagging question how do we put the extent /criteria of stigma into a measurable tool kits. People like Wim Barkel, Ben Naafs may have some idea. I, personally am discussing witth the carer and doctors  who are involved in caring for HIV and patients with other deformities and skin diseases.

I would like to thank Dr Ebenso, for raising this point.

Kind regards,

Pran

cortact: p.k.das@bham.ac.uk; or p.k.das@amc.uva.nl; or pran.k.das@gmail.com
tel: +44 (0)7951752761

 

---

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

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

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 

 

 

(LML) Are there any systematic reviews or evaluations of toolkits for challenging stigma?

Leprosy Mailing List – April 25,  2018

Ref.:    (LML)  Are there any systematic reviews or evaluations of toolkits for challenging stigma?

From:  Bassey Ebenso, Leeds, UK

---

Dear Pieter,

Dr Bassey mentioned the growing interest in toolkits for challenging stigma.  He himself was instrumental in producing the "Toolkit for understanding and challenging leprosy-related stigma" which was developed in 2016 for the EU-Funded CREATE project in partnership with The Leprosy Mission (TLM Trust India and TLM England & Wales).

No systematic review has yet been conducted of the impact or effectiveness of this toolkit, although we have plenty of anecdotal evidence from its use in 4 different Indian States that it is a helpful tool and appreciated by a range of different stakeholders who have used it.  CREATE project is hoping to present about this toolkit and its impact at the NNN in Ethiopia on 24-26 September and the CREATE project will undergo a formal external end of project evaluation in early 2019, at which point there should be some more rigorous evidence about the value of this toolkit.

I hope this is of some help to your enquiry.  Mathanraj (CCd above), the Research & Training Officer for CREATE project may be able to give more specific examples of how, when and where this toolkit has already been used and with what impact, if required.

With thanks

Gareth.

 

Gareth Shrubsole​ Senior Programme Manager Goldhay Way Orton Goldhay Peterborough  PE2 5GZ +44 (0)1733 404879

 

---

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

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

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 

(LML) Are there any systematic reviews or evaluations of toolkits for challenging stigma?

Leprosy Mailing List – April 28,  2018

Ref.:    (LML)  Are there any systematic reviews or evaluations of toolkits for challenging stigma?

From:  Bassey Ebenso, Leeds, UK

---

Dear Pieter,

There is abundant literature on interventions and approaches for tackling/reducing health-related stigma. There is also a growing body of systematic reviews that document the effectiveness of specific stigma-reduction interventions. However, literature on toolkits for challenging stigma, is limited.

The term toolkit is used broadly to describe the packaging of a combination of materials such as templates, guidelines, instruction sheets, videos, posters, intended to: i) fill knowledge gaps, ii) inform dialogue, and ii) improve behaviours for diverse audiences including, health workers, patients, community and health organizations, policy makers, and for the public.

Recently, the development of toolkits for challenging the stigma of specific conditions (e.g. TB, HIV, leprosy, gender-based violence etc.) is becoming popular. However, little is known about effectiveness of toolkits for changing behaviour and reducing stigma.

Do members know of empirical evaluations and/or systematic reviews of toolkits in the field of health, disability, gender, and international development that they can share? Thank you in advance for your help.

Regards,

Bassey

Dr Bassey Ebenso

Research Fellow

Nuffield Centre for International Health and Development

Leeds Institute of Health Sciences

University of Leeds

Room 10.28,  Worsley Building

Clarendon Way,

Leeds, LS2 9NL

 

Tel:  + 44 (0) 113 343 9642

Email: B.E.Ebenso@leeds.ac.uk ; Skype: bassey.ebenso ;

ResearchGate: https://www.researchgate.net/profile/Bassey_Ebenso

University Profile: https://medhealth.leeds.ac.uk/profile/600/1113/bassey_ebenso/3

Twitter: @B_Ebenso 

 

---

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

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

Contact: Dr Pieter Schreuder << editorlml@gmail.com

 

(LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy

Leprosy Mailing List – April 23,  2018

Ref.:  (LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy 

From:  Atul Shah, Mumbai; VP Shetty, Mumbai; Wim van Brakel, Amsterdam

---

 

Dear sir,

 

The basic question of role of nerve biopsy to rule in or rule out leprosy has not been addressed. Need more clarification on this as well as the site of biopsy.

 

Whether only electrical methods can conclusively define the DM as the aetiology particularly when all limbs show decreased sensory conduction and one upper limb also has partial motor affection grade 3+ . 

 

Hope to get an insight in these interesting cases.

 

Thanks. Best regards,

 

Dr. Atul Shah

Plastic surgeon

President, The Research Society,

Grant Medical College and Sir J J Group of Hospitals, Mumbai

---

Dear Pieter,

In our experience doing a biopsy of an involved sensory cutaneous nerve and histopathology is the most reliable in diagnosis of suspected pure neural cases of leprosy.

We also find doing a nerve conduction velocity study prior to biopsy helps in selecting the right nerve for biopsy. Sural nerve is the most frequently involved nerve in pure neural cases.

With regards,

VP Shetty

---

 

Dear Pieter,

Perhaps to add to what Dr Theuvenet has already written:

·       In diabetic neuropathy deep vibration sense is often lost (tuning fork or vibrometer on a bony prominence at the ankle or wrist). In our experience in leprosy, the deep sensation was usually intact.

·       In diabetic small fibre neuropathy, cold sensation is affected before warm sensation; our findings in the INFIT cohort study showed that, in persons affected by leprosy, warm detection thresholds were affected more often and earlier than cold sensation.

With kind regards,

Wim van Brakel

----------------------

Wim van Brakel, MD MSc PhD

Head Technical Department

Netherlands Leprosy Relief (NLR)

Wibautstraat 137k

1097DN Amsterdam

Netherlands

Tel. +31 20 5950529

Email: w.v.brakel@leprastichting.nl

URL: www.leprosyrelief.org

 

 

---

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

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

Contact: Dr Pieter Schreuder << editorlml@gmail.com

(LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy

Leprosy Mailing List – April 22,  2018

Ref.:    (LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy

From:  Eric Slim, Utrecht, the Netherlands

---

 

 

Dear Peter,

 

I agree with Wim important remarks concerning the difference between Diabetes andLeprosy related neuropathy (LML, April 21, 2018)

However, I would like to add some remarks.

1. Leprosy related neuropathy involves (more) often (significant) motor function impairment compared to diabetes related neuropathy.

2. Concerning Wim's comment:  "DM neuropathy will manifest itself after a much longer duration after the onset of the disease":

I would like to add: Diabetes often is diagnosed (to) late and neuropathy is already present at time of diagnose in a huge amount of diabetes patients (up to 60%).

3. Nerve enlargement can also be seen in diabetes related neuropathy but structural differences between diabetes and leprosy nerve impairment can be seen on ultrasound.

4. Neuropathy related muscle atrophy can be seen in both diabetes and leprosy and may result in both cases also in loss of strength. The distribution may differ (symmetrical versus asymmetrical) but also a symmetrical pattern can also be found in leprosy patients. However, significant motor function impairment is less found in diabetes (as mentioned in remark 1). 

5. I don't have much experience with tendon transfers in leprosy nor in diabetes but the risk of complication may be higher in patient with both diseases. This emphasizes the importance of an adequate diagnosis. However, the work done by dr Dellon suggests that also in diabetes, nerve repair and transplantation in the neuropathic foot is optional.  

 

6. Concerning the neuropathic foot: for ulcer prevention, treatment, use of orthoses and footwear, the expertise of both leprosy and diabetes is both applicable

 

With regards,

 

Erik Slim

 

MD, PhD, Physical Medicine and Rehabilitation.

St Antonius Hospital Nieuwegein/Utrecht The Netherlands.

 

---

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

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

Contact: Dr Pieter Schreuder << editorlml@gmail.com

Something went wrong. With this a new version.

 

(LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy

Leprosy Mailing List – April 21,  2018

Ref.:    (LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy

From:  Wim Theuvenet, Apeldoorn, the Netherlands

---

 

Dear Pieter,

 

Thanks to Dr. Sharma for sharing this dilemma (LML, April 20, 2018).

 

There may be a few considerations to assist in the differential diagnosis:

1. DM peripheral neuropathy will in general be more symmetrical/bilateral;

2. DM neuropathy tends to affect the lower extremities far more often /much earlier than the upper limbs;

3. DM neuropathy will manifest itself after a much longer duration after the onset of the disease;

4. With ultrasound you may see the (a)symmetry of the nerve enlargement;

5. A cytological needle aspiration of enlarged nerves, when showing AFB's will set the diagnosis of leprosy;

6. When still inconclusive I would treat as MB leprosy seeing the extend of the nerve involvement;

7. When not done yet would suggest to have a full PT function assessment and when there are serious functional problems to present the patient to Dr. Indra Napit, Anandaban Hosptal, for possible reconstructive surgery/ tendon transfers?

 

With very best wishes

 

Willem J.Theuvenet M.D, Ph.D

Plast.Rec. Surgeon and Consultant for TLMI and the NLR.

 

---

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

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

Contact: Dr Pieter Schreuder << editorlml@gmail.com

(LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy

Leprosy Mailing List – April 20,  2018

Ref.:    (LML) To differentiate between diabetic neuropathy and pure neuritic leprosy neuropathy

From:  Ramesh Sharma, Pokhara, Nepal

---

Dear Pieter, 

 

This is Dr. Ramesh Sharma, Dermatologist, working in Greenpastures' Hospital, Pokhara, Nepal which is a leprosy mission hospital. 

 

We come across some confusing cases regarding pure neuritic leprosy. We, at present, have a patient in our ward who has uncontrolled diabetes (HbA1c: 10.3) and subjective nerves enlargement with sensory loss of the hands and feet and motor atrophy of the muscles of the hands only. 'Nerve enlargement' in this patient could only be a subjective finding. It's been difficult for us to distinguish between peripheral neuropathy of diabetes and pure neuritic leprosy. 

 

1. Is there any point as to differentiate between diabetic and pure neural neuropathy?

2. Can we differentiate them by the atrophy of muscles (in Hansens disease) along with sensory loss?

3. We have not yet done a nerve biopsy (its on our plan). But, if we do a nerve biopsy, can it be taken as conclusive to rule in or rule out a pure neuritic leprosy?

 

Looking forward to your reply.

 

Regards,

 

Ramesh.

---

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

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

Contact: Dr Pieter Schreuder << editorlml@gmail.com