Leprosy Mailing List – September 6, 2019
Ref.: (LML) Leprosy Diagnosis and Treatment
From: Paul Saunderson, Alesund, Norway
Dear Pieter,
I would like to respond briefly to Dr Gelber's comments about leprosy diagnosis (LML, September 4, 2019), which I generally agree with, although I believe there are new possibilities to be explored.
He echoes others on the need to reinstate the use of skin smears to diagnose lepromatous leprosy. He also regrets the widespread loss of the clinical skills needed for detecting nerve enlargement.
In a paper written almost 20 years ago (1), Dr Guido Groenen and I showed that the accurate detection of nerve enlargement was a remarkably good substitute for the skin smear examination, if that were not available, in establishing the diagnosis of leprosy.
Over the intervening 20 year period, ultrasonography has developed to the extent that nerve enlargement can now be identified very precisely. It is a safe, quick and non-invasive procedure. At Leprosy Review, we are starting to get manuscripts which show that nerve ultrasonography is becoming part of the standard diagnostic workup for suspected cases of leprosy in many centers, especially in India and Brazil. The sensitivity of ultrasound as a diagnostic test seems to be around 90%, although it is early PB cases that may be missed, not MB cases. The specificity has not yet been determined, but is likely to be very high.
In many ways, access to ultrasonography (which involves expensive equipment and skilled technicians) is just as difficult to provide as access to skin smears. Nerve ultrasonography has several advantages, however: it is more sensitive, in that it can detect a majority of smear-negative cases; and it is quick and non-invasive, making it more suitable to use on larger numbers of people.
Another advantage that is less easy to quantify is that the use of ultrasound is spreading rapidly, while routine microscopy is somewhat in decline, as rapid immunological or molecular tests become standard, for example, for malaria or TB. It is possible that in 5 or 10 years time, when we hope it will have become a very rare disease, most district hospitals will use ultrasound as the easiest screening test for possible leprosy cases in their catchment area.
With kind regards,
Paul Saunderson
1. Saunderson P & Groenen G. Which physical signs help most in the diagnosis of leprosy? A proposal based on experience in the AMFES project, ALERT, Ethiopia. Lepr Rev 2000; 71, 34-42.
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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