The DiaLep study

Leprosy Mailing List – April 12^th, 2012

Ref.:    The DiaLep study
From:  W de Bruin, Amsterdam, The Netherlands

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Dear Salvatore,

I would be very grateful if you could post the following request via the leprosy mailing list (LML). 

Currently, the Netherlands Leprosy Relief is researching the possibility of combining care interventions for people affected by either leprosy or diabetes.  A study and a questionnaire have been developed for people with expertise in leprosy or in diabetes.  The name of the study is the DiaLep study.  We kindly ask the interested LML readers to contribute to our study by filling in the questionnaire.

It is available online at: https://www.surveymonkey.com/s/dialepstudy .  It will take approximately 15 minutes to complete the questionnaire.  We would appreciate if you could provide your input by 7 May 2012.  An offline version of the questionnaire is in attachment to this message; please only use it in case of a limited internet connection.

We encourage you to complete the questionnaire and to pass the link on to appropriate health-care workers, professionals and representatives of patient organisations active in the field of either leprosy or diabetes.  With as many responses as possible we aim to achieve a large sample and a broad perspective of the opinions on this topic worldwide.

The contact information of my colleague and mine are as follow:-

Email addresses are  w.d.bruin(at)leprastichting.nl and e.dijkkamp(at)leprastichting.nl

Office phone number is  +31 20 595 05 00.

Many thanks in advance for your collaboration and support.

Kind regards,

Willemijn de Bruin and Evelien Dijkkamp

Willemijn de Bruin

Leprastichting / Netherlands Leprosy Relief (NLR)

Postbus / P.O. Box 95005

1090 HA Amsterdam

The Netherlands

E-mail: W.d.Bruin(at)Leprastichting.NL

Clinical case. Borderline leprosy in reaction in a boy

 Leprosy Mailing List – April 6th, 2012 

Ref.:   Clinical case. Borderline leprosy in reaction in a boy.From: Warren G., Melbourne, Australia

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Dear Dr Noto,

I would like to congratulate Dr Barreto and Dr Cabral on the excellent case presentation (LML 24 March 2012) that opens the way to discussion of several important points.  There were some interesting picture of biopsies, but one wonders what type of lesions were biopsied.  One would expect those type of pictures from the BT end of spectrum but I wonder if any biopsy was taken from a vague lesion?

1. The lesions appeared at age 4 with no known contacts of leprosy, but we do not know the incidence of leprosy in the area or if the patient had lived elsewhere.  The state of Mato Grosso is well known for his leprosy endemicity.  Was any (extended) contact examination done?

2. The condition was diagnosed as eczema at several occasions, by different health staff and even by the local leprosy reference centre.  It does accent in endemic areas that any skin lesion not reacting to normal treatment needs to be followed up and the possibility of leprosy should be taken into account.  Even the local leprosy clinic did not think about this possibility.  This is an aftermath we are seeing in many place now that the statement that leprosy is eliminated has resulted in many early cases being missed.  WHAT WE DO NOT LOOK FOR WE WILL NEVER SEE!  One should be highly suspicious of eczema that continued for twelve months not reacting to treatment.

3. I am interested in the degree of affection of the nerves.  There is no mention of sensory changes (in the lesions, hands and feet).  Perhaps a little hard  to test, in a 5 year old. The history implies no motor nerve deficit, but the biopsy showed bacilli in nerves and some nerves were easily palpable and visible.  The use of steroids  is certainly indicated.  We see that the inflammation has settled clinically in 2 months so hopefully he should not develop further nerve involvement.  The steroids cannot reverse any real damage to the actual fibres that has occurred, but there is no point in continuing the steroids as their job is to reduce the inflammation.  However, it will not encourage regrowth of damaged fibres. 

4. Long experience with dozens of patient with this type of reaction has shown me that 10-12 weeks of steroids is all that most need and then the continued use of MDT, possibly with extra clofazimine to prevent and control further reaction.  I certainly did find that in lepra reaction in the BL/BBish type one often had both types of reaction at the same time (acute redness and even ulceration of the lesions that looked real BB/BT and ENL on the BL/LL ones).  In the pictures of the patient in question there is definitely a suggestion of BLish type lesions on wrists and also the ear lobe) and even around the knees.  Yes, he has downgraded, but lesions now are right across the spectrum and I would not be surprised if there was some early ENL in those arm and face (ear lobe) lesions or, that ENL comes once the steroid is discontinued.  Hence the suggestion that extra clofazimine may be of help. 

5. Steroids are often continued for a prolonged period and does a lot of harm to the patient’s own metabolism.  I have seen too many patients die because they had had long periods of steroids and for various reasons they were not restarted when medical complications arose (e.g. one teenage boy got a severe flue 6 months after 5 years of steroids stopped and he did not get adequate medical care and he died within a week). 

6. The other problem that is often forgotten is that steroids are effective  in preventing inflammation.  At the same time, the body’s own abilities to control the infection are slowed down by the steroids and this affects the ability of the body to reduce the degree of infection caused by M. leprae.  In fact in a well controlled drug trial severe LL patients were given Rifampycin daily under supervision for 5 years.  After that time the disease appeared controlled, but nerve biopsy and culture revealed M. leprae that were fully sensitive to the Rifampycin.  It is now accepted that the antibiotics while being able to kill the bacteria in the blood and other tissues, but cannot eliminate them from the nerves.  Once MDT is completed the bacteria come out, start multiplying again and the patient will relapse in years time. Hence, once definite durations for MDT were suggested by W.H.O., we  started counting the months recommended  as those not on steroids.  If a patient had 3 months steroids he had 24 plus 3 months of MDT for Multibacillary leprosy.  This certainly seemed to prevent many relapses.  In patients with less natural resistance ie the LL/BL type of disease that is well developed at diagnosis, I feel they need longer MDT than that recommended by W.H.O. to ensure no relapse. 

7. Hence I hope that the boy affected will have at least twelve months full MDT after the steroids are stopped.  He is obviously borderline in type and so should have some ability to  eliminate and control the infection. 

8. I am interested to see if he was given tricyclics.  Yes, I use them a lot on adults and think they are excellent in helping to minimise tension and fear of the disease.  However, I must confess  I rarely give tricyclics to small children though have frequently use Phenobarb with good results.  They  can help reduce the duration that one needs to give the steroids.

I do hope your presentation will encourage others to look more carefully for diagnosisand use steroids wisely.

Yours sincerely,

Grace Warren

Previously  Superintendent Hong Kong Leprosarium ( 1960-75)
Advisor in leprosy and   Reconstructive surgery in Asia  ( 1975-95)

Clinical case. Borderline leprosy in reaction in a boy

  Leprosy Mailing List – March 28th, 2012 

Ref.:   Clinical case. Borderline leprosy in reaction in a boyFrom: P. Vijayakumaran, Chennai, India

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Dear Salvatore,

I refer to the clinical case circulated by via the Leprosy Mailing List – March 24th, 2012.  Thank you very much to Dr Barreto and Dr Cabral for sharing the interesting case history (not so interesting for the person affected).  I congratulate the team for providing all details for better understanding of the situation and also appropriate management of the condition. I am not a pathologist.  Here are my impressions:

·         The presentation was atypical so that it could not be related to leprosy.

·         Health staff are not aware of presentations of leprosy.

·         Leprosy referral hospital may have un-trained staff who cannot identify leprosy.

·         Multiple nerve involvement is characteristic of borderline leprosy.  That too with in a period of one year goes more in favour.

·         Bacteriological Index of 2+ at all sites (probably all selective sites – that means active lesions) may indicate that the disease has progressed beyond borderline tuberculoid leprosy (towards lepromatous leprosy).

·         Biopsy - 3+ positive and presence of globi are indicative of lepromatous side of leprosy spectrum.

·         Biopsy – Globi and macrophages are characteristics of lepromatous side of the spectrum.

Fig.1 & 2               : Any trained eye will suspect leprosy.

Fig.3 & 4               : Misleading presentation because of scaling and central healing.

Fig.5, 6 & 7          : Trained eyes should be able to suspect leprosy.

Fig.8                    : Explains importance of examination of peripheral nerves. Again trained eyes and hands comes to my mind.

Fig.15 & 16          : Clearly clinical presentation of BB leprosy. 

This child is fortunate to have intact nerve function. This also warrants close observation for possibility of fresh episodes of reactions and especially neuritis. 

I once again thank the authors and the LML for sharing their experience. 

With best wishes,

Dr.P.Vijayakumaran,

Regional Medical Coordinator South,

German Leprosy and TB Relief Association India,

#4, Gajapathi street, Shenoy Nagar,

Chennai – 600030, India

Clinical case. Borderline leprosy in reaction in a boy

 Leprosy Mailing List – March 24th, 2012 

Ref.:   Clinical case. Borderline leprosy in reaction in a boy.From: Barreto, J., S. Paulo, Brazil

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Dear Salvatore and Pieter,

Thank you very much for inviting me to circulate a clinical case on the leprosy mailing list.  I believe it is a good and useful initiative.  Herewith we (myself and José Cabral Lopez) present the case of a 5 years old boy from Brazil with borderline leprosy in reaction.  We will really appreciate any comment about the case.

Best regards,

Jaison

Silent neuritis (Quiet Nerve Paralysis)

Leprosy Mailing List – March 9th, 2012 

Ref.:    Silent neuritis (Quiet Nerve Paralysis)From: H Srinivasan, Chennai, India

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Dear Dr Salvatore Noto,

Ref.: Query by Dr Narayanakumar (Kumbakonam, India) about “Silent neuritis”

Thank you, Dr Narayanakumar. My response is as follows :-

The term “Silent neuritis” is used by many to refer to the occurrence of nerve function deficit (NFD), usually motor paralysis, without concurrent or immediately antecedent episode of acute neuritis.  I preferred the term “Quiet Nerve Paralysis” (QNP) to refer to this phenomenon.

While leprologists were aware of its occurrence, I drew attention to the fact that it was associated with the occurrence of deformity in a significant proportion of patients [1].  Here I will not go into the reasons why I preferred the term ‘Quiet Nerve Paralysis’ to ‘Silent Neuritis’.  Interested colleagues may refer to reference [2].  

During the course of my investigations, in the field and in the sanatorium, on the origin and progress of deformities in leprosy patients, I found that motor paralysis and associated deformity was five times more common in patients giving a history of remembered attack(s) of acute neuritis of the concerned nerve trunk than in those not giving such a history.  However, I also found that such patients accounted for only about 20% to 25% of those showing paralytic deformity.  Even allowing for faulty memory, it appeared that a sizable proportion of patients developed deformity without developing acute neuritis.  We designated such patients as having ‘Quiet Nerve Paralysis’.

This group of patients comprised:
1). untreated or inadequately treated patients;
2).Patients adequately treated in the past and discharged as ‘cured’; as well as
3).patients still under treatment.
We hypothesized that uncontrolled leprosy was the cause of nerve paralysis in the first group and instituted proper anti-leprosy therapy in them.  We considered QNP as the manifestation of relapse of leprosy in the second group and treated them again with anti-leprosy treatment of the day.  As for the third group, we felt that, in the absence of other explanations, they probably had “subclinically operating reactional pathology” in them and so treated them with a standard course of prednisolone for three to four months or more depending on their response.  Varying proportion of patients showed partial or complete restoration of nerve function in all the three groups, indicating that our conjectures were probably correct, at least in those patients.  Those in the first two groups who did not show any sign of recovery of nerve function after three months of anti-leprosy therapy were given a standard course of steroid therapy for what it was worth.  If I remember right, there was no clinical evidence suggestive nerve compression in these patients and so nerve decompression was not offered to them.

We subsequently tried to carry out a prospective trial of steroid therapy for QNP in the field, but the results were not reliable due to operational problems.

I should also point out that the patients were from South India, and the study was done during the ‘dapsone era’ when dapsone monotherapy was the standard anti-leprosy treatment.  I do not know what the situation is like in present conditions of years of intensive coverage of the patient population with MDT and fewer cases of active leprosy in the environment.

H Srinivasan FRCS
Surgeon (Retd.)
25, First Seaward Road
Chennai - 600 041
India

[1] Srinivasan H, Rao KS, Shanmugam N (1982).  Steroid therapy in recent “quiet nerve paralysis” in leprosy. Leprosy in India  54(3) :  412 – 419.
[2] Srinivasan H, Gupte MD.  Experiences from studies on Quiet Nerve Paralysis, Ch. 3  in The Peripheral Nerve in Leprosy and Other Neuropathies, (pp 30 – 35), Ed. by Noshir H Antia & Vanaja P Shetty, Delhi, Oxford University Press, 1997.   

Disability index for leprosy patients. The Bechelli’s index

Leprosy Mailing List – February 25^th, 2012

Ref.:    Disability index for leprosy patients. The Bechelli’s index

From:  E. Rangel, Rio de Janeiro, Brazil

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Dear Salvatore,

Thank you very much to Prof Smith for sharing on the leprosy mailing list the results of the Disability Grading Survey.  In our service, here at FIOCRUZ, I use the BECHELLI’s index.  Kindly find in attachment the references (Word document - PDF document)

Best regards,

Emanuel Rangel
Physiotherapist

Neuritis, acute and chronic, in leprosy

Leprosy Mailing List – February 28^th, 2012 

Ref.:    Neuritis, acute and chronic, in leprosy

From:  H Srinivasan, Chennai, India

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Dear Dr Noto,

The following are my views regarding the queries raised about "Acute neuritis" in leprosy.  I think it will help starting from the definition of neuritis and then considering acute and chronic neuritis.  I also report some relevant aspects of histopathology.

Definition of leprosy neuritis

Leprosy neuritis is an inflammatory mononeuropathy occurring in leprosy.  In can be acute or chronic.

Acute leprosy neuritis 

Acute leprosy neuritis describes the clinical state characterized by pain occurring in an obviously thickened peripheral nerve trunk such as ulnar, median, lateral popliteal nerve etc.  It may occur in cutaneous nerve trunks also, but here there is no risk of disability and deformity, although the condition may be quite distressing to the patient.  Acute neuritis is of rapid (i.e., acute) onset, over the course of a few hours to a few days.  It may have been present for a few days to a few weeks by the time the patient is seen by the physician or paramedical worker.

It may be moderately severe or severe.  In moderately severe acute leprosy neuritis patient complains of severe pain, but the movement of adjacent joint is not restricted and sleep is not disturbed because of pain.  In severe acute leprosy neuritis patient complains of severe pain and the movement of adjacent joint is restricted due to the pain and patient admits that pain disturbs sleep. 

Often, acute neuritis occurs in a background of chronic neuritis.  Acute neuritis may occur along with cutaneous manifestations of type I or type II reaction, or as an isolated clinical manifestation of the reactional process.

The term “acute leprosy neuritis" when used in the histopathological context indicates presence of foci of polymorpho nuclear leucocyte infiltration in the nerve (micro or macro “hot abscess”).

Chronic leprosy neuritis

 “Chronic leprosy neuritis” is the clinical condition where there has been long standing ‘mild’ (patient admits to having pain in the nerve only on asking about it) to ‘moderate’ nerve pain (complains of pain even without asking about it, but says it is not severe) in one or more peripheral nerve trunks of the limb(s).   

Histologically, every case of leprosy shows some evidence of chronic neuritis at some site in the peripheral nervous system.  Leprosy is not diagnosed without such evidence.   

Clinical examination

On examination, the concerned nerve trunk is obviously thickened (swollen), and very tender (very painful on palpation), such that the patient is afraid of palpation of the nerve.  Range of active movement of the adjacent joint is restricted because of pain; and/or passively increasing the range aggravates pain in the nerve.  There may be clinical nerve function deficit relating to the affected nerve trunk, which may be pre-existing or of recent origin along with the attack of acute neuritis or, pre-existing nerve function deficit may have worsened coincident with the attack of acute neuritis or, there may not be any clinically identifiable nerve function deficit.  

Indications for Steroid therapy

Onset or worsening of clinical nerve function deficit relating to the affected nerve trunk (eg., sensory loss, muscle weakness or paralysis) along with acute neuritis or even while the condition is under treatment with other drugs is an absolute indication for immediate institution of steroid therapy in adequate dosage.  Continued severe nerve pain even in the absence of increasing nerve function deficit or in a destroyed nerve trunk (with no possibility of the nerve recovering) despite adequate analgesic therapy is often relieved by steroid therapy.

Nerve conduction studies

One does not wait for or depend on nerve conduction studies for diagnosing and treating acute neuritis.  They may be used, when available, for monitoring efficacy of therapy.  Nerve conduction velocity (NCVs) may be within normal limits when only slow conducting fibres are damaged.  Marginal improvement in NCVs without clinical improvement is of no material benefit to the patient.

Early detection of leprosy neuritis

Patient is the best person to suspect early the possibility of acute neuritis and report for treatment without delay.  So the patient should be trained to look for and suspect acute neuritis as well as onset/worsening of nerve function deficit of his or her thickened nerve trunks.  The paramedical and medical personnel must be sensitized to show concern and examine the patient very carefully and sympathetically when a patient reports for suspected acute neuritis and not play down or neglect the patient.  It goes without saying that they must know how to examine such patients.

H Srinivasan, FRCS
Surgeon (Retd)
25 First Seaward Road
Chennai - 600 041
INDIA

Periodical assessment of the patient by a combination of: - always look, palpate, compare and test

Leprosy Mailing List – February 15^th, 2012 

Ref.:    Periodical assessment of the patient by a combination of: - always look, palpate, compare and test.

From:  F Ross, UK

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Dear Salvatore,

Thanks for your publication of this excellent response from Drs Naafs and Schreuder to the question of acute neuropathy (LML Feb. 14^th 2012 [enclosed]).  If applied it will save a lot of pain and disability.

Best regards.

Felton Ross.

----- Original Message -----

From: Salvatore Noto

To: Salvatore Noto

Sent: Tuesday, February 14, 2012 10:26 AM

Subject: (LML) Proposal for "Guidelines for the management of acute neuritis in leprosy" - Part I. Definition, clinical signs and electrophysiology

Leprosy Mailing List – February 14^th, 2012

Ref.:    Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition, clinical signs and electrophysiology

From:  B Naafs, Munnekeburen;  P A M Schreuder, Maastricht, The Netherlands

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Dear Salvatore,

Very much, “thank you” to Dr Antoine Mahé (LML January 18^th, 2012) and to colleagues contributing to the topic about “acute leprosy neuritis”.  It is difficult to answer all Dr Mahé’s questions because one is always subjective!  Herewith are our answers:-

1) What is your definition of 'acute leprosy neuritis’?

<< Definition of acute neuritis:-  Acute neuritis in leprosy is the occurrence within a few days of increase in pain, or tenderness, decrease in voluntary muscle test (VMT) and sensory testing (ST) scores, severely diminished motor nerve conduction or nerve block in peripheral nerves serving the eye lids, face, hands and feet.  Since patients are not seen every day, “acute” goes up to 3 months.  >>

2) Which are the clinical symptoms and signs to be taken into account for justifying the implementation of a specific therapy of acute neuritis (i.e., systemic steroids):

<<. >>

2a Presence of pain: spontaneous? Provoked by palpation?  Or by movement?

<< All of them are important and justify therapy but, especially tenderness at palpation. >>

2b Recent occurrence of neurological dysfunction (sensory, motor, autonomic)?

<< All of them are important but, most decrease in VMT and ST scores, because these are easy to measure. >>

2c Definition of "recent"?  With or without pain?

<< We would consider “recent” when within 3 months. >>

 3) Relevance of electromyography and nerve conduction studies?

<< Nerve conduction studies are relevant but, they are not widely available. >>

4) Strategies for early detection of incipient neuritis during follow-up of known patients?

<< Periodical assessment of the patient by a combination of: - always look, palpate, compare and test.  Look at the face and eyes: do the eyes blink?  Any degree of lagophthalmos?  Any deviation of the mouth?  Look at hands and feet:- any dryness, atrophy or wounds?  Palpate* the peripheral nerves of predilection of leprosy.  Comparealways the two sides.  Test by performing the voluntary muscle test and sensory test on eyes, hands and feet.

We hope these answers help. 

Best regards,

Ben Naafs and Pieter Schreuder

* Description of the palpation of the peripheral nerves of predilection of leprosy is available on line at: - The Diagnosis of Leprosy – text and slides <<http://atlasofleprosy.hsanmartino.it/ >>

Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition, clinical signs and electrophysiology

Leprosy Mailing List – February 14^th, 2012 

Ref.:    Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition, clinical signs and electrophysiology

From:  B Naafs, Munnekeburen;  P A M Schreuder, Maastricht, The Netherlands

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Dear Salvatore,

Very much, “thank you” to Dr Antoine Mahé (LML January 18^th, 2012) and to colleagues contributing to the topic about “acute leprosy neuritis”.  It is difficult to answer all Dr Mahé’s questions because one is always subjective!  Herewith are our answers:-

1) What is your definition of 'acute leprosy neuritis’?

<< Definition of acute neuritis:-  Acute neuritis in leprosy is the occurrence within a few days of increase in pain, or tenderness, decrease in voluntary muscle test (VMT) and sensory testing (ST) scores, severely diminished motor nerve conduction or nerve block in peripheral nerves serving the eye lids, face, hands and feet.  Since patients are not seen every day, “acute” goes up to 3 months.  >>

2) Which are the clinical symptoms and signs to be taken into account for justifying the implementation of a specific therapy of acute neuritis (i.e., systemic steroids):

<<. >>

2a Presence of pain: spontaneous? Provoked by palpation?  Or by movement?

<< All of them are important and justify therapy but, especially tenderness at palpation. >>

2b Recent occurrence of neurological dysfunction (sensory, motor, autonomic)?

<< All of them are important but, most decrease in VMT and ST scores, because these are easy to measure. >>

2c Definition of "recent"?  With or without pain?

<< We would consider “recent” when within 3 months. >>

 3) Relevance of electromyography and nerve conduction studies?

<< Nerve conduction studies are relevant but, they are not widely available. >>

4) Strategies for early detection of incipient neuritis during follow-up of known patients?

<< Periodical assessment of the patient by a combination of: - always look, palpate, compare and test.  Look at the face and eyes: do the eyes blink?  Any degree of lagophthalmos?  Any deviation of the mouth?  Look at hands and feet:- any dryness, atrophy or wounds?  Palpate* the peripheral nerves of predilection of leprosy.  Comparealways the two sides.  Test by performing the voluntary muscle test and sensory test on eyes, hands and feet.

We hope these answers help. 

Best regards,

Ben Naafs and Pieter Schreuder

* Description of the palpation of the peripheral nerves of predilection of leprosy is available on line at: - The Diagnosis of Leprosy – text and slides <<http://atlasofleprosy.hsanmartino.it/ >>

Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition, clinical signs and electrophysiology

Leprosy Mailing List – February 11^th, 2012 

Ref.:    Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition, clinical signs and electrophysiology

From:  L Reni, Genoa, Italy

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Dear Salvatore,

Thank you very much to Dr Antoine Mahé for introducing such an important topic (LML January 18^th, 2012).  Herewith are my answers:-

1) What is your definition of 'acute leprosy neuritis' ?

<< "Acute leprosy neuritis", my definition:-

It is an acute inflammatory mononeuropathy presenting with pain spreading, from a point of entrapment (for example at the ulnar groove or in the cubital tunnel), along the nerve.

There is tenderness and/or swelling of the nerve; its palpation evokes a typical “electric shock” along the nerve with paraesthesia in the area of its cutaneous distribution (Tinel's sign).

The pain may be isolated or accompanied by neurological dysfunctions (sensitive and/or motor and/or autonomic).  The neuritis may be considered acute if symptomatology and/or signs have arisen within a few weeks.  >>

2) Which are the clinical symptoms and signs to be taken into account for justifying the implementation of a specific therapy of acute neuritis (i.e., systemic steroids):

<< The implementation of a specific therapy is necessary whenever a peripheral nerve lesion is suspected. >>

 2a Presence of pain: spontaneous? Provoked by palpation?  Or by movement?

<< The pain may be absent.  If present, it may be spontaneous, provoked by palpation or by movement. >>

2b Recent occurrence of neurological dysfunction (sensory, motor, autonomic)?

<< Neurologic dysfunction may be sensory (sensory deficit or paraesthesia) and/or motor and/or autonomic. >>

 2c Definition of "recent"?  With or without pain?

<< "Recent" means within a few weeks.  Pain may be absent. >>

3) Relevance of electromyography and nerve conduction studies?

<< Electromyography is useless.  Nerve conduction studies are useful; it allows the diagnosis in dubious cases, detecting the nervous lesion, while waiting echography and surgical approach.  Nerve conduction has proved to be useful in our experience demonstrating focal modifications in quite modest or dubious cases and previous to the appearance of clinical symptoms. >>

4) Strategies for early detection of incipient neuritis during follow-up of known patients?

<< The patient needs instructions about the possible symptoms leading to a dramatic evolution.  Sensory testing and voluntary muscle test are performed periodically.  Nerve conduction study is useful. >>

Best regards,

Lizia

Dr Lizia Reni

Department of Neurology

University of Genoa,

Genoa, Italy

Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition

Leprosy Mailing List – February 2^nd, 2012 

Ref.:    Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition

From:  H K Kar, New Delhi, India

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Dear Dr Noto,

Thank you very much to Dr Mahé and to the Association of the French speaking leprologists for this initiative (LML 18^th Jan. 2012).  Herewith I am trying to give my opinion on the first question:

1) What is your definition of 'acute leprosy neuritis' ?

My definition:-

<< Sudden onset of acute inflammation of the nerve presenting with acute pain in peripheral nerve or nerve tenderness and/or swelling due to nerve abscess with or without recent onset of neurological deficit of usually 6 months duration in a leprosy patient is called as “acute leprosy neuritis”.

Best regards,

Dr (Prof.) H K Kar
Consultant & HOD
Department of Dermatology, STD & Leprosy
P.G.I.M.E.R. and Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001

LL patients may have no obvious skin lesions and no changes in sensation for years

Leprosy Mailing List – January 24^th, 2012 

Ref.:    LL patients may have no obvious skin lesions and no changes in sensation for years
From:  G. Warren, Sidney, Australia

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Dear Dr Noto,

It was good to see Dr Lockwood’s letter (LML Jan. 20^th, 2012) regarding the “Elimination” in Brazil, and her acknowledgement that recognition of leprosy cases will continue for many decades.

One report states that in at least one country there is an incidence of 50% of graded 2 disability in new cases at diagnosis.  This surely means that the clinicians just do not know early leprosy. Unfortunately as, I have often said before, I believe that this is largely due to the WHO statement that to be diagnosed as leprosy the patient needs an anaesthetic skin patch!  I have worked in many countries (27) and find so many variants in early presentation, partly racial but, in some groups the highly infectious LL patients may have no obvious skin lesions and may have no changes in sensation for twenty years and, even then many of them do not have any anaesthesia; though they may have altered sensory perception.  In the same way as Most diabetics do not have anaesthetic feet; they feel each step as it hits the ground but they may not feel a cut or even a broken bone causes no pain.  Yes, I have seen WHO consultants refuse to register patients with positive skin smears because they had no anaesthesia.  Also I have seen many “Primary persistent neuritic” leprosy patients not registered because they have no skin patch.

Surely we need to somehow get these recognised so that we do get  more accurate figures.  The present statements that leprosy Elimination is progressing is causing reduction in available funds.  The present figures really do not give any idea of how much leprosy is spreading.  In India there are hundreds of children being diagnosed now.  Is it really changing or just that people are now looking and revising their strategies, for which I am very thankful.

Can these new Statistics from India inspire others to try and do something similar?  What can be done to modify that Definition of leprosy as published in the WHO guide to Elimination.  That definition is certainly not the one in most reliable Text books on Leprosy which state the patient needs at least one of three clinical signs, which are patches, nerve involvement or positive skin smears.  While that definition stands many early patients will not be diagnosed at a time when it is possible and easy to eliminate the disease before serious deformity has been caused.

Keep it up Brazil and may others follow your lead and may we proceed to a more practical approach to the control of this disease.  The use of that word elimination makes Governments try and forget that it is still a problem and can easily flare up again to a major problem unless constantly looked for.  I teach my students “What you do not look for you will never see”.  Let’s try and get everyone looking for leprosy again.

Grace Warren,

Previously advisor for the Leprosy Mission in Asia. (1975-1995)

Proposal for "Guidelines for the management of acute neuritis in leprosy” - Definition, symptoms and signs

Leprosy Mailing List – January 18^th, 2012 

Ref.:    Proposal for "Guidelines for the management of acute neuritis in leprosy”

            Definition, symptoms and signs

From:  A Mahé, Paris, France

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Dear Dr Noto,

With the ongoing transfer of the leprosy control activities to the general health services, the Bulletin of the French-speaking leprologists (BALLF) aims at providing to health personnel clear and understandable outlines of some of the conditions related to leprosy they may encounter.  The diffusion of the Bulletin is covering francophone Africa, South East Asia and the Caribbean area. Proposals of all LML affiliates are welcome.

Therefore, we would like to propose in our journal standardized "Guidelines for the management of acute neuritis in leprosy".  In that perspective, and owing to the relatively high variability of practices in that specific field, it seemed to us interesting to question the affiliates of the leprosy mailing list about their practices in their institutions.

We would be very grateful for those who would let us know those practices.  A synthesis will then be performed, and communicated to the leprosy mailing list.

We have selected the following questions about definition, clinical signs and electromyography (Part I.);

1) What is your definition of 'acute leprosy neuritis' ?

 2) Which are the clinical symptoms and signs to be taken into account for justifying the implementation of a specific therapy of acute neuritis (i.e., systemic steroids):

2a - presence of pain : spontaneous ? Provoked by palpation ? Or by movement ?

2b - recent occurrence of neurological dysfunction (sensory, motor, autonomic) ?

2c Definition of "recent" ? With or without pain ?

3) Relevance of electromyography and nerve conduction studies ?

4) Strategies for early detection of incipient neuritis during follow-up of known patients ?

Thank you so much for your answers and comments,

Dr Antoine Mahé

Editor of the Bulletin of the French-speaking leprologists (BALLF)

Dr Antoine Mahé

Dermatologie

Hôpital Pasteur

39, avenue de la Liberté

68024 Colmar Cedex

Secrétariat (+33) 03 89 12 44 65 / 41 58

Fax (+33) 03 89 12 47 69

Portable (+33) 06 31 27 68 71

NB Part II Medical and surgical therapy will follow.

Disability Grading Survey

Leprosy Mailing List – January 13^th, 2012

Ref.:    Disability Grading Survey

From:  C Smith, Aberdeen, Scotland, UK

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Dear Salvatore,

Could you please post this survey on WHO disability grading on the LML and ask as many people as possible to complete the survey.  It is simple and will only take 5 minutes to complete.  Once it has been completed click the SUBMIT button at the bottom and an acknowledgement will be sent. 

Can everyone please complete the survey in the next couple of weeks and we will circulate the responses and answers on the LML.

http://www.abdn.ac.uk/~sme577/Leprosy

Cairns Smith

School of Medicine and Dentistry,

University of Aberdeen,

Polwarth Building,

Foresterhill,

Aberdeen AB25 2ZD,

Scotland, UK

Telephone - (44) 1224 437266

Email: w.c.s.smith(at)abdn.ac.uk

Further information

Accurate assessment of disability due to leprosy using the WHO Disability Grading is important.  It is used to monitor diagnosis (it indicates whether diagnosis is early or late) and it is used as an indicator of the effectiveness of treatment (the progress of patients during MDT is monitored using the WHO disability grading).   

The WHO disability grade is a simple method to assess impairments in the Hands, Eyes and Feet of patients taking MDT.  It is described in the Operational Guidelines for the Enhanced Global Strategy (2011-2015) – see page 22 – 25.  The overall WHO Disability Grade (the WHO maximum Disability Grade) should be recorded for each patient, but it is also recommended that a patient’s progress through treatment should be assessed using the EHF score. The EHF score is when the grading for both eyes, both hands and both feet are added together. 

It is important that the WHO Disability Grades are accurate and reliable.  There is wide variation in the disability grading between and within countries.  This may be due to real differences or due to differences in the way the Grading is implemented.   We would like to check to see if disability assessments are conducted and recorded in the same way everywhere. To help assess this situation, we would like as many people as possible to complete the following 20 questions (your answers will be completely anonymous).  We will circulate the answers on the LML

Many clinicians are not taught to really examine the nerves

Leprosy Mailing List – November 12th, 2011 

Ref.:   Many clinicians are not taught to really examine the nerves.
From: G. Warren, Sydney, Australia

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Dear Dr  Noto,

Thank you very much for publishing the photos and thank you Dr Barreto for sending them in (LML Nov. 7^th, 2011). 

It is so good to see good photos of typical cases and, I especially appreciate the photos of the nerves.  Many clinicians are not taught to really examine the nerves and I frequently have been able to make a final diagnosis by finding an altered radial or ulnar nerve on the back of a hand.  One horse jockey had no feeling in some toes and no one could diagnose till I showed them the large superficial peroneal nerve!

One teenager, in Asia, complained of numbness and parasthesia, of index and long fingers and had no other obvious symptoms or signs so the general doctor, to whom he went, sent him  to a psychiatric hospital for many months.  Eventually they got him out and when I saw him he had a very large hard radial nerve on the back of that hand and large lymph nodes in neck and groin.  A Biopsy of one of them showed classical leprosy that even the  experienced professor was thrilled at finding- he was not often sent biopsies of lymph nodes!  Poor boy fortunately he did not develop any further major deformity.  Certainly not the classical case- but something to be aware of.

Thank you for the picture of the sural nerve abscess.  I must confess that although I have felt many nerve abscesses and seen many large sural nerves I have never seen one abscess in that manner in the middle of the calf.  It all goes to show that what we do not look for we will never see!  I wonder what I have missed?  Thank you for that.

Grace Warren.

Castle Hill, Sydney Aust.

Prev.  Advisor for Leprosy for the Leprosy Mission in Asia 1975-1995.