(LML) BT Hansen's Disease and nerve abscesses - surgical intervention or MDT alone?

Leprosy Mailing List – January 13, 2015

Ref.:  (LML) BT Hansen's Disease and nerve abscesses - surgical intervention or MDT alone?

From:  Grace Warren, Sidney, Australia

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Dear Pieter,

 

Thank you for the interesting letter from  Dr Sunil Ghate of Mumbai.(LML January, 9, 2015), and for including the photographs. I am glad that he has got the biopsy stating it is Borderline/tuberculoid.   This indicates that the patient already has M leprae sensitised T lymphocytes, and so we can assume that the abscesses are the result of the killing of the bacilli inside the nerves. He only lists a few nerves and fortunately the ulna at the elbow  is not large enough to photograph.

 

Yes many people recommend that the abscess needs to be opened. Fair enough if it is very large and causing pain or there is already a definite neural deficit. However, there are not many surgeons who are expert at merely opening the nerve sheath to release the pressure without damaging more of the fibres. The aim is to relieve the pressure not remove the affected nerve! It is not an easy thing to do and unfortunately most of the people whom I have seen who have had the abscess opened ( relieved)  have ended up with more neural deficit and often more nerve dysfunction  due to the surgical trauma. If the infection is properly controlled he will hopefully not get to much more loss of function and the nerves may become firmer and more easily palpable over the years. He will probably have many more slightly firm and enlarged nerves in years ahead. I   suspect that if it is really BT this may only occur on  the one arm  and the disease is localised to that area alone.

 

I have seen many patients with a similar problem during my work in Asia. While I consider that yes he needs a full MB course of MDT I would not hit him  hard at once and that is why I am rushing to answer as soon as possible. I would  not give the Rifampicin initially as this  rapidly kills the bacilli and I have often found that within a month of the commencement of full MTD this type of patient goes into a full reaction. Many BL/BB patients they complain that the MDT has made them worse -- and some refuse to have more MDT!! So this type of patient I commence on Clofazamine alone   initially for about 3 months.  Then, if not obvious signs of a reaction,  add the rest of the full MDT and give the full MDT for the recommended duration. Though I often do give for longer to ensure we have the disease properly controlled. 

 

The dose of Clofazamine depends of size of patient and  severity is relevant. Regular MDT recommends 300mgs once monthly and then 50 mgs daily but  when using it for treatment of reaction or initiation of treatment aiming to minimise reaction I may give 200mgs daily or 300mgs daily in a large patient.   Clofazamine is bactericidal but it is also anti-inflammatory and bacteriostatic.  So if a largish dose is given for say 3 months it will kill bacteria and prevent those present from multiplying and so control the infection but it will also help minimise the swelling from the inflammation.  It will also help eliminate any tendency to clinical reaction. I was involved in the original drug trials of Clofazamine in the 1960s and so am sure that even given alone it will control the disease with minimum problems and reaction. If I could only have one drug to treat leprosy I would use Clofazamine. So I would suggest to stop dapsone now and increase Clofazamine and give Lots of Vit B1 and Vit C (1000mgms daily)  and Magnesium,  preferable a good Multivitamin and mineral with at least 10mgms Vit B1 daily. I cannot think of anything else I ought to add at present. I know this is rather a radical approach but it sure has saved many from severe reaction and similar problems, and saved much nerve function.

 

I probably would not do anything about the enlargement of the nerves that is present except to keep record of them. They will probably persist for a long time maybe life- but with full MDT there should be no evidence of progression of the disease.

 

 

All the best.

 

Grace  Warren

Previously   Consultant in Leprosy and Reconstructive surgery for the Leprosy Mission in Asia (1975-1994)

 

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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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LML) BT Hansen's Disease and nerve abscesses - surgical intervention or MDT alone?

Leprosy Mailing List – January 11,  2015

Ref.:    (LML) BT Hansen's Disease and nerve abscesses - surgical intervention or MDT alone?

From: Maneesha Godbole, Hubli, Karnataka, India

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Dear Dr. Schreuder,

 

With reference to the letter of Dr. Sunil Ghate (LML, January 9, 2015):

-       If there is no nerve function impairment I would suggest leaving them alone, especially the ulnar and median.

-       No impairment means that the abscesses are obviously cold abscesses, not exerting any pressure on the nerves.

-       If appearance is bothering the patient, you can remove the one near the middle finger.

-       Most of the times, surgery to excise these abscesses causes more damage than leaving it alone.

 

The nerve function of course needs to be monitored closely.

 

Regards,

 

Dr.Maneesha Godbole

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

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

 

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(LML) BT Hansen's Disease and nerve abscesses - surgical intervention or MDT alone?

 

Leprosy Mailing List – January 11,  2015

Ref.:    (LML) BT Hansen's Disease and nerve abscesses - surgical intervention or MDT alone?

 

From:  Dinkar Palande, Pondicherry, India

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Dear Pieter,

 

 

I have the following comments, suggestions - with ref. to the information that is made available: Please pass them on soon.

 

1. It is not clear if the person is on prednisolon. He should be. I suggest 5mgms tds 5 days and then taper monitoring the sensory/motor assessments using graded nylons. Unless graded nylons are used one would not know if there is early nerve function deficit.

 

2. Is there pain in the ulnar nerve above the elbow on flexion of the elbow? With or without pronation of the forearm and closed fist? In any case please splint the elbow in a comfortable position.

 

3. The abscess in the ulnar nerve above the elbow is very likely to be in the dorsal cutaneous branch of the nerve which often joins the ulnar above the elbow.

 

4. No need to drain the abcesses for the present. Go on observing with very frequent monitoring - Pain, tenderness, stretch sign, sensory motor evaluation etc.

 

5. In case abscess evacuation (s) is decided on, mainly because of any signs of early or increasing nerve deficit.  PLEASE ensure that the surgery is done under magnification and by a surgeon USED to doing these nerve surgeries. It is not difficult to damage a nerve.

 

 

best wishes

 

 

dinkar d Palande

 

from dinkar d. palande

 

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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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(LML) BT Hansen's Disease and nerve abscesses - surgical intervention or MDT alone?

Leprosy Mailing List – January 11,  2015

Ref.:    (LML) BT Hansen's Disease and nerve abscesses - surgical intervention or MDT alone?

 

From:  P. Narasimha Rao, Hyderabad, India

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Dear Dr. Schreuder,

 

In reference to Dr Sunil's mail, I am here with posting the mail of Dr H Srinivasan sent to our LML few years back, explaining in detail the management of nerve abscess in response to a mail from Dr Ranthilaka.  If you feel it would be relevant, you may post it in this thread. 

This is with reference to the query of Dr Ranthilaka Ranawaka regarding management of nerve abscess (LML Aug. 25th, 2008). My views on this topic are as follows.

 

Dr H Srinivasan:

“Nerve abscesses in leprosy are usually ‘cold abscesses’ like tubercular cold abscesses.  They occur due to caseation followed by colliquative necrosis tuberculoid granuloma in nerve fibres.  They are commonly seen in major nerve trunks and cutaneous nerves of persons suffering from tuberculoid types of leprosy.  In major nerve trunks the abscess may be truly intraneural due to necrosis of a nerve fascicle (or even a part of a fascicle) within the nerve, with the ‘pus’ collected inside the nerve, or, the pus may track through the epineurium and come out as a collar stud abscess to form a ‘para-neural’ abscess.  Sometimes, a nerve bundle in the outer sheath of the nerve is the site of abscess formation and the abscess remains ‘para-neural’ from the beginning.  Occasionally, a lymph node adherent to the nerve sheath (e.g., epitrochlear node adherent to the ulnar nerve) develops caseous necrosis in tuberculoid leprosy and forms a para-neural abscess, clinically indistinguishable from a true nerve abscess tracking from inside the nerve.

The size of the abscess ranges from very small (minute micro abscesses) to very large ‘giant’ abscesses, many centimetres long and wide.  The presence of the abscess or it growing in size does not indicate disease activity.  Left alone, smaller abscesses tend to subside on their own while larger abscesses often do not do so.  They may even keep increasing in size.

There are two concerns associated with the nerve abscesses: i) the abscess per se and ii) the effect of the abscess on the function of the affected nerve trunk.

i)             Unlike acute inflammatory ‘hot’ abscesses, cold abscesses are relatively painless or there may be only mild nerve pain.  So pain is not a major consideration in the management of nerve abscesses.  Nor is “disease activity” a concern and that is determined based on other parameters and not on the presence or changes in the size of the abscess.  A very large abscess is a cosmetic concern.  A visible abscess may also be an embarrassment because it invites the curiosity of neighbours as to its cause (with may be serious social consequences).

 

ii)            The size of the abscess does not indicate the extent of nerve damage caused by it and the resulting nerve function deficit (NFD).  Even a small intra neural abscess can be associated with significant NFD, as the abscess may press on the surrounding fascicles and strangulate them (especially when the epineurium is thickened and fibrosed and does not allow expansion) because of increased intra neural tension.  This causes conduction blockage (neurapraxia) in even undamaged nerve fascicles and NFD.  This danger does not exist when the abscess breaks through the epineurium (with relief of intraneural hypertension) and becomes para-neural. When the abscess is para-neural from the beginning, there is little danger of the abscess giving rise to NFD.

 

Management of the abscess depends primarily on the state of the nerve affected. The nerve may show, at the time the abscess is noticed or complained of, (a) significant functional deficit by way of anaesthesia in its area of supply and / or paralysis or weakness of the muscles supplied by that nerve, or, (b) no significant functional deficit.

When functional deficit is noticed, one should enquire whether is well established (“irrecoverable”) or “recoverable”.  If NFD is well established or long standing (like e.g., long ante dating the onset of the abscess, severe muscle atrophy, muscle paralysis of more than six months duration), it may be considered “irrecoverable”. It may also be considered “irrecoverable” if NFD is complete (i.e., complete sensory-motor paralysis with paralysis of all the muscles normally supplied by the nerve in the case of a mixed nerve).

When NFD is considered “irrecoverable”, we may ignore this aspect and consider the abscess per se.  We can wait and see if it will subside of its own accord in the course of some months.  If it does not, and if the patient desires it, it is dealt with surgically.  The exception to this advice is when the abscess involves the overlying skin and there is an imminent danger of the abscess bursting through the skin.  In that case, the abscess is surgically dealt with straight away. 

If the NFD is incomplete or recent (some muscles normally supplied by the nerve are not paralysed or acting weakly, muscle atrophy not severe, paralysis/NFD is not long standing – less than six months duration), it may be considered to be “recoverable NFD” and the abscess is surgically dealt  with without much delay.    

When there is no NFD, ascertain by clinical examination whether the abscess is purely intra neural or whether it is a collar stud or a para-neural abscess.

When the abscess is identified as an “intraneural abscess” (fusiform swelling of the nerve, abscess part of the nerve and separate from it) it is dealt with surgically without delay.

When the abscess is identified as a “collar stud” or a “para-neural abscess” (abscess forming a swelling by the side of and adherent to the nerve), we can wait and see if it will subside of its own accord in the course of some months.  If it does not, and if the patient desires it, it is dealt with surgically. The exception to this advice is when the abscess involves the overlying skin and there is an imminent danger of the abscess bursting through the skin. In that case, the abscess is surgically dealt with straight away.

The intraneural abscess is evacuated, its walls curetted thoroughly and the necrosed fascicles are excised.  The wound is closed without drain.  Firm bandaging is done.

Para-neural and collar-stud abscesses are excised, in toto if possible.  The abscess track into the nerve is traced into the interior of the nerve and the necrosed fascicles are identified to their full extent and excised.  The wound is closed without drain.  Firm bandaging is done.

I hope the above is of some use.” H. Srinivasan, Chennai, India 

 

Regards,

 

Dr. P. Narasimha Rao, MD, D.D, PhD

 

Prof of Dermatology,

Bhaskar Medical college, 

Hyderaba

 
Phone- 040-23514566
Mobile-09849044898

 

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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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(LML) News from INFOLEP

Leprosy Mailing List – January 7,  2015 

Ref.:    (LML) News from INFOLEP

From:  Jiske Erlings & Ilse Egers, NLR, Amsterdam, the Netherlands

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Dear friends,

Happy New Year to you and your families!

2014 has been a busy and productive year at Infolep!

-       We added over 740 items to the Infolep portal. The portal now offers easy access to more than 24.265 publications.

-       Leprosy is still the main topic but we have also included material on CBR, Disability, NTDs, Stigma and WASH.  

-       The portal was used by 22.535 unique visitors from all over the world.

-       We dealt with over 200 requests for full text publications and literature searches.

 

From a survey we have done this summer we have learned that there is a growing interest and need for a one-stop source of information on NTDs and cross cutting issues in MMDP, like the Infolep portal is for the leprosy world. The next step will be to discuss possibilities of expanding Infolep services and portal with relevant partners.

We assure you that we will continue to strive for the best possible leprosy information services. 

Meanwhile you are warmly invited to:

- Use the portal at www.leprosy-information.org  and give us your feedback;

- Promote the portal and the availability of additional Infolep services in your network;

- Send us your publications on leprosy or material on leprosy in your language to include in the portal.

- Follow us on Facebook or on Twitter

 

Finally we would like to thank American Leprosy Missions, DAHW, Damien Foundation, Fairmed, Fontilles, Fondation Raoul Follereau, Lepra and Leprosy Relief Canada for their continued support!

 

With kind regards,

Jiske Erlings & Ilse Egers

 
Jiske Erlings

Medewerker InfoLep / Information Officer

Infolep Leprosy Information Services

Postbus / P.O. Box 95005 1090 HA Amsterdam The Netherlands Tel: +31 20 5950530 Mob: - Email: J.Erlings@Leprastichting.NL Web: www.leprosy-information.org

 

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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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(LML) The Leprosy Research Initiative

Leprosy Mailing List – January 7,  2015

Ref.:    (LML) The Leprosy Research Initiative

From:  Nicole Dinnissen, NLR, Amsterdam, the Netherlands

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Dear all,

 

The Leprosy Research Initiative (LRI) is pleased to announce a call for proposals for funding commencing in 2016 (see also LML December 21, 2014; correction date of submission) The LRI exclusively funds research on leprosy or that is strongly related to leprosy and welcomes proposals for all five LRI research priorities. Among the priorities of the LRI, research to 'Promote inclusion of persons affected by leprosy in society' is currently underrepresented. Therefore, the LRI will reserve €100,000 of the 2016 budget for pilot projects with a maximum total budget of €50,000 per project specifically for applications addressing inclusion research.

 

Researchers interested to apply for funding by the LRI are invited to complete and submit a Letter of Intent (LoI), giving an outline of the intended research. The LoI should use the format provided on the LRI website ( www.leprosyresearch.org/how-we-work ). Applications that do not follow this format will not be considered. An LoI may be submitted at any time during the year. However, to be considered for the budget round 2016, LoIs should be submitted by February 28^th, 2015 at 24:00 (Amsterdam time and date) by email to the LRI Secretariat, c/o Ms. Nicole Dinnissen (info@leprosyresearch.org). This letter will be screened by the LRI Steering Committee (SC). If the feedback by the SC is positive, the applicants will be invited to submit a full proposal before the next deadline (June 1^st 2015). 

 

With kind regards,

 

Nicole Dinnissen

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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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(LML) Clinical leprosy - a basic course for doctors, Bangladesh, 26th to 30th April, 2015

Leprosy Mailing List – January 5,  2014 

Ref.:  (LML)  Clinical leprosy – a basic course for doctors, Bangladesh, 26^th to 30^th April, 2015

From:  Ruth Butlin, TLMI, Bangladesh

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Dear Sir,

A basic course for doctors on clinical leprosy will be conducted in Nilphamari leprosy training centre  , Bangladesh, from 26^th to 30^th April, 2015. See attached file. For more information you can contact  Dr C Ruth Butlin (drbutlin@btinternet.com) or the training officer (ntc@tlmbangladesh.org)

Thank you.

Yours sincerely,

C Ruth Butlin

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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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