(LML) The Diagnosis of Leprosy

Leprosy Mailing List – April 12 ,  2016

Ref.:   (LML) The Diagnosis of Leprosy

From:  Grace Warren, Sidney, Australia

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Dear Pieter,

I have been interested following all the suggestions re  upcoming conference,  and the variations in statistics - partly  achieved by literally applying  the WHO definition as it appears many years ago.,  The Indian statistics of the numbers of children especially who have leprosy but it is not officially recognised so their official statistics look very good.

However, many times I have written about the numbers who never do have an anaesethetic patch as so many East Asian patients have infiltrated skin but no definite patch and no loss of pain sensation yet in the old days we could do slit skin smears that confirmed the diagnosis.   Now very few out clinics have the knowledge and ability to do the slit skin smears.

But I feel more and more that one very big problem that I am sure WHO could do something about is the teaching of leprosy in Medical Colleges.,

One year I lectured in all the medical colleges in one of the big countries accepted as being endemic. I was informed in most, that it was the first time that that college had had a lecture on leprosy!!!!!  What we do not know we never see and what we need is to ensure that the possibility of leprosy comes to the mind of doctors treating , especially children in endemic countries. Lepromatous leprosy is so easy hidden in the early days when it is easily passed on to the children.   After one lecture to the medical Practitioners the Chairman who happened to be the head of the local group said “Thank you for that. I hate to think how many I have missed over the years!” What a confession - but many doctors in these countries have no thought of leprosy as a diagnosis as they have not been taught to consider it !.

I do hope the teaching will become more widespread - and if  the definition could be varied, that could help. This letter  from Ben gives a few minor variations - but  we really need a few more possibilities to make people think  of Leprosy as a possible diagnosis.

 

Best regards,

 

Grace  Warren.  (Previously advisor for the leprosy Mission in Asia 1975-1995)

 

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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) Recent Articles on Leprous Neuropathy and Surgical Nerve Decompression

Leprosy Mailing List – April 12,  2016

Ref.: (LML) Recent Articles on Leprous Neuropathy and Surgical Nerve Decompression

From:  Eric Lee Wan, Baltimore, USA

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Dear Dr. Schreuder,

Thank you for managing the LML. I would like to take this opportunity to share with the community two recent publications from our group. They are attached and can be shared with LML readers.

They are cited as:

- Multiple Crush Concept Applied to Multiple Nerves in Leprous Neuropathy. Dellon AL. Clin Podiatr Med Surg. 2016 Apr;33(2):203-17.

- Treatment of Peripheral Neuropathy in Leprosy: The Case for Nerve Decompression Wan EL, Rivadeneira AF, Martinez Jouvin R, Dellon AL. Plast Reconstr Surg Glob Open. 2016 Mar;4:e637.

With warm regards,

Eric

--

Eric Lee Wan, BS

Research Fellow
Dellon Institutes for Peripheral Nerve Surgery &
Department of Plastic and Reconstructive Surgery,
Johns Hopkins University School of Medicine

USA Cell: +1 (240) 899 1181
Ecuador Cell: +593 098-877-5430
Colombia Cell: +57 (313) 780-6653
Skype: ericleewan

Patient information: ewan1@jhmi.edu
Personal and others: ewan1@jhu.edu or ericleewan@gmail.com

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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) Monthly overview of publications on leprosy and related issues - April 2016

Leprosy Mailing List �C April 5,  2016 Ref.:   (LML)  Monthly overview of publications on leprosy and related issues - April 2016 From:  Jiske Erlings, Amsterdam, the Netherlands   Dear Pieter,     Greetings from Infolep!   Below you will find a selection of recent publications on leprosy and related subjects. Feel free to contact me to receive the full text versions if a link to the full text is not included. Keep sending us your publications on leprosy or material on leprosy in your language to include in the portal. With kind regards,   Jiske Erlings INFOLEP Information specialist       New publications     Leprosy incidence, characterization of cases and correlation with household and cases variables of the Brazilian states in  2010. Castro SS, Santos JP, Abreu GB, Oliveira VR, Fernandes LF. in: An Bras Dermatol. 2016 Feb;91(1):28-33. Full text: http://www.leprosy-information.org/resource/leprosy-incidence-characterization-cases-and-correlation-household-and-cases-variables Evaluation of National Leprosy Eradication Program after Integration into General Health System in Rajkot District, Gujarat from 2003 to 2014. Chudasama RK, Lakkad SG, Patel UV, Sheth A, Thakkar D, Rangoonwala M. in: Indian J Dermatol. 2016 Jan-Feb;61(1):57-62. http://www.leprosy-information.org/resource/evaluation-national-leprosy-eradication-program-after-integration-general-health-system Field-friendly test for monitoring multiple immune response markers during onset and treatment of exacerbated immunity in leprosy. Corstjens PL, van Hooij A, Tjon Kon Fat EM, van den Eeden SJ, Wilson L, Geluk A. in: Clin Vaccine Immunol. 2016 Mar 30. Abstract: http://www.leprosy-information.org/resource/field-friendly-test-monitoring-multiple-immune-response-markers-during-onset-and-treatment Multiple Crush Concept Applied to Multiple Nerves in Leprous Neuropathy. Dellon AL. in: Clin Podiatr Med Surg. 2016 Apr;33(2):203-17. Abstract: http://www.leprosy-information.org/resource/multiple-crush-concept-applied-multiple-nerves-leprous-neuropathy Hansen's disease in association with immune reconstitution inflammatory syndrome. George A, Vidyadharan S. in: Indian Dermatol Online J. 2016 Jan-Feb;7(1):29-31. Full text: http://www.leprosy-information.org/resource/hansens-disease-association-immune-reconstitution-inflammatory-syndrome Childhood Leprosy in an Endemic Area of Central India.  Gitte SV, Sabat RN, Kamble KM. in: Indian Pediatr. 2016 Mar 8;53(3):221-4. Full text: http://www.leprosy-information.org/resource/childhood-leprosy-endemic-area-central-india Factors Contributing to the Delay in Diagnosis and Continued Transmission of Leprosy in Brazil - An Explorative, Quantitative, Questionnaire Based Study. Henry M, GalAn N, Teasdale K, Prado R, Amar H, Rays MS, Roberts L, Siqueira P, de Wildt G, Virmond M, Das PK. in: PLoS Negl Trop Dis. 2016 Mar 15;10(3):e0004542. Full text: http://www.leprosy-information.org/resource/factors-contributing-delay-diagnosis-and-continued-transmission-leprosy-brazil-explorative Some case reports which suggest correlation between biologics and leprosy, Mini-symposium on problems on leprosy. Ishida Y. in: Nihon Hansenbyo Gakkai Zasshi. 2016 Jan;84(3):133-7. Japanese Abstract: http://www.leprosy-information.org/resource/some-case-reports-which-suggest-correlation-between-biologics-and-leprosy-mini-symposium Hearing loss in leprosarium: Current status. Kosugiyama R, Kasai N, Etani T, Oshima A. in: Nihon Hansenbyo Gakkai Zasshi. 2016 Jan;84(3):125-31. Japanese. Abstract: http://www.leprosy-information.org/resource/hearing-loss-leprosarium-current-status Bayesian model, ecological factors & transmission of leprosy in an endemic area of South India. Joshua V, Mehendale S, Gupte MD. in:  Indian J Med Res. 2016 Jan;143(1):104-6. Full text: http://www.leprosy-information.org/resource/bayesian-model-ecological-factors-transmission-leprosy-endemic-area-south-india Serum uric acid levels during leprosy reaction episodes. Morato-Conceicao YT, Alves-Junior ER, Arruda TA, Lopes JC, Fontes CJ. in: PeerJ. 2016 Mar 14;4:e1799. Full text online: http://www.leprosy-information.org/resource/serum-uric-acid-levels-during-leprosy-reaction-episodes The originality and creativity of leprosy sequelae patients in regard to dental care. Nakagawa M, Shimizu A. in: Nihon Hansenbyo Gakkai Zasshi. 2016 Jan;84(3): 119-24. Japanese. PubMed PMID: 27008825. Abstract: http://www.leprosy-information.org/resource/originality-and-creativity-leprosy-sequelae-patients-regard-dental-care Hertoghe sign: an hallmark of lepromatous leprosy. Parrino D, Di Bella S. in: QJM. 2016 Mar 29. Full text: http://www.leprosy-information.org/resource/hertoghe-sign-hallmark-lepromatous-leprosy People like me don't make things like that?: Participatory video as a method for reducing leprosy-related stigma. Peters RMH, Zweekhorst MBM, van Brakel WH, Bunders JFG, Irwanto. in: Global Public Health. 2016. Abstract: http://www.leprosy-information.org/resource/people-me-dont-make-things-participatory-video-method-reducing-leprosy-related-stigma Peripheral hypertrophic neuropathy due to leprosy: Ultrasound and MR imaging findings. Pottecher P, Flageul B, Sibileau E, Laredo JD, Bousson V. in: Diagn Interv Imaging. 2016 Mar 2. Abstract: http://www.leprosy-information.org/resource/peripheral-hypertrophic-neuropathy-due-leprosy-ultrasound-and-mr-imaging-findings Pure neuritic leprosy: Current status and relevance. Rao PN, Suneetha S. in: Indian J Dermatol Venereol Leprol. 2016 Mar 30. Full text: http://www.leprosy-information.org/resource/pure-neuritic-leprosy-current-status-and-relevance Bosch and Bruegel. Disability in sixteenth-century art. Rutecki GW. in: Pharos Alpha Omega Alpha Honor Med Soc. 2016 Winter;79(1):44-54. PubMed PMID: 26930764. Abstract: http://www.leprosy-information.org/resource/bosch-and-bruegel-disability-sixteenth-century-art Leprosy Reactions Show Increased Th17 Cell Activity and Reduced FOXP3+ Tregs with Concomitant Decrease in TGF-β and Increase in IL-6. Saini C, Siddiqui A, Ramesh V, Nath I. in: PLoS Negl Trop Dis. 2016 Apr 1;10(4):e0004592. Full text: http://www.leprosy-information.org/resource/leprosy-reactions-show-increased-th17-cell-activity-and-reduced-foxp3-tregs-concomitant Pain and quality of life in leprosy patients in an endemic area of Northeast Brazil: a cross-sectional study. Santos VS, Santana JC, Castro FD, Oliveira LS, Santana JC, Feitosa VL, Gurgel RQ, Cuevas LE. in: Infect Dis Poverty. 2016 Mar 7;5(1):18. Full text: http://www.leprosy-information.org/resource/pain-and-quality-life-leprosy-patients-endemic-area-northeast-brazil-cross-sectional-study Prevalence of Disability and Associated Factors among Registered Leprosy Patients in All Africa Tb and Leprosy Rehabilitation and Training Centre (ALERT), Addis Ababa, Ethiopia. Shumet T, Demissie M, Bekele Y. in: Ethiop J Health Sci. 2015 Oct;25(4):313-20. Full text: http://www.leprosy-information.org/resource/prevalence-disability-and-associated-factors-among-registered-leprosy-patients-all-africa     Journals & Newsletters     Disability, CBR & Inclusive Development: http://dcidj.org/   Leprosy Review: http://www.lepra.org.uk/Pages/FAQs/Category/volume-85 Plos Neglegted Tropical Diseases: http://journals.plos.org/plosntds/   Revista de Leprología: http://www.leprosy-information.org/resource/revista-de-leprologia   WHO Goodwill Ambassador's Newsletter for the elimination of leprosy: http://www.leprosy-information.org/resource/who-goodwill-ambassador-s-newsletter-elimination-leprosy

Copyright © 2016 Netherlands Leprosy Relief, All rights reserved. You are receiving this mail because you opted in at our website. Our mailing address is: Netherlands Leprosy Relief Wibautstraat 137-k Amsterdam, 1097 HA Netherlands

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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 Diagnosis of Leprosy

Leprosy Mailing List – April 5,  2016

Ref.:   (LML) The Diagnosis of Leprosy

From:  Ben Naafs, Salvatore Noto, Pieter Schreuder

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Dear LML readers,

In response to the ongoing discussion about the diagnosis and classification of leprosy on LML we would like to emphasis that the 3 major criteria for the diagnosis of leprosy are already known for over 100 years. They are:

1) Loss of sensation to touch in a skin lesion.
This criterion can be replaced by loss of sensation for heat and cold, positive histamine test, absence of sweat after heat or running, or a difference with normal skin after injection of pilocarpine. This is all in the hypo-pigmented or erythematous skin patch.

2) Enlarged peripheral nerves on palpation
It can be replaced by ultrasound determination of the size of the nerves or by nerve function loss. Trauma and hereditary motor or sensory neuropathy have to be excluded.   Nerve conduction velocity studies may be of help.

3) Positive skin smear.
It can be replaced by skin or nerve biopsy with AFB's. Be sure that the destaining of the AFB's is for M.leprae and not for M.tuberculosis! This criterion can be also replaced by positive antiPGL1; and PCR or NASBA positive for M.leprae.

Two out of these three criteria confirm the diagnosis of leprosy. This does not mean that in the field an experienced health worker may not provisionally diagnose a patient on one criterion and start treatment. Because early treatment of leprosy prevents live long disability. It is a balance, this against the side effects of drugs and the stigma related to the diagnosis.

Early lepromatous, early borderline-lepromatous, early tuberculoid and indeterminate leprosy deserve special notes. Early lepromatous and early borderline-lepromatous often do not show loss of sensation in the skin lesion (or in the infiltrated skin) and may not have enlarged nerves or detectable nerve damage. Indeterminate leprosy does not show peripheral nerve involvement, and this can also be the case of early tuberculoid  leprosy.

Finally, in the field, in endemic areas with no available laboratory facilities, the experienced leprosy worker has to rely on clinical skills only.  That is: aspects of the lesions (borders, distribution, signs of inflammation; redness infiltration, etc.), detection of loss of sensation, neuritis, sequelae of nerve function loss and palpation of peripheral nerve trunks.

In cases of doubt, it is wise to re-examine the patient after 3 months; in general leprosy develops slowly.

Always consider the balance; side effects of treatment and stigma against damage to the patient by not treating.

With regards,

Ben Naafs, Salvatore Noto and Pieter Schreuder

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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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Re: (LML) Over-optimism and the antidote

That is true. The cost ebenfit ratio of this idea needs to be seriously looked at.

Tahir

On Sun, Mar 27, 2016 at 12:26 PM, Pieter Schreuder <editorlml@gmail.com> wrote:

Leprosy Mailing List – March 27,  2016

Ref.:   (LML)  Over-optimism and the antidote

From:  Joel Almeida, Mumbai and London

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Dear Pieter,

 

 

Every new prediction in leprosy can make us over-optimistic.

 

In 1991 we predicted the elimination of leprosy by MDT.  Instead, we merely eliminated leprosy services. Meanwhile, the incidence rate of new cases with visible deformity increased by 40% in India, between 2008/9 and 2014/15. The price is being paid by Indians who still needlessly suffer devastating permanent damage to their nerves, limbs and eyes.

 

What is the antidote to over-optimistic predictions?  A healthy "what if" analysis.  

 

What if our predictions and hopes are mistaken?  That approach can help us establish a safety net to protect trusting people from visible deformity. We can do this by appointing the skilled, mobile leprosy workers who can monitor nerve function regularly.  Then we can ensure anti-inflammatory treatment in time to prevent visible deformity.

 

Cuba has tried chemoprophylaxis of contacts and BCG, without denting the incidence rate of leprosy.  Micronesia has tried repeated mass chemoprophylaxis, but merely delayed the occurrence of new cases. The incidence rate returned to its former level. A randomised controlled trial of chemoprophylaxis among contacts showed a higher incidence rate of leprosy in the treated group 2 to 4 years later, although the numbers were too small for this difference to attain statistical significance.  

 

What if our hopes and predictions about chemoprophylaxis are over-optimistic?  What if chemoprophylaxis merely postpones the signs of leprosy?  What if the main sources of leprosy infection are, in fact, re-infected polar lepromatous patients after release from MDT?  Of course we hope for the best. However, we need to be prepared for the worst: a mere postponement of new cases instead of a dramatic reduction in the incidence rate.

 

If the worst happens, then the skilled, mobile leprosy workers will be a safety net that protects people from visible deformity. When it comes to the limbs and eyes of ordinary people, we need "safety first."  Then we can try whatever we want. 

 

It would seem ethically sound to include post-chemoprophylaxis surveillance, prompt MDT, nerve monitoring and prompt anti-inflammatory treatment in projects of chemoprophylaxis. Otherwise chemoprophylaxis might lead to the same kind of over-optimism, complacency and avoidable visible deformity as we have seen in the past.

 

Given our history of relying on over-optimistic predictions, we would do well to appoint skilled, mobile leprosy workers for nerve function monitoring. We would also do well to identify polar lepromatous patients at diagnosis, and to protect them from re-infection.

 

Regards,

 

Joel Almeida

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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) Over-optimism and the antidote

Leprosy Mailing List – March 27,  2016

Ref.:   (LML)  Over-optimism and the antidote

From:  Joel Almeida, Mumbai and London

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Dear Pieter,

 

 

Every new prediction in leprosy can make us over-optimistic.

 

In 1991 we predicted the elimination of leprosy by MDT.  Instead, we merely eliminated leprosy services. Meanwhile, the incidence rate of new cases with visible deformity increased by 40% in India, between 2008/9 and 2014/15. The price is being paid by Indians who still needlessly suffer devastating permanent damage to their nerves, limbs and eyes.

 

What is the antidote to over-optimistic predictions?  A healthy "what if" analysis.  

 

What if our predictions and hopes are mistaken?  That approach can help us establish a safety net to protect trusting people from visible deformity. We can do this by appointing the skilled, mobile leprosy workers who can monitor nerve function regularly.  Then we can ensure anti-inflammatory treatment in time to prevent visible deformity.

 

Cuba has tried chemoprophylaxis of contacts and BCG, without denting the incidence rate of leprosy.  Micronesia has tried repeated mass chemoprophylaxis, but merely delayed the occurrence of new cases. The incidence rate returned to its former level. A randomised controlled trial of chemoprophylaxis among contacts showed a higher incidence rate of leprosy in the treated group 2 to 4 years later, although the numbers were too small for this difference to attain statistical significance.  

 

What if our hopes and predictions about chemoprophylaxis are over-optimistic?  What if chemoprophylaxis merely postpones the signs of leprosy?  What if the main sources of leprosy infection are, in fact, re-infected polar lepromatous patients after release from MDT?  Of course we hope for the best. However, we need to be prepared for the worst: a mere postponement of new cases instead of a dramatic reduction in the incidence rate.

 

If the worst happens, then the skilled, mobile leprosy workers will be a safety net that protects people from visible deformity. When it comes to the limbs and eyes of ordinary people, we need "safety first."  Then we can try whatever we want. 

 

It would seem ethically sound to include post-chemoprophylaxis surveillance, prompt MDT, nerve monitoring and prompt anti-inflammatory treatment in projects of chemoprophylaxis. Otherwise chemoprophylaxis might lead to the same kind of over-optimism, complacency and avoidable visible deformity as we have seen in the past.

 

Given our history of relying on over-optimistic predictions, we would do well to appoint skilled, mobile leprosy workers for nerve function monitoring. We would also do well to identify polar lepromatous patients at diagnosis, and to protect them from re-infection.

 

Regards,

 

Joel Almeida

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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) Basic Dermatology Course for Medical Doctors

Leprosy Mailing List – March 13,  2016

Ref.: (LML)  Basic Dermatology Course for Medical Doctors

From:  Gopal Gurung, Pokhara, Nepal

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Dear Dr. Pieter,

Please circulate the attached BIKASH Nepal training announcement to all readers of LML.

Basic Dermatology Course for Medical Doctors

Course prerequisite: Medical background with competence in written and spoken English

Dates: 3rd to 8th April 2016

Venues: BIKASH Nepal Training Centre, Pokhara, Nepal

Thank you!

Gopal

====

Gopal Gurung

Program Manager

BIKASH Nepal

Green Pastures Complex

Pokhara, Kaski, Nepal

Ph: 00977 61 430562

Fax: 00977 61 430940

Web: www.bikashnepal.org.np

E-mail: ggurung@bikashnepal.org.np

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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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