Microscopic leprosy skin lesions in primary neuritic leprosy

The histologic diagnosis of primary neuritic leprosy (PNL) remains a public health care concern, especially when nerve biopsies cannot be performed. As such, some authors emphasize the importance of performing a skin biopsy of a hypoesthetic area even without clinically visible lesions. In this study, an attempt was made to define the histologic changes in the sensory altered skin of 42 clinically diagnosed PNL patients. Histologic alterations caused by leprosy were seen in 31% of these patients: 6 were classified as borderline tuberculoid and 7 as indeterminate. In addition, 33% showed mild, non-specific, mononuclear cell infiltrates around the blood vessels within the papillary and reticular dermis that probably reflected an early inflammatory reaction to Mycobacterium leprae infection. Only 36% of those biopsied had no significant lesions. Our results suggested that, while not all PNL patients are similar, histologic skin examination can contribute to early leprosy detection and commencement of adequate treatment.     

Borderline lepromatous leprosy with neurofibromatosis

The coexistence of leprosy with neurofibromatosis is rare both the diseases present with nerve thickening and skin lesions (patches and nodules). The coexistence of neurofibroma with borderline tuberculoid, lepromatous, histoid, and neuritic leprosy has been reported in the past. We report here a case of borderline lepromatous leprosy coexisting with neurofibromatosis in a 60 year-old male, who presented with neurofibromata and nerve thickening. Histopathology of skin biopsy from the leprosy and neurofibroma nodules confirmed the diagnosis of leprosy and neurofibroma.     

Giant nerve abscesses in leprosy

Two leprosy patients with neuritis caused by giant abscesses involving almost the entire ulnar nerve are described. One patient, who also had skin lesions, was diagnosed histopathologically as having borderline tuberculoid leprosy both on skin and nerve biopsy, and the other, with only nerve involvement, belonged to the pure neuritic group. The lepromin test was strongly positive (with a vesicular reaction in one patient) and lymphocyte transformation to Mycobacterium leprae antigen was raised. These lesions can be easily mistaken for a peripheral nerve tumour in places where leprosy is uncommon. A brief account of the management of nerve abscess in leprosy is given.     

Primary neuritic leprosy: a reappraisal at a tertiary care hospital

AIM: To study the clinico-epidemiological profile of primary neuritic leprosy. METHODS: Retrospective analysis of the leprosy records of clinically diagnosed patients of PNL who attended the Leprosy Clinic from 2000 to 2004 was carried out for details of presenting complaints, age and sex distribution, duration, number of nerves involved and pattern of nerve enlargement, BI (skin), nerve abscess, and deformities. RESULTS: There were 32 (4.6%) patients of PNL out of a total of 686. Majority (56.2%) had complaints for less than a year. There were 29 (90.6%) males, and 3 (9.4%) females, with 15-30 years as the commonest age-group (65.6%) involved. Paraesthesia and numbness were the presenting complaints in 20 (62.5%), and motor deficit (paresis) in 11 (34.4%); deformities (claw hand, foot drop, trophic changes) were seen in 16 (50%) cases. Polyneuritic pattern was noted in 21 (63.56%) patients and mononeuritic in 11 (16.5%) with ulnar nerve as the most commonly enlarged nerve (63.6%). Nerve abscess was noted in 4 (12.5%) cases. Slit-skin smear was positive in 2 (6.2%) cases only. DISCUSSION: PNL continues to be common in India. Sensory complaints are early and more common. The disease is more common in males. Polyneuritic pattern was predominant, and the ulnar nerve was the most commonly involved nerve. Majority of the cases belong to the tuberculoid spectrum. Early diagnosis depends on complete neurological examination in order to reduce the sequelae of the disease.     

Role of PGL-I antibody detection in the diagnosis of pure neural leprosy

Pure neural leprosy (PNL) is difficult to diagnose because skin lesions and acid-fast bacilli (AFB) in slit smears are absent. At present, the gold standard for PNL diagnosis is the histopathological examination of a peripheral nerve biopsy. Even so, detection of bacteria is difficult and histological findings may be non-specific. Furthermore, nerve biopsy is an invasive procedure that is only possible in specialized centres. Therefore, there is a need for additional diagnostic methods that may help to confirm the clinical diagnosis of PNL. In the present study, an additional laboratory test, the ELISA for anti-phenolic glycolipid I (PGL-I) IgM antibodies, was performed on 103 individuals with clinical and neurophysiological signs of peripheral neuropathy, of which 67 were diagnosed as PNL patients and 36 remained as 'not diagnosed as PNL', as well as on a control group of 34 patients with other neurological diseases. An antibody response was present in 14/67 (21%) of the patients diagnosed as PNL as compared with 3/34 (9%) of controls. Anti-PGL-I positivity was observed in 5/8 (63%) of the AFB positive cases. Patients whose diagnosis was confirmed solely by Mycobacterium leprae PCR on the nerve sample had 4/25 (16%) seropositivity. In addition, anti-PGL-I antibodies were detected in 9/40 (23%) of the PNL patients who were PCR negative for M. leprae DNA. Moreover, two patients who showed clinical and eletrophysiological manifestations suggestive of PNL were diagnosed with the help of their positive test results in the anti-PGL-I ELISA. In conclusion, detection of antibodies against PGL-I in patients with peripheral neuropathy is useful as an additional laboratory test to help PNL diagnosis.     

Clinical and histopathological observations on pure neuritic leprosy

Pure neuritic leprosy is a well accepted clinical entity. In the absence of skin lesions there is a greater possibility of missing the diagnosis of leprosy due particularly to a wide variety of pure neural manifestations that may mimic other peripheral neuropathies. Histopathological studies of pure neuritic leprosy have received less attention for ethical reasons and limitations of surgery. Classification of pure neuritic leprosy poses problems since the histological spectrum (e.g. Ridley-Jopling scale) is based chiefly on the skin picture. Review of the past literature shows conflicting reports about comparability of the skin and nerve pictures. This paper presents clinical and histopathological observations on twelve patients of pure neuritic leprosy, the interesting observations being that all the patients showed lepromin positivity and a narrower histological spectrum, ranging from TT to BB only.     

麻风患者166例统一联合化疗后2年随访

目的 探讨6个月麻风统一联合化疗方案对各型麻风患者的疗效。方法 对166例各型麻风患者采取世界卫生组织多菌型方案治疗6个月,观察临床和细菌学方面的疗效。结果 在166例患者中因各种原因退出31例,完成治疗并随访2年的患者135例。135例疗前查菌阴性者为45例（33.3%）,其余90例患者细菌指数从0.1 ~ 6.0不等,细菌指数疗前平均为2.91 ± 1.45,在停止治疗第2年末,45例细菌阴性患者显示总的皮损消退和改善率达到93.3%。神经体征改善率达80.0%。在90例查菌阳性患者中,皮肤损害消退和改善率达95.6%,神经改善率达77.8%。疗前细菌阳性的90例患者中有49例患者细菌阴转,占54.4%,平均细菌指数降低为0.66 ± 0.99。从开始治疗后的2.5年中,平均每年下降 0.9。在完成治疗停药随访满2年的135例患者中有25例发生麻风反应。其中Ⅰ型和Ⅱ型反应分别为13例和12例。在166例患者中,有1例多菌型患者在停止治疗后13个月复发。结论 统一联合化疗的近期疗效与常规MDT方案治疗2年的结果相似,其反应发生率差异以及远期复发率尚待观察。     

111例I型麻风反应的临床分析

目的：探讨ＷＨＯ／ＭＤＴ方案治疗中Ｉ型麻风反应的发生率,临床特点及治疗。方法：对１１１例Ｉ型麻风反应的发生率,与型别关系,临床表现,反应出现时间及持续时间进行分析。     

Evaluation of leprosy patients with 1 to 5 skin lesions with relevance to their grouping into paucibacillary or multibacillary disease

BACKGROUND: Patients with 1 to 5 skin lesions are arbitrarily categorized as belonging to the paucibacillary (PB) group for treatment purposes. With the decreasing prevalence of leprosy in India and modifications in leprosy program, the relevance of this grouping needs further study. AIMS: To study a group of leprosy patients with 1 to 5 skin lesions and compare the clinical parameters with histopathological findings and bacteriological status of the skin and nerve to evaluate the relevance of this grouping. METHODS: Seventy seven patients of leprosy with 1 to 5 skin lesions were included in the study. The number of skin lesions was recorded. Slit skin smears (SSS) and skin biopsies were taken in all patients and nerve biopsy was performed in 19 of them. The biopsies were evaluated for the type of pathology and AFB status. RESULTS: In these 77 patients (single skin lesions, 42; two lesions, 18; three lesions, 10; four lesions, 5; and five lesions, 2 patients) the clinical classification was indeterminate leprosy (IL) in 4, tuberculoid leprosy (TT) in 4 patients and borderline tuberculoid leprosy (BT) in 69 patients. Skin smears were positive only in 1 patient. The histological diagnoses in the skin were IL in 13, TT in 3, BT in 48 and borderline lepromatous (BL) in 4 patients. Acid-fast bacilli (AFB) were found in 14 out of 77 skin biopsies. Of the 19 nerve biopsies, 17 showed histological features of BT leprosy; of these, 12 demonstrated AFB on Fite staining. The bacillary index of granuloma (BIG) ranged from 1+ to 2+. The clinico-histopathogical correlation was 63% in the BT group, with 4 patients of this group showing features of BL on histopathology. When the presence of AFB was assessed, the percentage of positivity was 1.3% in SSS, 18% in skin biopsies and 63% in nerve biopsies. CONCLUSION: Our results point to the non-homogeneous nature of this group of leprosy patients with 1 to 5 skin lesions, with varied bacteriological and histopathological features. The significance of MB type findings on histopathology in patients grouped as PB leprosy should be resolved so that these patients may be given the drug therapy and the duration of therapy they warrant.     

A comparative evaluation of skin and nerve histopathology in single skin lesion leprosy

BACKGROUND: In spite of leprosy being a disease of nerves, ROM therapy for single skin lesion leprosy was based on clinical trials without much evidence-based studies of nerve pathology. The present study was undertaken to compare the histology of skin and nerve in single skin lesion leprosy, and to assess the scientific rationale and justification of single dose ROM therapy. METHODS: Twenty-seven untreated patients with single skin lesion without significantly thickened peripheral nerves were selected. Skin and nearby pure cutaneous nerve biopsies were studied under both H&E and Fite's stain. RESULTS: All the skin biopsies were negative for AFB and clinico-pathological correlation was positive in 51.85% of skin biopsy specimens. Histopathological diagnosis of leprosy was evident in 55.5% of clinically normal looking nerves, with AFB positivity in 29.6% of nerve biopsy specimens. Correlation between clinical diagnosis and nerve histopathology was poor (26%). CONCLUSIONS: Single skin lesion without thickened peripheral nerves as criteria for single dose ROM therapy is not logical, since the histological diagnosis of leprosy in normal looking nerves with presence of AFB is revealed in this study. Pure cutaneous nerve biopsy is a simple outpatient procedure, without complications. This study emphasizes the need to consider nerve pathology as an important tool for further therapeutic recommendations, than just clinical trials and skin pathology alone. Though single dose ROM therapy has been withdrawn recently, the principle holds good for any future therapeutic recommendations.     

Childhood leprosy in an urban clinic,Hyderabad, India: clinical presentation and the role of household contacts

A retrospective case note study was done of children below the age of 14 years who attended Dhoolpet Leprosy Research Centre (DLRC) over the decade 1990-1999. The aim of the study was to describe the pattern of clinical presentation, the role of household or near neighbour contacts and the incidence of neuritis and reactions. In all, 3118 leprosy patients were registered during this period, of whom 306 were children [182 (60%) male]; 95 children had a single patch, 159 had five or fewer than five patches and 37 had multiple patches. The youngest case detected was 9 months old. The spectrum of leprosy in these children was: TT 62 (20.3%); BT 203 (66.3%); BB 3 (1%); BL 23 (7.5%); LL 5 (1.6%) and PNL 10 (3.3%). Twenty-nine cases (9.4%) were smear positive. Ninety-one children (29.7%) developed a reaction, 86 type I and five type II. A history of contact was present in 119 (38.8%) cases, family contact in 113 (95%) and other than family in six (5%). Classification of the contact was available in only 60 patients. Among the contacts of the index case, 21 (35%) suffered from PB leprosy and 39 (65%) from MB leprosy. All contacts were from the immediate family. This study shows that childhood leprosy cases continue to present in significant numbers to this outpatient clinic. There is a high level of family contact with leprosy in these cases, strengthening the strategy of screening children in leprosy-affected households. The high incidence of reactions and nerve damage in children emphasizes the importance of early detection and treatment.     

Fine needle aspiration cytology (FNAC) of nerves in leprosy

Leprosy is primarily a disease of the peripheral nerves and a technique that is simpler than nerve biopsy is required to evaluate nerve involvement, especially in pure neuritic (PN) leprosy. This study was designed to evaluate the role of FNAC of the nerve in the diagnosis and classification of leprosy. A prospective study was carried out on 25 patients with clinically active leprosy and at least one thickened peripheral sensory nerve. Nerve aspirates were evaluated by May-Grunwald-Giemsa and Fite's staining. Lepromin test, slit skin smears (SSS), skin biopsies (except PN cases) and nerve biopsies were performed and compared with FNAC. FNAC of nerve from 23 cases (92%) yielded diagnostic aspirates. Acid fast bacilli were observed in six cases by FNAC. FNAC and nerve pathology were equally comparable with the other parameters evaluated. Based on the results, cytological criteria were developed for interpreting nerve aspirates and the cases were classified as paucibacillary (18), BB (2), BL (2), LL (1) and non-diagnostic (2). All PN cases showed diagnostic paucibacillary type cytology. FNAC of the nerve yields diagnostic aspirates in leprosy comparable with nerve pathology and the proposed cytological criteria may be useful in classification of nerve aspirates.     

Neuritic leprosy: epidemiology and therapeutic responsiveness.

We studied epidemiology, progression and therapeutic responsiveness in 62 cases of neuritic leprosy. Numbness was the main presenting symptom. Mononeuritis involving the ulnar nerve, followed by the common peroneal nerve was the commonest presentation. The lepromin test was positive in 34 cases while a slit-skin smear was negative in all cases. We treated 20 of these cases with dapsone monotherapy and 5 cases (25%) developed a skin lesion after an average duration of 3 months' treatment. We treated 42 cases with a combination of dapsone and rifampicin, and 3 cases (7%) developed a skin lesion after an average duration of 2-6 months. The subsequent diagnosis in cases developing skin lesions was borderline--lepromatous in 1 case, borderline-tuberculoid in 4 cases, tuberculoid in 2 cases and indeterminate in 1 case.     

Leprosy type 1 reaction as the first manifestation of borderline lepromatous leprosy in a young native German

While leprosy is usually a chronic disease, leprosy reactions may lead to acute problems. These reactions most often occur after initiation of therapy, but can also develop before treatment. Leprosy rarely presents with a reaction. We describe a German patient who presented in this unusual way in order to demonstrate the various tools used to confirm the diagnosis. A young German woman suddenly developed progressive functional loss of the left hand and within a few weeks an increasing number of erythematous macules and nodules appeared. Histological examination of a skin biopsy revealed tuberculoid granulomas, some located around small nerves: acid-fast bacilli were detected microscopically and DNA from Mycobacterium leprae was identified by polymerase chain reaction in the biopsy and a nasal swab: serological tests were positive. The disease was classified as borderline lepromatous leprosy. The acute neuritis followed by skin lesions represented a leprosy type 1 reaction in which the immune system reacts to bacilli previously unrecognized in nerve tissue, both in nerve and skin.     

Vasculitis attributed to the nicotine patch (Nicotinell)

Summary Nicotine-containing patches are used to facilitate tobacco withdrawal by mitigating abstinence symptoms and diminishing craving. We describe two patients who developed vasculitis in association with the use of a nicotine patch. The first concerns a patient who developed fever, arthritis, a generalized erythema and purpuric lesions, after 3 days use of nicotine patches. Laboratory results and a skin biopsy confirmed the diagnosis of a leucocytoclastic vasculitis. After stopping use of the patch, the patient recovered. On challenge, the symptoms reappeared. The second patient developed purpuric lesions during the use of nicotine patches, and recovered fully after these were stopped. In these patients, nicotine patches seem to be causally related to the development of vasculitis.     

20例鱼刺伤肉芽肿临床、病理及分子生物学检测分析

目的:分析鱼刺伤肉芽肿患者的临床特点、病理及分子生物学检测情况。方法:对我院门诊确诊的20例鱼刺伤肉芽肿患者临床资料进行回顾性分析。结果:20例患者中16例(80%)患者发病前有外伤史且与水产品或水有接触,4例(20%)无明显诱因;所有患者皮损发生于上肢,17例患者单侧发病,3例双侧发病;临床表现以原发皮疹、浅表破溃或多发结节为主。20例患者病理组织检查者均提示感染性肉芽肿;TB-IGRA阳性率为70%。17例(85%)患者于治疗后6个月内痊愈,1例治疗10个月后痊愈,2例正在随访中。结论:本文中患者海分枝杆菌感染多与日常接触水产品有关;临床以单侧发病为主;TB-IGRA阳性检出率高。     

Clinico-histopathological correlation of skin and nerve in leprosy

The histopathological features of skin tissue sections in patients clinically diagnosed as leprosy were correlated with the histopathological features of nerve specimens obtained from the same patients. Fifty untreated leprosy patients attending the Outpatient Department of the Department of Dermatology and Sexually Transmitted Diseases of Smt. Sucheta Kriplani and Kalawati Saran Children's Hospitals, New Delhi, India were included in the study. On correlating the histological features of skin and nerve tissue sections, concordant findings were found in 24 out of the 50 patients (48%) but discordance between the histopathological features of skin and nerve tissue sections were found in 26 out of 50 cases (52%). Of these 26 cases, the nerve tissue histology when compared with the skin histology showed features lower down the disease spectrum in 17 (34%) cases. Seven of the 50 patients (14%) showed histological features of leprosy higher in the disease spectrum in the nerve tissue sections than in the skin biopsy sections. One patient clinically LL leprosy demonstrated histopathological features of Histoid leprosy in the skin sections and LL in the nerve sections. The remaining one patient had features of TT leprosy in the skin tissue sections while the nerve tissue histopathology showed non-specific changes. Histological features of the skin tissue sections were consistent with the clinical diagnosis in 33 out of 50 cases (66%). When the clinical groups were correlated with the histological features of the nerve tissue sections, concordance was found in 30 of the 50 cases (60%). On comparison of the histological features of skin and nerve tissue sections with the clinical diagnosis, concordance was still lower i.e., 19 out of 50 cases (38%). Thus the histological features of the skin tissue sections correlated more frequently with the clinical diagnosis than did those of the nerve sections. The importance of neural histology lies in the fact that it shows a higher BI and a lower histological grading in some cases and if not performed the lapse can result in inadequate treatment, drug resistance and even relapse.     

Diagnostic exploration of enlarged peripheral nerves in suspected cases of leprosy. An analysis of 55 cases.

In 55 cases presenting with enlarged peripheral nerves without any skin lesions, a rice grain-sized biopsy of the nerve lesion was taken for histopathological examination. As a result definitive diagnoses could be established: leprosy was diagnosed in 32 cases. In 23 cases the cause of nerve enlargement was not leprosy: post-traumatic neuritis 9, cysts 5, hypertrophic neuritis 3, nonspecific 4, neurofibroma 1, and amyloidosis 1. In all of these cases there was a deficit of the nerve function and postoperatively there were no complications. The authors, as a result of this experience, believe that surgical exploration and biopsy is a harmless diagnostic tool for establishing a definitive diagnosis of leprosy in cases presenting with enlarged peripheral nerves without any skin lesions. In 23 out of 55 such cases the nerve enlargement was proved to be other causes than leprosy.     

The role of nerve biopsies in the diagnosis and management of leprosy

Skin and nerve biopsies from 81 patients clinically suspected to have leprosy were studied. Histologically 54% of the patients showed leprosy. Both nerve and skin biopsies were histologically diagnostic of leprosy in 64% of these cases while 32% were diagnostic in the nerve but not skin biopsy. In the 11 patients with multibacillary leprosy (BI greater than or equal to 2) a multibacillary picture was seen in all nerve biopsies while 8 patients exhibited a paucibacillary leprosy of the skin and a multibacillary leprosy in the nerve. The present results emphasize that leprosy is a disease of peripheral nerves and that diagnostic criteria other than skin parameters is important to reach a proper diagnosis. The evident possibility of having patients with a multibacillary leprosy in peripheral nerves and paucibacillary in skin emphasize the need of clinical studies to clarify the criteria for the diagnosis of paucibacillary leprosy and the drug regimen for this group of patients.