Tuberculoid leprosy: An in vivo microvascular evaluation of cutaneous lesions.

Tuberculoid leprosy (TT) is characterized by cutaneous lesions called plaques. Although microvascular ultrastructure of TT patients' skin is well-documented, little is known about functional aspects of their microcirculation. We aimed, for the first time, to evaluate, in vivo, the microcirculation of TT cutaneous lesions. Seven TT patients, males, under treatment were included in the study. The spectral analysis of frequency components of flowmotion (endothelial, sympathetic, myogenic, cardiac and respiratory) was performed using laser Doppler flowmetry (LDF). Endothelial dependent and independent vasodilatations were assessed by LDF associated to acetylcholine (ACh) and sodium nitroprusside (SNP) iontophoresis, respectively. Vessel density (VD), perfused vessel density (PVD), proportion of perfused vessels (PPV%), microvascular flow index (MFI) and flow heterogeneity index (FHI), reflecting tissue perfusion and oxygenation, were evaluated through sidestream dark field (SDF) imaging. All microvascular analysis were performed in TT lesions and in healthy skin in the contralateral limb of the same patient, used as control skin. VD, PVD and PPV% and MFI were significantly lower in the cutaneous lesion compared to contralateral healthy skin. The contribution of different frequency components of flowmotion, endothelial dependent and independent vasodilatations and FHI were not statistically different between control skin and cutaneous lesion. Our results suggest that TT cutaneous lesions have a significant impairment of tissue perfusion, which may aggravate peripheral nerve degeneration caused by Mycobacterium leprae infection.

Primary Neural Leprosy mimicking rheumatological disorders.

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, which affects mainly the skin and peripherical nerves. Brasil has not yet achieved its goal of elimination of the number of cases of this disease, ranking second in terms of absolute numbers worldwide, with India occupying the first position. Primary Neural Leprosy is considered to be a challenge in diagnosis, since it affects the peripherical nerve system with the absence of skin lesions, thus mimicking rheumatological disorders, like in the case presented. A male, 31, with no previous comorbidities, five years ago, started feeling severe pain in the left ankle as well as morning hand pain and stiffness. After many years of being submitted to intense rheumatological disease investigation, they all proved to be negative. Upon physical examination, the patient presented no skin lesions, symmetric polyarthritis in metacarpophalangeal joints and thickness of the left sural nerve. Lab exams showed no alterations and bacilloscopy was negative. Ultrasonography was used to investigate the thickness of the left sural nerve. Biopsy showed a minimal amount of perineural lymphocytes and positive AFB testing. Based on the electroneuromyography, the conclusion was multiple mononeuropathy, and multibacillary polychemotherapy was started. Leprosy remains a public health problem in Brasil. Due to the high prevalence of the disease, our medical colleagues must be alert and trained to recognize this clinical presentation of leprosy. Correct referral to Reference Centers accelerates research, contributing to an accurate diagnosis, classification, and treatment, thus preventing irreversible sequelae with severe functional disability.

Dermatoscopy in leprosy and its correlation with clinical spectrum and histopathology: a prospective observational study.

BACKGROUND: Leprosy, a chronic granulomatous infection has varied clinical presentations spanning across different spectrums. The scope of dermatoscopy is vast and has been studied for other granulomatous disorders like sarcoidosis. OBJECTIVES: The objective of this study was to describe the dermatoscopic features of the entire spectrum of leprosy and to correlate with clinical and histopathological findings. METHODS: This was a prospective observational study of treatment naïve leprosy patients over a period of 1 year. The study patients were categorized as per Ridley-Jopling classification based on clinical, slit skin smear and histopathological findings. Most representative lesions were photographed, evaluated by dermatoscopy and were biopsied. RESULTS: A total of 30 patients (21 males and 9 females) were recruited; 2 cases of tuberculoid leprosy, 12 cases of borderline tuberculoid (3 with type 1 reaction), 8 cases of borderline lepromatous, 6 cases of lepromatous leprosy (3 with type 2 reaction) and 2 cases of Histoid leprosy. The dermatoscopic featues consistently seen were yellowish orange areas and vascular structures like linear branching vessels and crown vessels correlating with the presence of dermal granulomas and dilated vessels. Broken pigment network, white chrysalis like areas were seen in addition. Tuberculoid spectrum also had absence of or diminished hair follicles and eccrine duct openings correlating with presence of peri-appendageal granuloma and appendageal destruction. Scaling and follicular plugs were other features in lesions of type 1 reaction. CONCLUSION: Yellowish-orange areas and vascular structures are the common dermatoscopic features of leprosy. Broken pigment network and paucity of appendageal structures are additional specific features.

Second-harmonic generation imaging analysis can help distinguish sarcoidosis from tuberculoid leprosy.

Sarcoidosis and tuberculoid leprosy (TL) are prototypes of granulomatous inflammation in dermatology, which embody one of the histopathology limitations in distinguishing some diseases. Recent advances in the use of nonlinear optical microscopy in skin have enabled techniques, such as second-harmonic generation (SHG), to become powerful tools to study the physical and biochemical properties of skin. We use SHG images to analyze the collagen network, to distinguish differences between sarcoidosis and TL granulomas. SHG images obtained from skin biopsies of 33 patients with TL and 24 with sarcoidosis retrospectively were analyzed using first-order statistics (FOS) and second-order statistics, such as gray-level co-occurrence matrix (GLCM). Among the four parameters evaluated (optical density, entropy, contrast, and second angular moment), only contrast demonstrated statistical significance, being higher in sarcoidosis (p = 0.02; 4908.31 versus 2822.17). The results may indicate insufficient differentiating power for most tested FOS and GLCM parameters in classifying sarcoidosis and TL granulomas, when used individually. But in combination with histopathology (H&E and complementary stains, such as silver and fast acid stains), SHG analysis, like contrast, can contribute to distinguishing between these diseases. This study can provide a way to evaluate collagen distribution in granulomatous diseases.

Dermoscopy of borderline tuberculoid leprosy.

INTRODUCTION: Leprosy is a chronic granulomatous condition caused by Mycobacterium leprae, and borderline tuberculoid (BT) leprosy is the most common type of leprosy and presents with large, well- to ill-defined hypopigmented patches. It is known for atypical presentations. Dermoscopy of granulomatous conditions is well documented. However, there is no description of dermoscopy of BT leprosy in the literature. Authors evaluated the dermoscopic patterns of BT leprosy. CASE REPORT: Patients with BT leprosy were studied for dermoscopic patterns. A total of 12 patients (8 male, 4 female) with a median age of 25 years were present. Mean duration of disease was 6 months. The most frequent pattern was white areas (100%) followed by decreased density of hairs. Yellow globules were observed in 8 (66.66%) patients. Decreased white dots (represent sweat duct openings) and branching vessels were noted in 6 (50%) and 4 (33.33%) patients, respectively. CONCLUSION: This is the first report of dermoscopy of BT leprosy in the literature, and new dermoscopic observations were made by the authors. Dermoscopy of BT leprosy shows characteristic patterns, thus it adds valuable information for the diagnosis of BT leprosy.

Nerve abscess in pure neural leprosy mistaken for peripheral nerve sheath tumour with disastrous consequence: what can we learn?

A 34-year-old Indian man presented to an orthopaedician with gradually progressive hypoesthesia affecting his right lower limb and an ipsilateral common peroneal nerve swelling around the knee. The nerve swelling was diagnosed as a peripheral nerve sheath tumour based on MRI findings and was excised, only to be revealed as leprous nerve abscess on histopathology later. The patient developed right foot drop as a result of common peroneal nerve biopsy. This case presents several learning points in the diagnosis of pure neural leprosy.

Leprosy with ulnar nerve abscess: ultrasound findings in a child.

We report the ultrasound findings of a typical case of nerve abscess due to leprosy in an 11-year-old boy. The patient had previously undergone pediatric multibacillary leprosy multidrug therapy (MDT) in accordance with World Health Organization guidelines. He presented to our service with bilateral ulnar neuritis with no response to prednisone (1 mg/kg). Right ulnar nerve ultrasound revealed nerve hypoechogenicity, fascicular pattern disorganization, marked fusiform thickening, and a round anechoic area suggestive of intraneural abscess. Intense intraneural power Doppler signal was detected, indicating active neuritis. Intravenous methylprednisolone had a poor response and the patient was submitted to ulnar nerve decompression, which confirmed nerve abscess with purulent discharge during surgery. As the patient weighed more than 40 kg, treatment with a pediatric dose was considered insufficient and adult-dose MDT was prescribed, with improvement of nerve pain and function. Although leprosy is rare in developed countries, it still exists in the USA and it is endemic in many developing countries. Leprosy neuropathy is responsible for the most serious complications of the disease, which can lead to irreversible impairments and deformities. Nerve abscess is an uncommon complication of leprosy and ultrasound can efficiently demonstrate this condition, allowing for prompt treatment. There is scant literature about the imaging findings of nerve abscess in leprosy patients. Radiologists should suspect leprosy in patients with no other known causes of neuropathy when detecting asymmetric nerve enlargement and nerve abscess on ultrasound.

Nailfold capillaroscopy in leprosy.

Due to mounting evidences of interaction between Hansen's bacilli with endothelial cells and the paucity of studies addressing the presence of nailfold capillaroscopic alterations in patients with Hansen's disease, a study was carried out in order to verify the presence of capillaroscopic alterations in patients with leprosy in its various forms and its correlation with clinical parameters. Ten patients were evaluated at a specialized university service. Sixty percent of those had some capillaroscopic change, such as micro-hemorrhages, ectatic, bushy and corkscrew capillaries. Such changes were unspecific, which suggests there is not a specific pattern for this disease.

Pure neuritic leprosy presenting as ulnar nerve neuropathy: a case report of electrodiagnostic, radiographic, and histopathological findings.

Hansen's disease, or leprosy, is a chronic infectious disease with many manifestations. Though still a major health concern and leading cause of peripheral neuropathy in the developing world, it is rare in the United States, with only about 150 cases reported each year. Nevertheless, it is imperative that neurosurgeons consider it in the differential diagnosis of neuropathy. The causative organism is Mycobacterium leprae, which infects and damages Schwann cells in the peripheral nervous system, leading first to sensory and then to motor deficits. A rare presentation of Hansen's disease is pure neuritic leprosy. It is characterized by nerve involvement without the characteristic cutaneous stigmata. The authors of this report describe a case of pure neuritic leprosy presenting as ulnar nerve neuropathy with corresponding radiographic, electrodiagnostic, and histopathological data. This 11-year-old, otherwise healthy male presented with progressive right-hand weakness and numbness with no cutaneous abnormalities. Physical examination and electrodiagnostic testing revealed findings consistent with a severe ulnar neuropathy at the elbow. Magnetic resonance imaging revealed diffuse thickening and enhancement of the ulnar nerve and narrowing at the cubital tunnel. The patient underwent ulnar nerve decompression with biopsy. Pathology revealed acid-fast organisms within the nerve, which was pathognomonic for Hansen's disease. He was started on antibiotic therapy, and on follow-up he had improved strength and sensation in the ulnar nerve distribution. Pure neuritic leprosy, though rare in the United States, should be considered in the differential diagnosis of those presenting with peripheral neuropathy and a history of travel to leprosy-endemic areas. The long incubation period of M. leprae, the ability of leprosy to mimic other conditions, and the low sensitivity of serological tests make clinical, electrodiagnostic, and radiographic evaluation necessary for diagnosis. Prompt diagnosis and treatment is imperative to prevent permanent neurological injury.

Radiological study of the paranasal sinuses in lepromatous leprosy.

Thirty patients of lepromatous leprosy have been studied by radiological investigation for affection of paranasal sinuses. It has been found that leprosy involves all groups of sinuses and maxillary antrum is found to be more commonly affected. Diffuse hypertrophy type of lesion is more commonly recorded in maxillary antrum, in x-ray of paranasal sinuses. The clinical significance and importance of extension of disease in the sinuses is discussed in the light of available literature.