Nitric oxide metabolites in sera of patients across the spectrum of leprosy.

Leprosy, a chronic infectious disease, caused by Mycobacterium leprae infection, manifests itself as a clinical spectrum depending on the patients' immunological response, finally leading to peripheral nerve damage and deformities in the patients. Nitric oxide (NO) which is known to contribute to pathogenesis of several neurological diseases has been detected in tissues and urine of leprosy patients. This is the first study assessing NO as its stable end products, nitrites and nitrates, in sera of patients across the spectrum of the disease as a possible parameter of prognostic value. Comparison of NO metabolites showed a significant increase in multibacillary patients and patients with type I reactions as compared to healthy control individuals. These levels reduced significantly after treatment. This study has further borne out the utility and reliability of the cadmium-reduction method of estimation of NO metabolites--a relatively inexpensive procedure that lends itself to large-scale screening and follow-up of patients.

Adenomatoid odontogenic tumor - hamartoma or true neoplasm: a case report.

Adenomatoid odontogenic tumor (AOT) is an uncommon tumor of odontogenic origin with a relative frequency of 2.2 - 7.1%. As the histogenesis of AOT is still uncertain, it is sometimes categorized as a hamartomatous lesion rather than a true neoplasm. We report a case of AOT in the right maxillary anterior region in a 20-year-old woman. The tumor showed some unusual and aggressive features that suggested it was a true neoplasm.

Observations from a 'special selective drive' conducted under National Leprosy Elimination Programme in Karjat taluka and Gadchiroli district of Maharashtra.

The special selective drive (SSD) was conducted on a request from the Joint Director of Health Services (Leprosy and TB) Government of Maharashtra. The study team comprised the Foundation for Medical Research (FMR), assisted by a member of the Acworth Leprosy Hospital Society for Research, Rehabilitation and Education in Leprosy and two from Kushtrog Nivaran Samiti (KNS). The drive was conducted in select villages covered by 6 primary health centers (PHCs) in Karjat taluka of Raigad district and 45 PHCs in Gadchiroli district from March to May 2009 and had the cooperation of the district and PHC level staff. The aim was to train and deploy community level workers (CWs) for early leprosy case detection and through them, to create leprosy awareness in the community. A total of 1053 CWs (126 in Karjat taluka, 927 in Gadchiroli district) were given intensive training by the team. The CWs then carried out a one-day house-to-house leprosy awareness drive in their areas and listed persons such 'suspects' in both Karjat taluka (no. = 514) and Gadchiroli district (no. = 1325). Around 40% of 'suspects' presented themselves at the PHCs for examination by the medical team; of these 38 (29%) and 281 (45%) respectively turned out to be previously undetected definite cases of leprosy. The PHC-wise NCDR ranged from 5 - 27/10,000 in Karjat (14/10,000) and 2 - 35/10,000 in Gadchiroli (average 13/10,000), both rates being much higher than the reported State average of 1.1/10,000. There was a high proportion of child cases (14 and 24% respectively) and grade 2 disability (18% and 12% respectively) which indicate continued transmission of leprosy and delayed diagnosis of cases. The study also notes poor diagnostic skills among the PHC staff. Significant shortage and irregular disbursement of MDT from district store PHCs, combined with transport problem which probably contributed to delay in treatment in over 50% of the cases confirmed by the team.

Detection and classification of leprosy: future needs and strategies.

This paper focuses on the obstacles and dilemmas in detection and classification of leprosy cases and suggested strategies for the same. This review attempts to raise some cardinal issues within leprosy diagnosis and the need for capacity building at clinical and field level in light of research conducted. It also recommends strategies to overcome these obstacles.

Isolation of mycobacterium leprae from untreated borderline tuberculoid, mid-borderline and indeterminate cases using the mouse foot pad technique--a study of 209 cases.

Using the mouse foot pad (MFP) system, isolation of Mycobacterium leprae was attempted in 209 skin biopsies obtained from 114 borderline tuberculoid (BT), 62 mid borderline (BB) and 33 indeterminate (1) untreated cases. Unequivocal growth in the foot pads of mice was seen in 100 (47.8%) cases. Of these 100 cases that showed growth in the mouse foot pad system, in 20 cases acid fast bacilli (AFB) were detected in small numbers (1 + ) in either smear or homogenate. The remaining 80 (42%) cases were negative for AFB in both smear and homogenate. The occurrence of viable bacilli and percentage take at 12 months was highest in BB (76 and 86%) followed by BT (38 and 75%) and I (30% and 52%) cases. In most of the BT (65%) and I (60%) cases, the first peak was seen only at 12 months. These results confirm that viable bacilli can be isolated and expanded from a good proportion of negative BT-BB cases using immunocompetent Swiss White mice.

Clinical, histopathological and bacteriological study of 52 referral MB cases relapsing after MDT.

Fifty-two BB-LL relapse cases referred to our centre during 1997-2003 were investigated in detail. Twenty-four cases had been treated with extended MB-MDT [until smear negativity (NON-FDT)]. The remaining 28 cases (54%) had received one of the fixed duration regimens (FDT), of whom 11 had 24 months and 6 had 12 months of WHO MB-MDT. Eleven cases had received rifampicin/ofloxacin (RO) treatment. Follow-up slit skin smear reports were available for 41 cases, all but three cases had been smear negative at some point after release from treatment. None of the cases showed any clinical or bacteriological evidence of upgrading, i.e. LL to BT where as downgrading BB to BL occurred in five cases. The duration between cessation of treatment and reappearance of lesions (DCTR) varied from 2 to 15 years. The mean DCTR was longest (9.4 years) for the NON-FDT and 24 months MB-MDT cases. The mean DCTR was significantly lower in the 12 months MB-MDT and RO treated cases (6.8 and 6.2 years, respectively). Four of RO treated cases and four cases with multiple episodes of reaction had DCTR less than 5 years. Inadequate treatment/poor killing of Mycobacterium leprae results in early onset relapse, whereas 'persisting' or 'drug resistant mutants' contribute to late onset relapse.

Granular cells in ameloblastoma: An enigma in diagnosis.

Ameloblastoma is an epithelial odontogenic tumor exhibiting diverse microscopic pattern that occurs singly or in combination with other patterns. This article describes a case of granular cell ameloblastoma (GCA) involving mandible in a 55-year-old male. The possibility of granular component is there in other odontogenic and nonodontogenic lesions. Sometimes dilemma exists in the diagnosis of such lesions. The purpose of this article is to unveil the hidden characteristics in GCA, which might help in differential diagnosis of GCA.

The pathology of early leprous neuropathy.

A qualitative and quantitative study was made of early changes in nerves from 10 patients with tuberculoid or lepromatous type of leprosy. Five nerve biopsies, taken from sites remote from skin lesions, were considered to be unaffected when examined by paraffin histology but showed abnormalities in semi-thin resin sections and by electron microscopy; 5 showed mild to moderate involvement by paraffin histology. Changes in 'unaffected' nerves in both types of leprosy included the presence of subperineurial oedema; occasional evidence of fibre regeneration, sometimes with atypical features; increased numbers of small myelinated fibres, possibly a consequence of axonal atrophy; a few thinly remyelinated fibres, probably due to secondary demyelination, and some loss of unmyelinated axons. In more affected nerves there was variable loss of axons, both myelinated and unmyelinated. Demyelination was not a conspicuous feature; there was evidence of axonal atrophy in some fibres. Similarities in some of the changes observed in tuberculoid and lepromatous types of leprosy suggest a common mechanism of nerve damage, at least in the early stages. The presence of abnormalities in nerves at a distance from skin lesions implies a more diffuse nerve involvement than might have been expected in both types of leprosy.

Teased fibre studies in leprous neuropathy.

Nerve biopsies were taken from four cases of leprosy, which included borderline tuberculoid, borderline and lepromatous types. They were examined in 1-micron resin sections and in teased preparations. The most common finding in teased fibres from each leprosy type was paranodal demyelination affecting successive internodes. In transverse sections some fibres showed changes associated with axonal atrophy. Together, these findings suggest that demyelination in some cases may be secondary to axonal changes. In addition, there was evidence of focal areas of demyelination affecting whole internodes of many fibres at the same level across the nerve and which was possibly caused by local factors.

Persistence of Mycobacterium leprae in the peripheral nerve as compared to the skin of multidrug-treated leprosy patients.

Skin and nerve biopsies obtained from 18 multibacillary (MB) and 16 paucibacillary (PB) cases of leprosy who had been fully treated by the WHO regimen were assessed for bacterial load using different staining techniques. In addition skin and nerve homogenates of 10 MB cases were tested for 'persistor' Mycobacterium leprae using immunosuppressed mice. While significant amounts of integral bacilli and BCG cross-reactive antigen of M. leprae were detected both in skin and nerve tissues of all the MB cases (100%), 56% of skin and 62% of nerve biopsies of PB cases also showed the presence of BCG cross-reactive antigen. Detection of 'persistor' M. leprae in 2/10 skin biopsies (20%) and 3/10 nerve biopsies (30%) of MB cases was thought to be unexpectedly high after 2 years of MDT.

Higher incidence of viable Mycobacterium leprae within the nerve as compared to skin among multibacillary leprosy patients released from multidrug therapy.

As identified by a significant growth in the footpads of immunosuppressed mice, the incidence of viable bacteria in a group of 26 multibacillary (BL-LL) patients released from multidrug (MDT) treatment was found to be two times more in the nerves (46%) as compared to skin (23%). Evidently there was a positive correlation between the overall bacterial load and the incidence of viable organisms. Bacterial growth was also observed in two out of five cases where neither the skin nor the nerve homogenate had shown any presence of acid-fast bacilli. Histopathology of biopsies, skin as well as nerve, including those having viable bacteria did not show any features of active disease.

Clinical and electrophysiological evaluation of nerve function impairment following cessation of multidrug therapy in leprosy.

Seventeen multibacillary (MB) and 15 paucibacillary (PB) cases of leprosy who had had regular and adequate multidrug therapy (MDT) were examined clinically and electrophysiologically at periodic intervals for 1 year following cessation of MDT. All the major nerves were assessed for nerve function impairment (NFI). Overall, two MB (13.3%) and three PB (20%) cases showed signs of deterioration clinically and/or electrophysiologically. The nerve conduction (NC) follow-up studies revealed no significant improvement in the sensory conduction in both the MB and PB groups of nerves, whilst motor conduction showed a significant improvement at the first 6-monthly follow-up among the MB group of nerves. At the study onset, sensory impairment (MB = 62%, PB = 25%) predominated over motor in terms of both severity and frequency. The lower extremity was more frequently and severely affected than the upper in both groups of patients. As an individual test, NC measurement proved to be more sensitive in detecting NFI, but the combination of physical palpatation for nerve thickening and graded nylon test (GNT) was closely comparable to measurement of nerve conduction.

Primary resistance to single and multiple drugs in leprosy--a mouse footpad study.

Skin biopsy homogenates obtained from three cases of lepromatous leprosy with no prior history of antileprosy treatment were tested in the mouse footpad for the sensitivity of Mycobacterium leprae to multiple drugs. One of the inocula was sensitive to all the three drugs tested using the highest concentration each of DDS 0.01 g%, RFP 0.03 g% and CLF 0.01 g%. The 2nd inocula showed growth in the presence of 0.01 g% DDS only. While the 3rd inocula (Pt. KU) tested resistant to all the three drugs in the first, i.e. man to mouse, as well as in the second passage, i.e. mouse to mouse.

A semi quantitative analysis of bacterial load in different cell types in leprous nerves using transmission electron microscope.

Thirty lepromatous (BL-LL) and 25 tuberculoid (TT-BT) nerve lesions obtained from untreated cases of leprosy were scanned using transmission electron microscope for assessing the bacterial load in different cell types. Major bulk of infection was seen in the Schwann cells of nonmyelinated fibres, in both early lepromatous and tuberculoid nerve lesions, suggesting that M. leprae spread mainly via the Schwann cells within the nerve.

Ultrastructural study of mouse dorsal root ganglion cultures infected long term with M. leprae.

Ultrastructural changes in the mouse dorsal root ganglion cultures infected long-term with viable M.leprae were studied. Subtle cytomorphological changes and loss of neurites noted in the long-term infected cultures were correlated to early events in the nerve damage.

Intracellular localization of dapsone and rifampicin in skin and nerve of multidrug treated leprosy patients.

Intracellular localization of antileprosy drugs dapsone (DDS) and rifampicin (RFP) was carried out on skin and nerve lesions obtained from multidrug treated, multi (BL-LL)- and pauci (BT-TT) bacillary cases of leprosy using immunocytochemical techniques. Intracellular localization of the above drugs especially in macrophages and Schwann cells was aimed by using rabbit raised anti DDS and RFP polyclonal antibody in an indirect peroxidase assay. Our study records both intra and extracellular staining with anti DDS and RFP antibodies in the skin as well as nerve lesions of MB and PB cases treated with MDT. All the nerves under investigation had moderate to severe pathology and hence free diffusion of the drug could be attributed to the broken barrier. Basal lamina around the Schwann cell did not seem to form a barrier. It was also noted that the drug (metabolite) persisted over a long period of time).

Evaluation of the neurotoxicity of dapsone in the mouse model.

Effect of DDS was studied using the mouse model. It was observed that DDS did not have any neurotoxic effect. On the contrary it showed a protective action towards the nerve, when administered in the early stages following definite establishment of nerve lesions.

Effect of T-cell depletion on bacterial multiplication and pattern of nerve damage in M. leprae-infected mice.

Various mechanisms for nerve damage in tuberculoid leprosy have been proposed. A common feature amongst them is the crucial role played by T-cells. Therefore, the present study was designed to determine the role of T-cells in the induction of nerve damage in leprosy using two different protocols for obtaining graded levels of T-cell depletion: (i) Cyclosporine A, for depletion of T-helper cells and (ii) Anti Thy 1.2, for total depletion of T-cells. The findings indicate that the early changes seen in the unmyelinated fibres may not involve T-cells. However, the later stages of nerve damage associated with demyelination are dependent on T-cell responses.