Case Report: Diagnostic Pitfalls in an Atypical Case of Primary Neuritic Leprosy.

Primary neuritic leprosy is a form of leprosy clinically limited to the peripheral nerves without obvious skin lesions. Diagnosing leprosy in the absence of typical dermatological features is challenging and often causes a delay in diagnosis. We describe a case of primary neuritic leprosy with atypical features and the roles that histological confirmation using nerve biopsy of an unenlarged nerve and newer techniques, such as polymerase chain reaction and high-resolution ultrasonography, play in improving the diagnosis.

Hepatitis B screening in US travelers seen at the Boston area travel medicine network.

BACKGROUND: Persons born in countries with hepatitis B surface antigen (HBsAg) prevalence ≥2% have increased risk for unrecognized hepatitis B virus (HBV) infection. Testing at pre-travel consultations is a strategy to identify previously undiagnosed HBV infections. Using records of travelers seen at the Boston Area Travel Medicine Network (BATMN) sites, we assessed how these travel clinics currently assess HBV status, describe test results, and describe characteristics of those tested and immunized for HBV. METHODS: Demographic data and trip information were collected for all travelers seen at the BATMN sites from June 2008 through July 2010. Proportions of those tested for HBV were determined, and differences between those tested and not tested were analyzed. RESULTS: Among 13,732 travelers enrolled during the study period, 2,134 (16%) were born in HBV-risk countries (HBsAg prevalence ≥2%); 532/2134 (25%) had previous HBV test results and 230 (11%) had tests performed at the travel clinic visit. Past results showed that 33/453 (7.3%) were HBV-infected (HBsAg+), 252/481 (52.4%) were immune (anti-HBs+, HBsAg-), 164/303 (54.1%) were susceptible (anti-HBs-, HBsAg-, anti-HBc-), and 38/314 (12.1%) had possible HBV exposure (anti-HBc+, HBsAg-, anti-HBs-). Among 230 travelers tested during the travel clinic visit, 7/213 (3.3%) were HBV-infected, 95/218 (43.6%) were immune, 106/179 (59.2%) were susceptible, and 10/182 (5.5%) had possible HBV exposure. CONCLUSION: The travel clinic offers an opportunity to capture, identify, and educate infected persons unaware of their infection, educate those with known results, and initiate preventive action (eg, vaccination) for those still susceptible.

Short report: A calcified Taenia solium granuloma associated with recurrent perilesional edema causing refractory seizures: histopathological features.

We describe the first detailed histological description of an excised calcified Taenia solium granuloma from a patient who developed recurrent seizures associated with perilesional edema surrounding a calcified cysticercus (PEC). The capsule, around a degenerated cysticercus, contained marked mononuclear infiltrates that extended to adjacent brain, which showed marked astrocytosis, microgliosis, and inflammatory perivascular infiltrates. The presence of large numbers of mononuclear cells supports an inflammatory cause of PEC. Immunosuppression or anti-inflammatory measures may be able to treat and prevent PEC and recurrent seizures.

Leprosy and the peripheral nervous system: basic and clinical aspects.

Leprosy is one of the most common causes of nontraumatic peripheral neuropathy in the developing world. The causative agent, Mycobacterium leprae, has a predilection for Schwann cells, where the organism multiplies unimpeded by organism-specific host immunity, resulting in destruction of myelin, secondary inflammatory changes, and destruction of the nerve architecture. The cardinal diagnostic features of leprosy are anesthetic skin lesions, neuropathy, and positive skin smears for the bacilli. However, patients may rarely present without skin lesions in pure neuritic leprosy. Electrodiagnostic findings early in the disease reveal demyelinating features, such as slowing of conduction velocity and prolongation of latencies, but as the disease progresses secondary axonal damage commonly ensues. Electrodiagnostic studies are also useful to monitor for toxicity secondary to therapy, particularly thalidomide-associated neuropathy. Nerve biopsy of a sensory cutaneous nerve is sometimes essential to confirm a diagnosis of leprosy. Significant advances in understanding of the pathogenesis, mapping of the genome, and other advances in molecular biology may result in better preventive and therapeutic modalities, and the goal of eradicating leprosy as a global problem may yet be realized.

Dengue fever mimicking plasma cell leukemia.

Extreme plasmacytosis in peripheral blood is a rare finding most often associated with plasma cell leukemia but rarely with other malignancies, infectious diseases, or drug reactions. We report the case of a 40-year-old man who was a US expatriate working and traveling in East Asia. He presented with complaints of fever, myalgia, headache, vomiting, and diarrhea of 3 days' duration. An initial evaluation revealed elevated liver function tests, thrombocytopenia (68 x 10(3)/microL), and a white blood cell count of 5.8 x 10(3)/microL with 19% plasma cells (1100/microL), 9% abnormal plasmacytoid lymphocytes (520/microL), 37% polymorphonuclear leukocytes, 3% band forms, 27% lymphocytes, 4% monocytes, and 1% eosinophils. An extensive evaluation was performed, including infectious disease serologies, a bone marrow biopsy, and flow cytometry. During the course of 3 days, his symptoms and hematologic findings improved dramatically. Serologic results were reactive for dengue (immunoglobulin M [IgM] positive, reciprocal IgG titer, 655 360), consistent with a secondary infection of unknown serotype. He remains well 4 years later. To our knowledge, plasmacytosis to this degree has not been described in dengue fever, but atypical lymphocytosis is common. In patients from dengue-endemic areas, even extreme plasmacytosis should be assessed to determine whether it is transient and related to an acute illness before proceeding to an extensive evaluation.