Small-fibre neuropathy in leprosy the role of in vivo confocal microscopy: A cross-sectional study.

Background Leprosy (or Hansen's disease) continues to present considerable challenges regarding containment and early diagnosis. Leprosy is considered to be primarily a neural disease that first affects the sensory function of small fibres. Although the condition is well described in terms of clinical manifestations and histology, few studies have been undertaken to detect damage done to small-fibre sensory nerves. In vivo confocal microscopy is a useful tool for conducting a detailed evaluation of these structures, although its use in individuals affected by leprosy has still not been explored. Objective To evaluate in vivo confocal microscopy findings in Hansen's disease patients and their association with clinical variables relating to this disease. Method A cross-sectional case-series type study was carried out between October 2019 and May 2021, in Recife, Pernambuco, Brazil. Socio-demographic and clinical data were gathered from 21 patients with leprosy. The douleur neuropathique 4 neuropathic pain questionnaire was used to evaluate pain. In vivo confocal microscopy of the cornea was employed to evaluate the small-calibre fibres. Findings were compared with those for a control group of 23 healthy individuals. Results In relation to clinical parameters, 90.5% of the patients were classified as "multibacillary" according to the World Health Organization criteria, and 70% as dimorphic or borderline, in accordance with the Madrid classification. Around 52.4% had received a diagnosis after one year or less of living with the disease, while 95.2% presented alterations in small-fibre sensory function and 35% presented such alterations in the large fibre. Neuropathic pain was present in 81% of the patients. In vivo confocal microscopy found no statistically significant difference in mean age and distribution according to sex between the Hansen disease patients and the control group of healthy individuals. The median-of-means for dendritic cells and volume of sub-basal nerve fibres in the control group were used to test for normality. Both eyes of all leprosy patients examined contained higher number of dendritic cells than the median value and a volume of sub-basal nerve fibres lower than the mean. These differences were statistically significant (P < 0.001 and P < 0.001, respectively). Multibacillary individuals had a median number of dendritic cells two times that of paucibacillary individuals (P = 0.035). Limitations No association was found between the variables examined using in vivo confocal microscopy and clinical variables relating to small-fibre damage, the neuropathic pain questionnaire or alterations detected by the neurological examination. We believe, however, that Cochet-Bonnet esthesiometry of the cornea may have revealed such an association. Conclusion In vivo confocal microscopy is a useful diagnostic tool for detecting small fibre loss in individuals affected by leprosy and may constitute a useful addition to the range of tools available to help curb the effects of neuropathy in these patients.

A super-infection in the cornea caused by Stemphylium, Acremonium, and α-Streptococcus.

BACKGROUND: Polymicrobial keratitis with fungus and bacteria can lead to blindness and is challenging to treat. Here, we introduce a case of fungal keratitis caused by two different strains in addition to definite bacterial super-infection caused by an α-Streptococcus sp., and describe the importance of microscopic examination. CASE PRESENTATION: A 74-year-old woman, who had a past history of infection with leprosy, presented with conjunctival hyperaemia, pain, and corneal opacity in her right eye. Under the presumptive diagnosis of infectious keratitis, corneal scrapings were stained by various reagents and inoculated on several agar plates. Microscopic findings of the scrapings revealed fungi and a small number of Gram-positive cocci. Multiple anti-fungal therapies with levofloxacin ophthalmic solution were administered. Although empiric treatment was initially effective, keratitis recurred 10 days after its initiation. Repeated corneal scraping revealed an abundance of Gram-positive chain cocci and a small amount of fungi, resulting in the switching of an antibiotic medication from levofloxacin to moxifloxacin and cefmenoxime. Keratitis resolved gradually after the conversion. Stemphylium sp., Acremonium sp., and α-Streptococcus sp. were simultaneously isolated from the corneal scrapings. CONCLUSIONS: To the best of our knowledge, this is the first case of fungal keratitis caused by Stemphylium sp., and also the first case of super-infection in the cornea caused by two different fungi and one bacterium. Microscopic examination of the corneal scrapings was beneficial in rapid decision of changing to appropriate drug according to the dominancy of pathogenicity.

Lepra Ocular, conceptos actuales / An update in ocular Leproxy

Se cree que la lepra es la enfermedad sistemática con mayor incidencia de repercusión ocular, La afectación ocular se produce sobre todo en las formas lepromatosas. Las manifestaciones oculares son proteiformes y se relacionan con la invasión por el bacilo de las estructuras del segmento anterior y/o anejos, reacción inflamatoria y/o afectación neural de las estructuras oculares. La manifestación extraocular más frecuente es la madarosis de las cejas. La córnea es la parte más afectada del globo presentando una forma de queratitis patognomónica de localización temporal superior. En el iris aparecen también lesiones características como atrofia peripupilar aspecto atigrado y miosis insalvable por denervación. Es además característica la uveítis aguada y crónica. Las lesiones esclerales, son infrecuentes, aunque muy espectaculares. En el fondo de ojo solo se han descrito lesiones de forma esporádica

Leprosy the systemic disease with higher incidence of ocular findings. Eye disease is shown especially in lepromatous disease. Ocular complications are assorted and related to anterior segment and/or extraocular structures invasion by Mcobacterium leprae, inflammatory reaction, and nervous damage of the ocular structures. Superciliary madarosis is the most common extraocular finding. Cornea is the main affected structure of eye. There is a characteristic keratitis located in the superior temporal quadrant. The iris shows typical lesions like peripupilary atrophy, the pupil can be miotic and not responsive to mydriatics because of denervation. The scleral lesions are rare but amazing. Posterior segment lesions have been sporadically described

[Ocular impairment in leprosy].

Leprosy causes several ocular disorders, and it also causes aftereffect with high frequency in various ways. Primary impairment is the ocular disturbance caused with direct invasion of nerve and ocular tissue by Mycobacterium leprae. Secondary impairment is the complication of nerve paralysis and residual inflammation due to primary disorder. Main work at Japanese national leprosariums has been the control of primary and secondary impairment in recent years. Clinical ophthalmic study in the leprosarium revealed a increase of age-related ocular disease in addition to aftereffect of leprosy. Severe sequelae due to sensory and functional disturbance will require suitable applications of advanced clinical technologies.

Treatment outcome of Moraxella keratitis: our experience with 18 cases--a retrospective review.

PURPOSE: To analyze the clinical presentation, predisposing risk factors, in vitro antimicrobial susceptibility, and especially the outcome of therapy of Moraxella keratitis. METHODS: Retrospective review of 18 culture-proven cases of Morarella keratitis. RESULTS: Morarella keratitis was associated with Hansen's disease, uncontrolled diabetes mellitus, herpes zoster ophthalmicus, and chickenpox of the recent past and severe protein energy malnutrition. Other associated ocular conditions included lagophthalmos, blepharitis, steroid therapy, corneal degeneration, and scleritis. In four patients, no systemic or ocular predisposing factors could be identified. Three patients presented with an indolent peripheral, anterior stromal infiltrate while the remaining patients showed a central or paracentral ulceration with or without hypopyon. Moraxella species was the only pathogen isolated in 11 cases, whereas mixed infection was seen in seven cases. All isolates were sensitive to ciprofloxacin. Eight of 18 strains of Moraxella were resistant to cefazolin. All 14 eyes for which the follow-up data were available responded to medical treatment alone. CONCLUSIONS: Although considered to be associated with poor outcome, our experience suggests that a favorable outcome can be expected in Moraxella keratitis. Cefazolin resistance (as seen in our series) may pose a problem and, hence, monitoring of antimicrobial susceptibility would be beneficial. In view of cefazolin resistance, ciprofloxacin monotherapy appears to be an effective method in the medical management of these cases.

Enfermedad de Hansen Tuberculoide en región orbitaria / Hansen's disease tuberculoid in orbit region

La incidencia de complicaciones oculares en la Enfermedad de Hansen es mayor en la forma lepromatosa, dada por la mayor presencia del bacilo en las estructuras oculares y sus anexos, por los fenómenos reaccionales tipo 1 y 2, y por daño neurológico del V y VII par craneal. Se observan complicaciones en la córnea, conjuntiva, párpados, iris, pestañas, cejas, cuerpo ciliar, glandula lagrimal y conducto lacrimonasal, con deterioro progresivo hasta la ceguera. Se presenta más precozmente en pacientes con lepra tuberculoide y tardíamente en la forma lepromatosa. Presentamos el caso de una paciente femenina de 78 años de edad con manifestaciones clínicas única de Enfermedad de Hansen Tuberculoide en región periorbitaria izquierda, de un año de evolución

Envolvimento ocular na hanseníase: estudo em pacientes de ambulatório / Ocular invlvement in leprosy: study in patients of ambulatory

Foram estudados 67 pacientes (134 olhos), encaminhados aleatoriamente do ambulatório de hanseníase da Faculdade de Medicina de Jundiaí. Näo tínhamos conhecimento prévio da forma clínica, para näo interferir no exame ocular. Do total, 86 olhos (64,2 por cento) tinha envolvimento ocular, sendo a forma Virchoviana a mais frequente (69,2 por cento), seguida da Dimorfa (18,6 por cento), indeterminada (7 por cento) e tuberculóide (4,7 por cento). Dos anexos oculares, a madarose parcial de supercílios e cílios foi a mais frequente 45 por cento e 40 por cento respectivamente. no globo ocular, a sensibilidade corneana esteve diminuída em 15,1 por cento e atrofia estromal de íris, foi a alteraçäo iriana mais encontrada , 8,3 por cento. Sessenta e quatro porcento dos pacientes seguidos ambulatorialmente para controle da habnseníase tinham alteraçöes oculares. A forma Virchowiana foi a mais frequente com 69,7 por cento dos casos de envolvimento ocular. A madarose e clios e supercílios, assim como a alteraçäo de sensibilidade corneana säo achados importantes nos indivíduos com hanseníase.

Quantitative assessment of the visibility of unmyelinated corneal nerves in leprosy.

Unmyelinated corneal nerves were counted in 383 leprosy patients whose eyes looked normal on clinical examination and in an equal number of healthy controls. Visibility of these nerves was decreased significantly (p < 0.01) in the nasal half of the cornea in both patients and controls. There was a significant (p < 0.01) inverse correlation between age and the visibility of these nerves in patients and controls. There was a significant (p < 0.05) reduction in the visibility of these nerves as the spectrum of the disease moved from the tuberculoid to the lepromatous pole. There was no significant correlation between visibility of these nerves and the smear positivity of the patient. Neither did duration of the disease nor the duration of antileprosy treatment alter the visibility of these nerves significantly. Overall, there was a reduction in the visibility of these nerves in patients who had had leprosy reactions.

Pigmented corneal nerves in leprosy patients treated with clofazimine

Clofazimine (Lamprene) é uma droga utilizada no tratamento da infecçäo bacilar e nos estados reacionais da hanseníase. Seus efeitos colaterais incluem pigmentaçäo marrom-avermelhada da pele; escurecimento das lesöes cutâneas; coloraçäo vermelha da urina, fezes, escarro e suor; pele seca e sintomas gastro-intestinais. Pigmentaçäo da conjuntiva é o efeito colateral ocular mais comum. Alteraçöes da córnea e retina também já foram descritas. Relatamos, pela primeira vez, pigmentaçäo de nervos corneanos em 2 pacientes com o diagnóstico de lepra lepromatosa, que foram tratados com Clofazimine

Ocular manifestations of Hansen's disease.

A detailed ophthalmic evaluation including slitlamp biomicroscopy, measurement of corneal sensitivity using Cochet and Bonnet aesthesiometer, Schirmer's test and Goldmann applanation tonometry was carried out in 89 patients of Hansen's disease attending the leprosy clinic with or without ocular symptoms and willing to undergo eye evaluation. Thirty-one patients had lepromatous leprosy (8 with erythema nodosum leprosum), 56 patients had borderline disease (13 with reversal reactions) and 2 had tuberculoid disease. In addition to the well documented changes of lagophthalmos (6.7%), uveitis (7.3%) and cataracts (19%), we noted prominent corneal nerves in 133 eyes (74.7%), beaded corneal nerves in 19 eyes (10.7%), corneal scarring in 10 eyes (5.6%), corneal hypoaesthesia in 51 eyes (28%) and dry eye in 18 eyes (13%). Beaded corneal nerves and/or stomal infiltrates occurred mainly in the lepromatous group (75%). Ocular hypotony (IOP less than 12 mm Hg) was not seen more frequently in Hansen's as compared to age and sex matched controls with refractive errors or cataracts (33.7%, vs. 37.8%, p = 0.33). Our study highlights the primary corneal involvement with corneal neuropathy as the predominant feature of Hansen's disease.