Spectrum of purpura fulminans: report of three classical prototypes and review of management strategies.

Purpura fulminans is a rare syndrome of intravascular thrombosis and hemorrhagic infarction of the skin that is rapidly progressive and is accompanied by vascular collapse and disseminated intravascular coagulation. It usually occurs in children, but this syndrome has also been noted in adults. The three forms of this disease are classified by the triggering mechanisms. We describe three classical cases of purpura fulminans of the three classical prototypes treated at our center and their varied clinical outcomes. We also describe a case of acute infectious purpura fulminans secondary to systemic leptospirosis which to our best knowledge is the first reported case in world literature. The various treatment options for purpura fulminans have also been reviewed.

Marjolin ulcer: an overlooked entity.

Marjolin ulcer is a well-defined, but uncommon malignant ulcer that occurs in chronic wounds and cutaneous scars. Jean-Nicolas Marjolin was credited with describing this phenomenon in 1828. This entity is frequently overlooked and therefore inadequately treated leading to a poor prognosis. The malignant transformation of an ulcer is most commonly associated with burn scars, but has been reported in many other types of chronic, non healing wounds such as traumatic wounds, venous stasis and chronic pressure ulcers, fistulas, lacerations and leprosy ulcers. Development of malignancy tends to be slow with an average time of approximately 25 years. Various theories concerning pathogenesis of Marjolin ulcer have been proposed. Well-differentiated squamous cell carcinoma (SCC) is the most common histological type of Marjolin ulcer. Biopsy with histopathologic interpretation remains the gold standard for the diagnosis, with radical surgical excision being the treatment of choice. A high index of suspicion should be held by any health care provider when evaluating a chronic, non healing wound. This is a case report of a Marjolin ulcer arising on the left buttock of a patient with a long-standing history of a traumatic wound.

Mycobacterium ulcerans infection in North Queensland: the 'Daintree ulcer'.

BACKGROUND: As the third most common mycobacterial infection in the world after tuberculosis and leprosy, Mycobacterium ulcerans is a major health and development problem that has become the focus of a World Health Organisation (WHO) initiative seeking to reduce the burden of this disease. The Daintree River catchment in north Queensland is an endemic focus for Mycobacterium ulcerans infection, known locally as the 'Daintree Ulcer'. The aim of this study is to analyse the changing pattern of the disease over the last 44 years in the region. METHODS: The study is a descriptive review of all human cases where infection had been acquired in an endemic region of far north Queensland. Demographic information, lesion characteristics, management and outcomes were recorded in a database. RESULTS: Over the period there were 92 cases of M. ulcerans infection. The average age was 41.7 years and 56.7% were male. There was distinct clustering of cases in several defined locations in the area. Most cases (90%) presented with ulcers, and all but three patients were treated surgically. Excision and skin grafting was more commonly used in the period between 1964-1988. Excision alone was the most common treatment used thereafter. Earlier recognition and smaller lesion size is thought to have contributed to the change in surgical practice. CONCLUSIONS: Ulcers caused by M. ulcerans infection are a distinct clinical entity in tropical North Queensland. Early recognition, diagnosis and prompt surgical intervention has minimised morbidity associated with this disease.

Mycobacterium ulcerans ulcers: a proposed surgical management algorithm.

Mycobacterium ulcerans (MU) is the third common mycobacterial infection after tuberculosis and leprosy. In endemic areas, MU ulcers should be considered in the differential diagnosis of any unusual or nonhealing lesion or ulcer. Diagnosis and treatment should be instigated promptly. Delay may lead to disfiguring or disabling scars. Surgical management, therefore, should aim towards early excision, with clear margins of the ulcer. We present 4 consecutive patients treated by our department within a 6-month period for MU ulcers. The presentation, diagnosis and surgical management are described. Based on our experience and after reviewing the literature, we have developed a surgical algorithm for the management of MU ulcers.

Systemic suppression of interferon-gamma responses in Buruli ulcer patients resolves after surgical excision of the lesions caused by the extracellular pathogen Mycobacterium ulcerans.

Buruli ulcer (BU), caused by Mycobacterium ulcerans, is the third most common mycobacterial infection in immunocompetent humans besides tuberculosis and leprosy. We have compared by ex vivo enzyme-linked immunospot analysis interferon-gamma (IFN-gamma) responses in peripheral blood mononuclear cells (PBMC) from BU patients, household contacts, and individuals living in an adjacent M. ulcerans nonendemic region. PBMC were stimulated with purified protein derivative (PPD) and nonmycobacterial antigens such as reconstituted influenza virus particles and isopentenyl-pyrophosphate. With all three antigens, the number of IFN-gamma spot-forming units was reduced significantly in BU patients compared with the controls from a nonendemic area. This demonstrates for the first time that M. ulcerans infection-associated systemic reduction in IFN-gamma responses is not confined to stimulation with live or dead mycobacteria and their products but extends to other antigens. Interleukin (IL)-12 secretion by PPD-stimulated PBMC was not reduced in BU patients, indicating that reduction in IFN-gamma responses was not caused by diminished IL-12 production. Several months after surgical excision of BU lesions, IFN-gamma responses of BU patients against all antigens used for stimulation recovered significantly, indicating that the measured systemic immunosuppression was not the consequence of a genetic defect in T cell function predisposing for BU but is rather related to the presence of M. ulcerans bacteria.

Pinch skin grafting in non-healing leprous ulcers.

Treatment of leprous ulcers has remained inadequate, owing to the fact that most of these ulcers are still being managed conservatively especially in developing nations, probably due to financial constraints. Pinch skin grafting, though obsolete now (2), tries to bridge this gap between cost and effectiveness. It is a simple office-based technique, not requiring much expertise or investment, and can be done in a simple set-up such as a side room (3). Also, pinch skin grafting has an added advantage over single grafts, in that even if one graft is rejected, there are other grafts, which successfully heal, and epidermize to the surrounding. Moreover, if the ulcer is draining, the discharge flows out in between the grafts, thus preventing the whole graft from being rejected. The only disadvantage to pinch skin grafting is the final cosmetic appearance, which might not be most pleasing. We had very good results with all four patients who underwent this procedure in our institution. The procedure and the final result are described in detail in this report.

[How does one treat the osteitis and osteoarthritis of the extremities in older leprosy patients using granulated table sugar?]. / Comment guérir les ostéites et ostéo-arthrites des extrémités des anciens malades de la lèpre par le sucre cristallisé alimentaire?

A common problem of osteitis and septic arthritis is the recurrent bone infection after surgical debridement, a problem frequently encountered in patients with sequela leprosy. In these cases the authors propose the use of an ancient method of post surgical wound care based on the treatment with ordinary granulated sugar. The hyperosmolar climate created this way in the wounds inhibits the bacterial growth, enhances bacterial death and therefore permits the growth of granulation tissue in order to recover the debrided nude bones. At ILAD (Leprosy Institute of Dakar), 36 osteitis and septic arthritis were treated and healed during the last 2 years from March 1995 to March 1997 using this technic. All the wounds healed in the mean-time of 44 days. Only two of them needed a second debridement and healed afterwards. Up to now the method using ordinary sugar was applied in the treatment of infected wounds, eschars and postsurgical infections. Our experience shows that it also can be indicated to treat bone infections. This method is easy to apply also under often difficult field conditions and is very cheap.

Recent advances in restorative surgery of extremities in leprosy.

A better understanding of the pathology and mechanisms of nerve damage has changed the plan of treatment of neuritis. A concept of "Preventive Nerve Surgery" has come up during last few years. The genesis of plantar ulcers and its presentation is better understood now. The recent developments in the treatment of paralytic deformities of hand and foot have been outlined.

Sensory recovery in the plantar aspect of the foot after surgical decompression of posterior tibial nerve. Possible role of steroids along with decompression.

In leprosy, involvement of the posterior tibial nerve leads to sensory loss in the plantar aspect of the foot. As a result plantar ulcers are common and lead to deformity and disability. Restoration of plantar sensation can prevent ulcer formation. Posterior tibial decompression was done for the recovery of sensation in the plantar aspect of the foot. Seventy-two patients under went decompression on 84 feet, 25 received steroids pre- and post-operatively. The recovery of sensation was better if surgery was done before 6 months of onset of anaesthesia. Decompression along with steroids gave better results than decompression alone in patients with active neuritis especially in BT cases whereas in BB, BL and LL cases there was no significant improvement of sensation. The results are discussed.

Surgical treatment of plantar ulcers in leprosy.

Plantar ulcers present a serious problem in the management of leprosy. After studying the mechanism of ulceration and the causes of their indolence, it appears that the treatment of the disease by antileprotic drugs is not sufficient. The underlying causes, such as anaesthesia, bony deformities and paralysis, should usually be treated by surgical means. Anaesthesia can be reversed by decompression of the posterior tibial nerve if this is done early. Deformities should be corrected by procedures on the soft tissues or bones, and chronic infection eradicated to prevent recurrence of the ulceration. A combination of procedures may sometimes be needed.

Surgical treatment of plantar ulcers in leprosy

Plantar ulcers present a serious problem in the management of leprosy. After studying the mechanism of ulceration and the causes of their indolence, it appears that the treatment of the disease by antileprotic drugs is not sufficient. The underlying causes, such as anaesthesia, bony deformities and paralysis, should usually be treated by surgical means. Anaesthesia can be reversed by decompression of the posterior tibial nerve if this is done early. Deformities should be corrected by procedures on the soft tissues or bones, and chronic infection eradicated to prevent recurrence of the ulceration. A combination of procedures may sometimes be needed.

"Dorsal incision" the treatment of complicated forefoot plantar ulcers in the anaesthetic foot.

The in-patient treatment of 107 complicated forefoot plantar ulcers occurring in the anaesthetic foot by the operation of dorsal incision is presented. The operative technique of dorsal incision and subsequent wound dressing is described. 69 ulcers healed prior to discharge and all but 3 ulcers healed in an average of 27.2 days. In-patient stay averaged 31.4 days. The complications of the procedure are presented. Emphasis is placed on health education of the patient regarding care of the anaesthetic foot. Further follow up is suggested to see if dorsal incision reduces the recurrence of plantar ulceration.

Metatarsal head pressure (M. H. P.) sores in leprosy patients

Excision of head and neck of the corresponding metatarsal bone for M.H.P. sore cases was done in 43 patients both in dorsal and plantar approach and the effect of this operation has been evaluated after follow up for more than 1 year. The result of this operation was extremely satisfactory.