Neurological Complications of Leprosy.

Leprosy is a challenging international health concern. Despite tremendous efforts in reducing worldwide disease prevalence in the past decades, some countries remain endemic and are plagued by high levels of disability. The neurological complications of leprosy are varied and complex, with current research focused on evaluating tools for earlier diagnosis of neuropathy, especially in resource-limited countries. While treatment with multidrug therapy is highly effective, active research aims to simplify regimens to improve adherence, minimize adverse effects, and prevent antimicrobial resistance. Although promising progress has been made in the past decades, further efforts are needed to push the international community toward achieving worldwide elimination.

Chronic aspects of leprosy-neglected but important.

The chronic aspects of leprosy are discussed here. They are a consequence of the peripheral nerve damage that affects many patients during their lifetime with leprosy. The peripheral nerve damage leaves people unable to feel and with weakness in their hands and feet. They are at risk of damaging their hands and feet, causing the disabilities and deformities that characterise late leprosy. More than 200 000 new leprosy patients are diagnosed globally each year. Better data are needed from cohort studies to estimate the number of patients developing nerve damage and modelling studies are needed to estimate the number of patients who develop disabilities. For some of them, this will be a lifelong disability. Nerve damage is caused by inflammation in leprosy-affected nerves. Patients with nerve damage of <6-mo duration need treatment with steroids. About 66% of multibacillary patients will develop nerve damage. Plastic graded monofilaments can be used to detect nerve damage in leprosy and diabetic clinics. Assessing nerve damage and treating patients with steroids in leprosy programmes needs to be strengthened. The World Health Organization has a successful programme for supplying antibiotics for treating leprosy infection to national leprosy programmes. They should take responsibility for providing steroids to national programmes since this is a core part of the treatment for >66% of multibacillary patients. Patients need to be asked about neuropathic pain symptoms and treated if necessary. Treated leprosy patients are at risk of developing ulcers in their feet. Treatment and prevention needs to be improved through health education, providing protective footwear and patient empowerment.

Lepra Lepromatosa con incio neural puro. A propósito de un caso / No disponible

En la lepra lepromatosa, cuando los troncos nerviosos periféricos son invadidos producen lesiones en la medida en que la enfermedad progresa de manera simétrica y dejan graves secuelas en etapas avanzadas de la enfermedad. Se trata de un paciente masculino, de 56 años de edad, con antecedentes de haber sido tratado por la especialidad de neurología por más de 20 años, debido a que tenía trastornos de la sensibilidad en miembros inferiores, en forma de calcetín que había sido diagnosticado como neuropatía sin causa aparente que acude a consulta de cuerpo de guardia del Hospital Manuel Ascunce de Camagüey, refiriendo que desde hacía unos años presentaba lesiones en forma de manchas por todo el cuerpo, que no le picaban. Al examen dermatológico se constata cuadro cutáneo diseminado constituido por placas infiltradas eritematosas, de bordes mal definidos, en número de más de una veintena, acompañadas de trastornos de la sensibilidad y disminución del vello a ese nivel. Además, con infiltraciones difusas de cara y pabellones auriculares, trastorno de la sensibilidad en miembros inferiores y troncos nerviosos engrosados. La variedad neurítica pura es muy discutida y se cree que los casos que fueron diagnosticados como tales presentaron lesiones cutáneas que pasaron inadvertidas y no dejaron secuelas

In lepromatous leprosy, when the peripheral nervous trunks are invaded they produce lesions to the extent that the disease progresses symmetrically and leave serious sequelae in advanced stages of the disease. This is a 56-year-old male patient with a history of having been treated by the specialty of neurology for more than 20 years, because he had sensory disorders in the lower limbs, in the form of a sock that had been diagnosed as a neuropathy without apparent cause, he went to the on call unit at the Manuel Ascunce Hospital in Camagüey, saying that for some years he had had lesions in the form of spots all over his body that did not itch. The dermatological examination revealed a disseminated cutaneous plaque composed of infiltrated erythematous plaques with poorly defined edges, in a number of more than twenty, accompanied by disorders of sensitivity and hair loss at that level. Also with diffuse infiltration of the face and ears, sensory disturbance in the lower limbs and thickened nerve trunks. The pure neuritic variety is very controversial and it is believed that the cases that were diagnosed as such presented cutaneous lesions that went unnoticed and did not leave sequels

Prevalence of neurological disorders in French bulldog: a retrospective study of 343 cases (2002-2016).

BACKGROUND: French Bulldog (FB) has significantly gained in popularity over the last few years, and seems to be frequently affected by various neurological conditions. The purpose of this retrospective study was to report the prevalences of neurological diseases in a large population of FB, presented with neurological signs between 2002 and 2016, and for which a definitive diagnosis was established. A secondary objective was to identify epidemiological characteristics regarding specific diseases in this singular breed. RESULTS: During the study period, 533 FBs were presented for neurological signs, representing 18.7% of all admitted FBs (N = 2846). In total, 343 FBs with definitive diagnosis were included in this descriptive epidemiological study. Hansen type I intervertebral disk herniation (IVDH) was by far the most common neurological disorder (45.5% of all cases). The IVDH location was cervical in 39.8%, and thoracolumbar in 60.2% of cases. The median ages for cervical and thoracolumbar IVDH were 4.2 and 4 years, respectively. C3-C4 was the most commonly affected disk (57.8% of cervical IDVH) all locations combined. Spinal arachnoid diverticulum (SAD) was detected in 25 FBs, representing the second most common myelopathy (11.3%). A concurrent spinal abnormality was identified in 64.0% of SAD cases. Brain tumours represented 36.8% of encephalopathies, with glioma (confirmed or suspected) being the most common. Meningoencephalitis of unknown origin (MUO) represented 25.0% of brain disorders, females less than 5.5 years being more likely to be affected. Aside from central nervous system conditions, otitis interna associated with peripheral vestibular signs and bilateral congenital deafness (associated with white coat) were also common. CONCLUSIONS: The findings of this study suggest that FB seems to be prone to several neurological diseases. IVDH is clearly predominant in FB and cervical location seems more represented than in other breeds. FBs affected by IVDH tend to be younger than previously described, either for both cervical and thoracolumbar locations. Thoracic SAD was the second most common myelopathy, with a concurrent spinal anomaly identified in two thirds of the cases. MUO was more likely to affect young to middle-aged females. These findings could be of interest for owners, breeders, practicing veterinarians and insurance companies.

Bullous pemphigoid and antecedent neurological diseases: An association with dementia.

BACKGROUND: Bullous pemphigoid is the most common subepidermal immunobullous disorder. Studies have reported the association between bullous pemphigoid and various neurological diseases. AIMS: The aim of this study was to evaluate whether bullous pemphigoid is associated with pre-existent neurological diseases and whether specific diseases exhibit this association. METHODS: All dermatology inpatients from January 2010 to May 2015 were analyzed. Bullous pemphigoid cases were identified based on clinical features and consistent histopathologic and direct immunofluorescence findings. Patients with other autoimmune bullous skin disorders were excluded. An equal number of inpatients with other skin conditions were selected randomly as age- and sex- matched controls. RESULTS: Out of 3015 inpatients, 103 cases of bullous pemphigoid and 103 age- and sex-matched controls were included. Seventy six patients with bullous pemphigoid had a history of at least one neurological disease. After adjusting for age, gender, race, functional status and neuro-psychiatric medications, patients with bullous pemphigoid were found to be approximately thrice as likely to have a history of at least one neurological disease than were controls (odds ratio: 2.88; 95% confidence interval: 1.32-6.26; P = 0.008). Amongst the pre-existing neurological diseases, only dementia was statistically more prevalent in bullous pemphigoid cases compared to controls (adjusted odds ratio: 2.61; 95% confidence interval: 1.19-5.75; P = 0.017). Parkinson disease and psychiatric disorders demonstrated a higher adjusted risk among bullous pemphigoid patients but the difference was not statistically significant. LIMITATIONS: The limitations were potential referral and selection bias, as the patients were inpatients. There is a possible misclassification as the diagnosis of neurological diseases was performed using medical records. The duration from the diagnosis of neurological diseases to bullous pemphigoid could not be accurately determined as it was a retrospective review of records and most neurological diseases have a prolonged course. CONCLUSIONS: Pre-existent neurological disease, specifically dementia, was found to be associated with bullous pemphigoid.

Neurological diseases and bullous pemphigoid: A case-control study in Iranian patients.

INTRODUCTION: Neurological diseases are important co-morbidities found in association with bullous pemphigoid. Various neurological conditions (stroke, Parkinson's disease, dementia, epilepsy and multiple sclerosis) have been reported as associations of this bullous disease; whether these are significant has not been definitely proved. However, the presence of neurological conditions is a predictor of poorer prognosis. OBJECTIVES: Our aim was to examine the association of bullous pemphigoid and neurological diseases in Iranian bullous pemphigoid patients. METHODS: The medical records of one hundred and sixty consecutive bullous pemphigoid patients who presented to the Autoimmune Bullous Diseases Research Center, Tehran, Iran, from 2006 to 2011 were examined for evidence of any neurological disease. The control group comprised of 317 age- and sex-matched subjects. RESULTS: Neurological diseases were seen in 42 (26.4%) patients with bullous pemphigoid and in 29 (9.1%) controls (odds ratio: 3.53 (2.1-5.9), P< 0.001). Comparing cases to controls, stroke was seen in 17.5% versus 4.1%, odds ratio 4.96 (2.49-9.88); dementia in 5.6% versus 1.9%, odds ratio 3.09 (1.08-8.84); Parkinson's disease in 2.5% versus 2.2%, odds ratio 1.14 (0.33-3.94); epilepsy in 2.5% versus 0.6%, odds ratio 4.04 (0.73-22.3); and multiple sclerosis in 0 versus 0.3% odds ratio 1.00 (0.98-1.01). LIMITATIONS: The main limitations of our study were referral bias, retrospective design and a rather low sample size. CONCLUSIONS: Neurological diseases in general, and stroke and dementia in particular, were significantly associated with bullous pemphigoid in our study.

The demographic and clinical characteristics of leprosy in Saudi Arabia.

Leprosy is a chronic disease caused by Mycobacterium leprae. Although the occurrence of leprosy has declined in Saudi Arabia, it has not yet been eradicated. To our knowledge, this descriptive retrospective study is the first to assess the clinical presentation of leprosy at the time of diagnosis in Saudi Arabia. All study subjects were leprosy patients admitted to Ibn Sina hospital, the only referral hospital for leprosy in Saudi Arabia, between January 2000 and May 2012. A total of 164 subjects, the majority of whom (65%) were between 21 and 50 years of age, were included, and the male-to-female ratio was 2.8:1. Of these 164 patients, 63% were Saudis, and 77% of all admitted patients were from the western region. Lepromatous leprosy was observed most frequently (33%), and 31% of cases had a positive history of close contact with leprosy. At the time of diagnosis, 84% of all subjects presented with skin manifestation. The prevalence of neurological deficit at the time of diagnosis was 87%. Erythema nodosum leprosum (E.N.L.) developed in only 10% of all subjects. Further studies are needed to determine the clinical characteristics pertaining to each type of leprosy in the region, and training courses in caring for and diagnosing patients with leprosy should be organized for health workers.

Factors associated with the worsening of the disability grade during leprosy treatment in Brazil.

OBJECTIVES: To analyse factors associated with the worsening of physical disabilities during the treatment of leprosy in Brazil in cases that were newly diagnosed in 2009. METHODS: This epidemiological study performed as a retrospective cohort investigated the factors associated with the worsening of the physical disability grade during the treatment of paucibacillary and multibacillary leprosy cases. Logistic regression with a confidence interval of 95% was used to analyse the variables associated with the worsening of disability grade. RESULTS: The cases with the greatest odds for worsening physical disability grade were patients from the south (odds ratio [OR] = 2.60) and southeast regions (OR = 1.74); with multibacillary disease (OR = 3.48); who were illiterate (OR = 2.26); and with reactive episodes (OR = 2.42). CONCLUSIONS: The factors associated with higher odds of worsening physical disability during treatment demonstrate failure to apply appropriate remedial measures to prevent disabilities, and greater attention should be given to patients with the most severe disease.

Prevalence of Disability and Associated Factors among Registered Leprosy Patients in All Africa Tb and Leprosy Rehabilitation and Training Centre (ALERT), Addis Ababa, Ethiopia.

BACKGROUND: Delay in leprosy diagnosis and treatment causes disabilities due to nerve damage, immunological reactions and bacillary infiltration. Leprosy disability leads not only to physical dysfunction and activity limitation but also disrupts social interaction of affected individuals by creating stigma and discrimination. This study was aimed at assessing leprosy disability status in patients registered at All African TB and Leprosy Rehabilitation and Training Centre. METHODS: Medical records of leprosy patients registered from September 11, 2010 to September 10, 2013 G.C were reviewed. Prevalence of disability calculated, bivariate and multiple logistic regressions were used to determine crude and adjusted odds ratios with 95% confidence interval. RESULTS: The overall prevalence of disability was found to be 65.9% from all categories of patients (40.2% Grade I and 25.7% Grade II). The Prevalence among the new category was 62.8% (39.1% Grade 1 and 23.7% Grade 2). Those ageed above 30 years, with duration of symptoms 6-12 months and above 24 months, with sensory loss, nerve damage and reversal reaction were more likely to develop disability. CONCLUSION: In this study the prevalence of disability, both Grade I and II, is very high. Disability was associated with age, duration of symptom, sensory loss, signs of nerve damage and reversal reaction. These risk factors indicate the existence of delay in diagnosis and treatment of leprosy cases. Therefore, the national leprosy control program should investigate leprosy case detection and diagnosis system in the country and work on improving early case detection and prevention of disability.

[Neurologic diseases in a rural tropical area: experience at a primary health care center in the Boeny region of Madagascar]. / Pathologies neurologiques en milieu tropical et rural : expérience malgache d'un centre de santé primaire de la région de Boeny.

There is, to our knowledge, no study reporting the demand for health care related to neurological diseases in rural tropical areas of developing countries. Neurology is nonetheless more or less closely related to the priority health issues in these countries. Over a 6-week period, 626 patients were seen at the primary health center in the town of Madirovalo, Madagascar. Neurological disorders accounted for 11.1% of the consultations. The neurological disorders most frequently leading to consultations were headaches (42.7%), with primary headaches accounting for 16%; next came leprosy neuropathy (14.7%), with a worrisome total of 8 new cases; other peripheral neuropathies (13.3%), and epilepsy (12%). The relatively low share of the latter seems likely related to families' frequent use of traditional healers rather than Western medicine. Neurological diseases appears to represent a significant part of the health-care demand of people living in rural tropical areas of developing countries, and specific support in this specialization is essential.

Rabies, tetanus, leprosy, and malaria.

The developing world is still endemic to rabies, tetanus, leprosy, and malaria. Globally more than 55000 people die of rabies each year, about 95% in Asia and Africa. Annually, more than 10 million people, mostly in Asia, receive postexposure vaccination against the disease. World Health Organization estimated tetanus-related deaths at 163000 in 2004 worldwide. Globally, the annual detection of new cases of leprosy continues to decline and the global case detection declined by 3.54% during 2008 compared to 2007. Malaria is endemic in most countries, except the US, Canada, Europe, and Russia. Malaria accounts for 1.5-2.7 million deaths annually. Much of the disease burden related to these four infections is preventable.

Progression of leprosy disability after discharge: is multidrug therapy enough?

OBJECTIVE: To evaluate the risk factors related to worsening of physical disabilities after treatment discharge among patients with leprosy administered 12 consecutive monthly doses of multidrug therapy (MDT/WHO). METHODS: Cohort study was carried out at the Leprosy Laboratory in Rio de Janeiro, Brazil. We evaluated patients with multibacillary leprosy treated (MDT/WHO) between 1997 and 2007. The Cox proportional hazards model was used to estimate the relationship between the onset of physical disabilities after release from treatment and epidemiological and clinical characteristics. RESULTS: The total observation time period for the 368 patients was 1 570 person-years (PY), averaging 4.3 years per patient. The overall incidence rate of worsening of disability was 6.5/100 PY. Among those who began treatment with no disability, the incidence rate of physical disability was 4.5/100 PY. Among those who started treatment with Grade 1 or 2 disabilities, the incidence rate of deterioration was 10.5/100 PY. The survival analysis evidenced that when disability grade was 1, the risk was 1.61 (95% CI: 1.02-2.56), when disability was 2, the risk was 2.37 (95% CI 1.35-4.16), and when the number of skin lesions was 15 or more, an HR = 1.97 (95% CI: 1.07-3.63). Patients with neuritis showed a 65% increased risk of worsening of disability (HR = 1.65 [95% CI: 1.08-2.52]). CONCLUSION: Impairment at diagnosis was the main risk factor for neurological worsening after treatment/MDT. Early diagnosis and prompt treatment of reactional episodes remain the main means of preventing physical disabilities.

Tumor necrosis factor-α antagonists: Side effects and their management.

As elevated levels of tumor necrosis factor-alpha (TNF-α) are associated with disease severity in psoriasis and psoriatic arthritis, TNF-α antagonists are being used to treat moderate to severe disease in patients who have contraindications, fail to respond or develop side effects to conventional systemic therapies. It is of utmost importance to be well versed with the possible adverse effects and contraindications of TNF-α antagonists so that they can be used effectively and safely. Many of their adverse effects have been well studied in patients of rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) and may not be completely applicable in psoriasis. This is because patients with RA and IBD are on multiple immunosuppressants while those with psoriasis are mostly receiving single systemic therapy and often have comorbidities that distinguish them from those with RA or IBD. Also, some of the side effects are still controversial and debated. Long-term prospective randomized controlled studies are needed to better understand the associated risk in patients of psoriasis. Baseline screening and periodic monitoring during treatment can reduce and help in early identification and appropriate management of the adverse outcomes. This article reviews the side effects known to be associated with TNF-α antagonists, their pathomechanisms and management guidelines. Some of the common side effects include infusion and injection site reactions, infections particularly reactivation of tuberculosis, autoantibody formation and drug induced lupus erythematosus, liver function abnormalities, hematological, and solid organ malignancies.

Neurological disability in leprosy: incidence and gender association in Sergipe, Brazil.

The environmental impact assessment process is over 40 years old and has dramatically expanded. Topics, such as social, health and human rights impact are now included. The main body of an impact analysis is generally hundreds of pages long and supported by countless technical appendices. For large, oil/gas, mining and water resources projects both the volume and technical sophistication of the reports has far exceeded the processing ability of host communities. Instead of informing and empowering, the reports are abstruse and overwhelming. Reinvention is required. The development of a visual integrated impact assessment strategy that utilizes remote sensing and spatial analyses is described.

Gaining a comprehensive understanding of pruritus.

Pruritus is a common symptom associated with many dermatoses, systemic abnormalities, and psychiatric / psychosomatic diseases. Additionally, pruritus is one of the most intractable symptoms due to its complex pathogenesis involving an increasing number of mediators and receptors, undefined neurophysiologic pathways, unclear cerebral processing, and psychophysiology interaction. Clinically, the first challenge of dermatologists is how to get general and interdisciplinary vision of pruritus and to preliminarily figure it out whether there might be underlying systemic or psychosocial disorders. The second challenge is to select efficient individual tailored anti-pruritic treatment, which includes targeted drugs and cognitive-behavioral therapy.