Histoid leprosy: a retrospective study of 40 cases from India.

BACKGROUND: Rare variants of leprosy pose a diagnostic challenge even to astute clinicians and histoid leprosy is one such form of disease with unique clinical and histopathological features. There are very few large series on this entity, mainly reported from India. OBJECTIVES: To study the epidemiological and clinical characteristics of patients with histoid leprosy. METHODS: We undertook this retrospective study including patients registered with the leprosy clinic of our tertiary care referral centre from January 1991 to December 2006. Data regarding demographic details, clinical features, treatment, complications and course following treatment were extracted from the records of the leprosy clinic. RESULTS: The incidence of histoid leprosy among the registered patients of our clinic was 1.8% (40 of 2150). There was a significant male preponderance with a male/female ratio of 5.7 : 1. The anatomical areas of involvement were thighs/buttocks (67.5%), arms (62.5%), back (52.5%), face (47.5%), forearms (47.5%) and legs (35%) in descending order of frequency. This variety of leprosy was found most commonly in patients with a primary diagnosis of lepromatous leprosy (40%). De novo histoid lesions, i.e. lesions of histoid leprosy developing without evidence of lesions of other types of leprosy in the Ridley-Jopling classification, appeared in 12.5% of patients only. Only three patients had received antileprosy treatment before presentation. Episodes of erythema nodosum leprosum (ENL) had occurred in 40% of patients, although only one patient manifested ENL after the diagnosis of histoid leprosy. The disease responded satisfactorily to the respective World Health Organization multidrug therapy regimens in all except in one patient who relapsed with borderline lepromatous leprosy. CONCLUSIONS: As the bacillary load is very high in these patients, they can form a potential reservoir of the infection in the community especially in the postleprosy elimination era. Contrary to the earlier belief in the dapsone era, most of our patients manifested disease without any history of inadequate or incomplete antileprosy therapy.

Leprosy and herpes zoster; an association or dissociation?

Nerve involvement is common to the pathogenesis of both leprosy and herpes zoster. We report two cases of borderline leprosy in which the skin lesions characteristically spared the healed zoster scar. Possible mechanisms and relationship are discussed.

Psychiatric morbidity in vitiligo: prevalence and correlates in India.

BACKGROUND: Vitiligo, a common pigmentary disorder, is recognized to be associated with a high psychiatric morbidity, yet compared to other dermatological disorders like leprosy, psoriasis, etc., it has not been subjected to detailed evaluation of its psychological consequences. The data from the developing countries on this aspect in particular is meager. METHODS: One hundred and thirteen cases with vitiligo were evaluated along with 55 healthy controls comparable for sociodemographic profile and matched on attitude to appearance scale. Clinical details, impact of illness, associated dysfunction and psychological morbidity were additionally assessed. RESULTS: Twenty-eight patients with vitiligo were found to have psychiatric morbidity, a clinic prevalence rate of 25% (95% confidence interval 20.3-29.3%). The majority of the cases had a diagnosis of adjustment disorder. Psychiatric morbidity was significantly correlated with dysfunction arising out of illness. CONCLUSIONS: Vitiligo is associated with high psychiatric morbidity. There is a need to develop cross-cultural database on psychosocial aspects and psychiatric morbidity associated with vitiligo.

Psychiatry morbidity in vitiligo: prevalence and correlates in India

BACKGROUND: Vitiligo, a common pigmentary disorder, is recognized to be associated with a high psychiatric morbidity, yet compared to other dermatological disorders like leprosy, psoriasis, etc., it has not been subjected to detailed evaluation of its psychological consequences. The data from the developing countries on this aspect in particular is meager. METHODS: One hundred and thirteen cases with vitiligo were evaluated along with 55 healthy controls comparable for sociodemographic profile and matched on attitude to appearance scale. Clinical details, impact of illness, associated dysfunction and psychological morbidity were additionally assessed. RESULTS: Twenty-eight patients with vitiligo were found to have psychiatric morbidity, a clinic prevalence rate of 25 per cent (95 per cent confidence interval 20.3-29.3per cent). The majority of the cases had a diagnosis of adjustment disorder. Psychiatric morbidity was significantly correlated with dysfunction arising out of illness. CONCLUSIONS: Vitiligo is associated with high psychiatric morbidity. There is a need to develop cross-cultural database on psychosocial aspects and psychiatric morbidity associated with vitiligo.

Involvement of male genitalia in leprosy.

Four hundred and sixty-seven male patients with leprosy were screened for genital involvement. Genital lesions were observed in 6.6% of all male cases of leprosy. They were seen most frequently in lepromatous leprosy (25.8%), followed by borderline lepromatous (13.3%) and borderline tuberculoid (1.4%) leprosy.

Impact of combined Mycobacterium w vaccine and 1 year of MDT on multibacillary leprosy patients.

A total of 20 bacteriologically positive multibacillary (MB) leprosy patients older than 18 years of age with a bacterial index (BI) of 2+ or greater were given standard World Health Organization multiple drug therapy (MDT-MB) for 12 consecutive months plus four intradermal doses of Mycobacterium w vaccine at 3 monthly intervals (Study group). Twenty age-matched MB patients were given WHO/MDT alone (Control group). The patients of both groups were followed up for 1 year. Improvements in the patients were periodically monitored by clinical (Ramu's score), bacteriological (SSS), histopathological (skin biopsy) and immunological (lepromin conversion) parameters. Study group patients showed more significant improvements in all parameters except for lepromin conversion compared to patients in the Control group. The incidence of type 1 reaction was more in the Study group (30% vs 10%), while the incidence of type 2 reaction was more in the Control group (25% vs 15%). Neuritis associated with reactions was seen more often in the Control group compared to the Study group (20% vs 10%). The addition of Mycobacterium w vaccine as an adjunct to the 1-year WHO/MDT regimen appears to be significantly more beneficial in MB leprosy patients with a high initial BI compared to WHO/MDT given alone. Studies on larger numbers of patients with extended follow up will be in order.

Dyschromatosis universalis hereditaria.

Dyschromatosis universalis hereditaria is a common disorder in Japan. We report a case in an Indian woman with no family history of the disorder.

Keratoacanthoma Arising in an Organoid Nevus (nevus Sebaceous).

Organoid nevi may rarely be complicated by development of keratoacanthoma. We report a 21-year old man who presented with a hyperkeratotic papule developing over a well demarcated hyperpigmented irregular plaque on the forehead. Histopathology revealed features suggestive of keratoacanthoma developing in a lesion of nevus sebaceous. Literature search revealed 11 such reported cases. Most of the reported patients were young and had lesions on the face. Such lesions should be excised completely to prevent any malignant change in the future.

Presence of M. leprae in tissues in slit skin smear negative multibacillary (MB) patients after WHO-MBR.

This study looked for M. leprae in the lymph node, nerve and skin of multibacillary (MB) leprosy patients who become slit skin smear negative after the completion of WHO-MBR. Twenty-five WHO-MBR-treated multibacillary leprosy patients were studied; borderline lepromatous (BL) leprosy (n = 11) and lepromatous (LL) leprosy (n = 14)). Fifteen patients had reaction (erythema nodosum leprosum 11, upgrading reaction 4) either at presentation or during therapy. All patients attained slit skin smear negativity after WHO-MBR (range 24-39 months. Sixteen (64%) patients with multibacillary leprosy showed fragmented bacilli in skin and nerve biopsy or lymph node aspirates after WHO-MBR. Lymph node aspirates alone revealed M. leprae in seven patients, followed by nerve in two and skin in one patient. Four cases showed M. leprae at all sites followed by nerve and skin or lymph node in one case each. A pretreatment bacteriological index (BI) of 4+ or more was significantly associated with the presence of M. leprae at the end of treatment. Also, significantly more lymph node aspirates contained M. leprae in comparison with nerve or skin biopsies. All seven cases in whom treatment was extended beyond 24 months showed M. leprae in tissues even after attaining slit smear negativity. In conclusion, M. leprae persist in tissues after 2 years of WHO-MBR and patients with an initial BI of 4+ or more need to be closely followed up after stopping MDT.

Palmoplantar lesions in leprosy.

Palms and soles are considered immune to leprosy. A study was carried out to assess the frequency of lesions over palms and soles and to correlate their occurrence with various parameters. Two hundred eighty leprosy patients were screened for lesions over palms and soles. Palmo-plantar lesions were observed in 10% of the patients screened. Slit-skin smears and biopsies were done from routine sites and palmo-plantar lesions. Histopathology and slit-skin smear confirmed the presence of disease. Eight were in type I reaction, and 50% of patients with type I reaction screened showed lesions over palms and/or soles. The reason for this is not known; probably inapparent lesions become apparent during reactions. Lesions of various morphology were observed. Silky hand was observed in one case.

Macular lesions in leprosy: a clinical, bacteriological and histopathological study.

Among 150 untreated patients of leprosy, 19 had only macular lesions; three were of the indeterminate type, and eight each were of the tuberculoid and the borderline types, according to the Indian Association of Leprologists (IAL, 1981) classification. The clinical, bacteriological, and histopathological parameters of these 19 patients were studied both before and after six months of WHO Multi Drug Therapy (MDT/1982). A single macule was present in seven (36.84%) patients. In twelve (63.16%), two or more were seen. In eighteen (94.74%), one or more peripheral nerves were enlarged. The size of the macules varied from 5 to 15 cm, and there were no changes seen even after treatment. In most (94.74%) of the patients, the macules were hypopigmented. The surfaces were rough and dry in seven (36.84%) but smooth in the other twelve (63.16%). The margins were well defined in the seven (36.84%) patients with single macules but ill defined in the other twelve (63.16%). After six months of antileprosy treatment, the single macules showed some resolution. Slit skin smear examination was negative in all cases before and after treatment. Clinico-histopathological correlations were seen in only six (31.58%) patients; the clinical diagnoses were indeterminate and tuberculoid leprosy in three (15.79%) patients each. In the indeterminate group, the clinico-histopathological correlation was 100%; it was 37.50% in the tuberculoid group. There were no correlations between the clinical and histopathological parameters in thirteen (68.42%) cases. After six months of treatment, the histopathology became nonspecific in all patients. The lepromin test was positive in six (31.58%) patients; four were of the tuberculoid group and one each from the indeterminate and borderline leprosy groups. Hence, although macular lesions can be seen throughout the leprosy spectrum, it is difficult to correlate their clinical, bacteriological and histopathological parameters.

Immunological defect in leprosy patients: altered T-lymphocyte signals.

The early events of activation were studied in paucibacillary (TT/BT) and multibacillary (BL/LL) leprosy patients by stimulation of their lymphocytes with mitogenic agents (calcium ionophore A23187/PMA) and Micobacterium leprae antigen (PGL-1). Maximum proliferation in response to PMA/A23187 and PGL-1 was observed in the BT/TT patients and the control group, respectively. Inositol triphosphate (IP3) and calcium were constitutively elevated in BT/TT and LL/BL patients. PMA/A23187 caused an increase in both IP3 and [Ca2+]i in BT/TT patients and controls. PGL-1 marginally increased IP3 levels in BT/TT patients. In the LL/BL patients, although PMA/A23187 increased IP3 levels, but no change was seen in [Ca2+]i, PGL-1 had no effect. Protein kinase C levels were seen to be associated with particulate fractions in BT/TT patients and were found to increase further in response to PMA/A23187. PGL-1 did not increase translocation of protein kinase C in controls or LL/BL patients. A preactivated and sensitised state of T-lymphocytes was observed in BT/TT patients, responsive to antigen and mitogens, whereas the cells of LL/BL patients were unresponsive to PGL-1. The altered signal transduction events characterised in the MB patients thus correlate well with the anergic state of their cells.