Diagnosing multibacillary leprosy: a comparative evaluation of diagnostic accuracy of slit-skin smear, bacterial index of granuloma and WHO operational classification.

BACKGROUND: In view of the relatively poor performance of skin smears WHO adopted a purely clinical operational classification, however the poor specificity of operational classification leads to overdiagnosis and unwarranted overtreatment while the poor sensitivity leads to underdiagnosis of multibacillary (MB) cases with inadequate treatment. Bacilli are more frequently and abundantly demonstrated in tissue sections. AIMS AND METHODS: We compared WHO classification, slit-skin smears (SSS) and demonstration of bacilli in biopsies (bacterial index of granuloma or BIG) with regards to their efficacy in correctly identifying multibacillary cases. The tests were done on 141 patients and were evaluated for their ability to diagnose true MB leprosy using detailed statistical analysis. RESULTS: A total of 76 patients were truly MB with either positive smears, BIG positivity or with a typical histology of BB, BL or LL. Amongst these 76 true-MB patients, WHO operational classification correctly identified multibacillary status in 56 (73.68%), and SSS in 43 (56.58%), while BIG correctly identified 65 (85.53%) true-MB cases. CONCLUSION: BIG was most sensitive and effective of the three methods especially in paucilesional patients. We suggest adding estimation of bacterial index of granuloma in the diagnostic workup of paucilesional patients.

Cutaneous manifestation of diabetes mellitus.

One hundred consecutive diabetes mellitus patients attending the diabetic clinic of the hospital constituted the study group. One hundred age and sex matched non-diabetics were taken as controls. The majority, 63%, belonged to the 41-60 years age group and 98% had non-insulin dependent diabetes. Among the study group, 64% had one or more cutaneous manifestations as compared to 22% in the controls. This was statistically highly significant (p < 0.001). Infections comprised the largest group affecting 35 of the 64 cases. Among the bacterial infections, pyodermas were observed in 11 and erythrasma in one. Fungal infections were seen in 21, dermatophytoses in 11, and candidiasis in 10. Herpes zoster was seen in 2 cases. Pruritus was observed in 10, neurological abnormalities in the form of paresthesias was seen in 6, mal perforans in one, and meralgia paresthetica in one. Diabetic dermopathy was seen in 6 and rubeosis in 4. Six dermatoses strongly associated with DM were seen, namely one each of waxy skin syndrome, granuloma annulare, eruptive xanthoma, scleredema adultorum, and 2 cases of diabetic bulla. Ten patients exhibited other dermotoses less associated with diabetics: xanthelasmo palpebrarum in 5 patients, acrochordi in 4, and pigmented purpuric dermatoses in one. Likewise syndromes of insulin resistance were seen in 4 patients of whom 3 had aconthosis nigricans and one had congenital lipodystrophy. Furthermore, 9 patients had dermatoses known to be associated with an increased incidence of diabetes; vitiligo in 4, acquired perforating dermatoses in 3, and lichen planus in 2. Four patients had dermatoses known to be associated with diabetes: psoriasis in 3 and diffuse alopecia in one. Three had adverse drug reactions to anti-diabetic therapy.

Cutaneous tuberculosis in children a clinico-microbiological study.

Twenty untreated patients of cutaneous tuberculosis varying from 2-12 years of age were included in the study. The incidence of cutaneous tuberculosis amongst the paediatric dermatological patients was 0.36%. Of these, 10 had lupus vulgaris, 8 had scrofuloderma, 3 had tuberculosis verrucosa cutis and 2 had lichen scrofulosorum. Three patients concomitantly had more than one type of skin tuberculosis. Systemic involvement in the form of pulmonary and osseous system was seen in 45% cases. The tuberculin test was uniformly positive. Affirmative clinico-histopathological correlation was observed in all the patients. However, acid fast bacilli could not be demonstrated in any of the sections. Only one patient (scrofuloderma) exhibited AFB on smear examination. In the same patient, M. tuberculosis could be cultured on L-J medium. However, Elisa for IgM antibodies in serum was positive in 12 (60%) cases. Need for newer techniques in the diagnosis is emphasised.

Histopathological Patrern of Early Syphilis.

Thirty six untreated cases of early syphilis comprising 10 primary and 26 secondary syphilis were included in the study. Primary syphilis depicted classical istopathological features of ulceration, exocytosis, perivascular infiltrate of lympocytes and plasma cells along with endothelial cell proliferation. Secondary syphilis, however, depicted intriguing features. Lichenoid infiltrate along with basal layer dissolution was seen in 3 and psoriasiform appearance in 1 cases. Three cases showed granulomatous reaction. One case manifesting as pruritic follicular rash had classical features on histopathology. Vascular changes were absent or inconspicuous in as many as 22.2% and 8.3% respectively.

Primary drug resistance to both rifampicin and dapsone in a paucibacillary leprosy patient.

A thirty-one year old male patient was diagnosed and treated for a pure or better primary neuritic case of leprosy with dapsone (100 mg daily for 2 years) and rifampicin (600 mg daily for 6 months). From the very outset, the patient did not show any improvement; on the top of it, he subsequently, developed a cutaneous patch, which on histopathological examination, revealed classical features of BT leprosy. Acid-fast bacilli were absent both in skin slit smear and histologic section. A primary resistance to both dapsone and rifampicin, even in paucibacillary patient, is speculated.

Histochemical Profile of Vitiligo.

Fifty untreated vitiligo patients were subjected to histo-chemical examination using dopa reaction technique. Dopa positive melanocytes were absent in a large majority (82%) of cases. Increase in the number of supra-basal clear cells was observed in 70 percent. Presence of inflammatory infiltrate at dermo- epidermal junction along with basal cell layer-dissolution was seen in 7 cases. Grayish-black, void cells considered to be inactive melanocytes, were seen in the basal layer.

Laboratory Diagnosis of Neisseria Gonorrhoeae with Special Reference to Beta-lactamase Producing Strains.

Sixty untreated patients of gonorr ioea were subjected to clinico- bacteriological study with special reference to betalactamase producing strains. Unilateral epididymitis was observed in 2 and multiple peri-urethral abscesses were found in 1. One male patient was asymptomatic. One strain of gonococcus isolated from an unmarried male patient showed resistance to 10 IU penicillin disc and positive rapid iodometric test for beta-lactamase enzyme.

The histopathology of type I (lepra) and type II (ENL) reactions in leprosy.

The histopathological features in type I (lepra) reaction comprised a loose and disorganised granuloma in the upper and mid-dermis, dermal edema and variable cellular contents, namely, epithelioid cells, lymphocytes, giant cells, and macrophages. While ENL reactions, were characterised by predominant involvement of subcutaneous vessels, vasculitis, and polymorphonuclear infiltration in and around the blood vessels.

Clinical Profile of Vitiligo in North India.

A clinical analysis of L50 patients having vitiligo revealed the incidence among new patients to be 1.25%. The male /female ratio was 1.3:1. Patients below the age of 30 years constituted 85%. Family history of vitiligo was available in 240/o. The different morphologic, Patterns consisted of vitiligo vulgaris (90 cases), vitiligo areata (22 cases), vitiligo acro-facialis (11 cases), vitiligo univers (11 cases , vitiligo mucoaae (9 cases),and vitiligo zosteriformis (7 cases). Association with diabetes meffitus (5 cases), alopecia areata (4 cases), Hashimoto's thyroiditis (1 case) and pemphigus vulgaris ( 1 case ) was observed.

Association of Pemphigus Vulgaris with Vitiligo.

A patient had vitiligo for 10 years with development of new lesions for the last. Four months. Concomitant with the recent activation of vitiligo, he developed pemphigus vulgarism. Corticosteiroid therapy controlled pemphigus vulgaris, and also halted the development of new vitiligo lesions. Histopathologic study revealed inflammatory infiltrate at the dermo-epidermal junction along with basal cell layer dissolution suggesting atuoimmune, origin of vitiligo.

Erythema nodosum leprosum (ENL) in histoid leprosy.

The morphological features of ENL, occurring in histoid leprosy are described. Its infrequent occurrence has been emphasised. The possible immunopathogenesis of its occurrence in histoid leprosy is briefly outlined.

Age-at-onset of leprosy. (An analytic data from Northern India).

Very little information is available from Northern India about various intriguing facets of epidemiology of leprosy. Age-at-onset is a very important aspect of the epidemiology of the disease process. In the present study an analytic data of the patients from Northern India is presented. The mean age-at-onset of leprosy in males was 31.49 years and in female 29.43 years. The mean age-at-onset for N, N ? L and L types was 30.14, 30.12 and 34.13 years respectively. The data compared well with those of earlier series.

Application of clinical and histopathological classification of leprosy.

A simultaneous clinical and histological study in 82 new, untreated leprosy patients was undertaken using the criteria of Ridley and Jopling. The disparity between the clinical and the histological diagnosis was abundantly clear, because in only 35 patients the two conformed with each other while in others there was a shift of one step towards either the tuberculoid or the lepromatous end of the spectrum. In 18 patients from other groups of leprosy, histologic delineation had features of indeterminate leprosy.