Morphoea with prominent plasma cell endoneuritis.

Morphoea (localized scleroderma) is a cutaneous inflammatory condition characterized by the development of indurated and discoloured plaques. The histological features of morphoea typically include a superficial and deep perivascular and periadnexal chronic inflammatory infiltrate associated with variable degrees of dermal and/or subcutaneous sclerosis. The infiltrate is typically composed of lymphocytes, macrophages and conspicuous plasma cells. The early stages of morphoea may have a very prominent inflammatory infiltrate associated with subtle sclerosis. In addition, the inflammatory infiltrate may show a perineural and rarely intraneural distribution. We report two cases of morphoea that histologically showed plasma cell endoneuritis associated with subtle dermal sclerosis. These two cases highlight the potential for diagnostic confusion with infectious and inflammatory diseases, particularly leprosy and lupus.

Presence of viable Mycobacterium leprae in environmental specimens around houses of leprosy patients.

PURPOSE: Leprosy is a chronic systemic infectious disease caused by Mycobacterium leprae, one of the first organisms to be established as the cause for disease in humans. Because of high prevalence pockets of leprosy in the endemic regions, it is necessary to identify the possible sources of M. leprae in the environment and its mode of transmission. MATERIALS AND METHODS: Slit skin smears (SSSs) from lesions were collected in 70% ethanol from 50 leprosy cases staying in the leprosy resettlement village and hospital from a high endemic area. One hundred and sixty soil samples were collected from different areas around the leprosy hospital and from the resettlement village of cured leprosy patients where active cases also resided at the time of sample collection. M. leprae specific gene region (RLEP 129 bp) and 16S rRNA targets were used for polymerase chain reaction (PCR) based detection for the presence and viability of M. leprae. An rpoT region was also amplified to determine presence of numbers of 6 bp tandem repeats. RESULTS: All the SSS samples collected from patients showed three copies of rpoT region (6 bp tandem repeat, an ancient Indian type). Fifty-two soil samples showed presence of M. leprae DNA whereas M. leprae specific 16S rRNA gene was amplified in sixteen of these samples. PCR amplification and fragment length analysis showed 91 bp, i.e., three copies of the rpoT 6 bp tandem repeats from soil samples and similar three copies observed in patient samples. CONCLUSION: Presence of viable M. leprae in the soil having same rpoT genotype of M. leprae noted in patients suggests that it could be the same strain of M. leprae. M. leprae found in the soil could be the one that is excreted out by the patient. Significance of its viability in the environment and its pathogenicity with respect to transmission needs to be further explored. Findings of this study might provide possible insights for further exploration into understanding transmission patterns in leprosy and also will throw light on identifying potential for existence of extra human source or reservoirs of M. leprae, if any.

Interleukin-17F single-nucleotide polymorphism (7488T>C) and its association with susceptibility to leprosy.

The objective of this study was to investigate the association, if any, between the interleukin-17F (7488T>C) (rs763780) polymorphism and susceptibility to leprosy and to elucidate the relationship between IL-17F genotypes and clinical profile of the disease. DNA was extracted from the peripheral venous blood of leprosy cases (n = 140), which were classified as per WHO classification into paucibacillary (PB) (n = 53) and multibacillary (MB) (n = 87) categories and healthy controls (n = 84) without any signs and symptoms of leprosy. The IL-17F (7488 T/C) polymorphism was genotyped using amplification refractory mutation system - polymerase chain reaction (Allele-specific amplification). In both PB and MB categories of leprosy cases, the homozygous TT genotype frequency was significantly higher than that of the healthy controls (78.70% vs. 29.76%, P < 0.05). The heterozygous TC genotype was higher in the controls than in the leprosy cases (57.14% vs. 17.68%, P < 0.05). TT genotype was more associated with the type 1 reactional states and tuberculoid/borderline tuberculoid groups in leprosy than the TC genotype. This study reveals that the IL-17F (7488T>C) single-nucleotide polymorphism is associated with susceptibility to leprosy and polymorphism confers decrease in risk of contracting leprosy in the north Indian cohort.

Single nucleotide polymorphisms typing of Mycobacterium leprae reveals focal transmission of leprosy in high endemic regions of India.

Earlier studies indicate that genotyping of Mycobaterium leprae based on single-nucleotide polymorphisms (SNPs) is useful for analysis of the global spread of leprosy. In the present study, we investigated the diversity of M. leprae at eight SNP loci using 180 clinical isolates obtained from patients with leprosy residing mainly in Delhi and Purulia (West Bengal) regions. It was observed that the frequency of SNP type 1 and subtype D was most predominant in the Indian population. Further, the SNP type 2 subtype E was noted only from East Delhi region and SNP type 2 subtype G was noted only from the nearby areas of Hoogly district of West Bengal. These results indicate the occurrence of focal transmission of M. leprae infection and demonstrate that analysis by SNP typing has great potential to help researchers in understanding the transmission of M. leprae infection in the community.

Nerve conduction studies in paucibacillary and multibacillary leprosy: a comparative evaluation.

Involvement of peripheral nerves in patients with leprosy results in sensory, motor and autonomic dysfunctions along with deformities and disability. Pattern of nerve involvement is different for different forms of leprosy. In this study, we evaluated and compared the nerve conduction parameters of paucibacillary leprosy with that of multibacillary leprosy. In this study, 40 consecutive patients of leprosy (19 cases of paucibacillary and 21 cases of multibacillary leprosy) were included. Nerve conduction studies were performed according to the standard procedure described in the manual of the machine. We observed that patients with multibacillary leprosy had significantly more severe changes in nerve conduction parameters as compared to that of paucibacillary leprosy. In paucibacillary leprosy, the dominant pattern of nerve involvement was that of mononeuropathy, however, in 6 paucibacillary cases the nerve involvement was in form of mononeuritis multiplex. Electrophysiological assessment also revealed involvement of clinically uninvolved nerves. Nerve conduction parameters were suggestive of mixed axonal as well as demyelination of the peripheral nerves.

A modified two-step treatment for actinomycetoma.

BACKGROUND: Combination antibiotic regimens are effective in the treatment of actinomycetoma but many treatment schedules require supervised parenteral therapy for prolonged periods. We describe a schedule that includes parenteral medication in an initial, short phase followed by a longer phase of oral medication. METHODS: Sixteen patients with clinically diagnosed mycetoma, who did not show any evidence of a fungal etiology, were treated presumptively for actinomycetoma. Evidence of actinomycotic infection was found on microscopy of granules / discharge and / or histopathological examination in eight (50%) patients. The treatment consisted of an intensive phase (Step 1) with gentamicin, 80 mg twice daily, intravenously and cotrimoxazole, 320/1600 mg twice daily orally for four weeks. This was followed by a maintenance phase with cotrimoxazole and doxycycline, 100 mg twice daily till all sinuses healed completely. The treatment was continued for 5-6 months. RESULTS: Treatment response was assessed monthly. At the end of the intensive phase, there was a significant improvement in all 16 patients. Nine patients who continued the maintenance phase of the regimen had complete healing of sinuses with marked reductions in swelling and induration in 2.4 +/- 1.7 months. Maintenance treatment was continued for a mean of 9.1 +/- 4.3 months in these patients. Six patients have remained free of disease activity during a follow-up period of 11.1 +/- 4.2 months after treatment was stopped. Two patients developed leucopenia and thrombocytopenia necessitating withdrawal of cotrimoxazole. CONCLUSION: This regimen was effective in treating actinomycetoma. The short duration of the phase requiring parenteral therapy makes it convenient to administer.

Immunogenetics of mycobacterial infections in the North Indian population.

Several lines of evidence highlight the genetic basis of risk to develop mycobacterial diseases. Human leukocyte antigen (HLA)-DR2 alleles (DRB1*1501 and DRB1*1502) have been found to be strongly associated with mycobacterial disease, especially the more severe forms such as lepromatous leprosy and multidrug-resistant pulmonary tuberculosis. In this study, DNA-based high-resolution typing techniques of polymerase chain reaction-sequence-specific oligonucleotide probe were used to determine the distribution of HLA-DR/DQ alleles in patients with leprosy and pulmonary tuberculosis. Analysis of different DR2 subtypes based on valine/glycine dimorphism at codon beta86 in pocket 1 of HLA-DR showed an inverse relationship of DR2 alleles with V/G as the severity of disease increased both in leprosy and in pulmonary tuberculosis.

Mycobacterial infections: PARK2 and PACRG associations in leprosy.

An overview of investigations indicating an important role of host genetics, both major histocompatibility complex (MHC) and non-MHC, in leprosy.

Association of variants in the IL12B gene with leprosy and tuberculosis.

There is a great range in outcomes after mycobacterial infections, and this is probably due to individual variation in immune responses. One of the key cytokine regulators of the immune response is interleukin (IL-) 12. The IL12B gene encodes the p40 chain of both IL-12 and IL-23 and it has two major variant sites at which different alleles are associated with increased levels of gene expression and with susceptibility to a range of immune-related diseases. We hypothesized that IL12B variants associated with increased expression would be as associated with susceptibility to persistent mycobacterial infection. We tested this hypothesis by genotyping Indian subjects, having either leprosy or tuberculosis (TB), as well as ethnically matched controls. Subjects with leprosy were less likely to have the 3'UTR genotype associated with lower IL12B expression (P= 0.001). Subjects with TB were not only more likely to have the high-expressing IL12B promoter genotype (P= 0.01) but also more likely to have this in the same haplotype with the high expressing 3'UTR allele (P= 0.0009). These results suggest these infectious diseases may be improved by modulating IL-l2p40 production.

Detection of M. leprae by reverse transcription- PCR in biopsy specimens from leprosy cases: a preliminary study.

A reverse transcription (RT)-PCR assay targeting 16S rRNA of Mycobacterium leprae has been used to detect M.leprae specific nucleic acids. This study has been initiated to gain experience about detection of RNA from seven biopsy specimens by RT-PCR assay using species- specific primers described earlier. These biopsy specimens were from clinically confirmed and untreated leprosy cases belonging to BB and BL types. The earlier reported method was established in our laboratory. 171 bp fragment by RT-PCR was amplified from 4/7 cases. The positives results by RT-PCR were from the biopsies from fresh or short term treated cases whereas negative results were from specimens from long term treated cases showing clinical features of relapse. DNA targeting PCR (36 KDa) showed positivity in both groups. These results suggest that RT-PCR positivity possibly reflect the presence of viable organisms. Thus as earlier predicted RT-PCR assay may be useful for viability determinations for assessing the response to chemotherapy as well as presence of persisters in relapse cases.

Evaluation of a new fixed duration (12 weeks) multi-drug regimen of bactericidal drugs in multibacillary leprosy.

UNLABELLED: Leprosy still remains a public health problem mainly in Asia, Africa and South America. The WHO Expert Committee on Leprosy recommended, in 1997, the simplified treatment of leprosy for multibacillary (MB) cases, by reducing the duration of treatment from 24 to 12 months. From the operational point of view even this reduced duration is still long and monthly supervised drug administration may not always be practical in those areas where the accessibility is difficult and health infrastructure weak. The present study was carried out to compare the safety and efficacy of a new fixed duration regimen consisting of four bactericidal drugs with WHO/MDT (MB). METHODS: Thirty adult patients were randomly allocated to two groups. Group 1 (18 patients) received a new regimen of daily rifampicin 600 mg, sparfloxacin 200 mg, clarithromycin 500 mg and minocycline 100 mg for 12 weeks. Group 2 (12 patients) received WHO/MDT (MB) for 12 months. A detailed clinical evaluation and laboratory investigations, BI and MI were done at the baseline, every 4 weeks for 12 weeks, and thereafter every 8 weeks till 48 weeks. Skin biopsies were taken and chest X-rays were done at 0, 12 and 48 weeks. RESULTS: At 48 weeks, the net percentage clinical improvement in group 1 was 73.92% and in group 2 it was 66.66%. The net percentage reduction (NPR) in BI in group 1 was 19.17% and in group 2 it was 18.87% (p = 0.09). NPR in MI in both groups was 100% by 8 weeks, and somewhat faster in group 1. In group 1, 8 patients had mild gastrointestinal side-effect, and 16 had minocycline-induced hyperpigmentation. Three patients in group 1 developed type I reversal reactions. CONCLUSION: The regimen containing daily doses of rifampicin 600 mg, sparfloxacin 200 mg, minocycline 100 mg and clarithromycin 500 mg for 12 weeks was found to be an acceptable, effective and safe alternative regimen for MB leprosy with an additional operational advantage of shorter duration of treatment.

Chilblain lupus erythematosus mimicking acrofacial vitiligo.

Chilblain lupus erythematosus with depigmentation is a rare presentation of lupus erythematosus that may simulate vitiligo. A 52-year-old lady with such a manifestation is being reported.

Leiomyomas in a naevoid distribution.

A 59-year-old man developed gradually appearing and slowly progressive tender papulo-nodular lesions in a naevoid distribution on the left side of the trunk since the age of 49 years. The histopathological features were classical of leiomyoma.

Utility of fine-needle aspiration cytology in the classification of leprosy.

The role of fine-needle aspiration cytology (FNAC) in the diagnosis of benign skin lesions has been restricted primarily to the evaluation of bacteriologic and morphologic indices in leprosy. This study was undertaken to evaluate the efficacy of FNAC in the diagnosis and classification of lepromatous lesions. Aspirates of 94 newly diagnosed cases of leprosy were studied, and the bacterial load was determined by modified Ziehl-Neelsen (ZN) stain. A skin biopsy was taken from the same site at the same sitting. Frozen and paraffin sections stained with hematoxylin-eosin (H&E) and ZN stains were examined from the biopsy specimen. In 61 of 94 cases (64.9%), the aspirates were satisfactory. Both diagnosis and classification of leprosy were possible in 40 of these 61 cases; the rest of the aspirates showed nonspecific chronic inflammation. The 39 cases of leprosy where a biopsy was available from the same site were classified on FNAC into tuberculoid (TT and BT), lepromatous (LL and BL), and midborderline (BB) subtypes. Taking the histologic diagnosis and Ridley-Jopling classification to be the gold standard, a strong concordance in tuberculoid leprosy cases (18 of 20 cases, 90%) and in lepromatous cases (15 of 16 cases, 93.7%) was observed. Midborderline cases of leprosy posed a problem, and a correct cytohistological correlation was observed in only one of the three cases.

Primary cutaneous amyloidosis involving the external ears along with the classical sites.

A 26-year-old woman had multiple itchy persistent gradually progressive papular lesions on the forearms and shins for 10 and 4 years respectively. She also noticed similar lesions on both the ears for 4 years. There were no systemic symptoms. Cutaneous examination revealed multiple 2-3 mm discrete firm hyperpigmented papules on the extensors of forearms, shins and earlobes. Skin biopsy from all sites demonstrated deposits of amyloid in the papillary dermis. The patient was treated with cyclophosphamide 50 mg daily orally. There was more than 50% improvement in her lesions.

Evaluation of leprosy lesions by skin smear cytology in comparison to histopathology.

Cytological evaluation of leprosy skin lesion was done to evaluate cytohistological correlation. Twenty five clinically suspected patients of leprosy were evaluated by performing fine needle aspiration (FNA) in nodular lesions and slit skin smear technique in flat lesions to classify across R-J scale. May-Grunwald-Giemsa (MGG) and Ziehl-Neelsen stain were employed on slit skin smears and fine needle aspiration material. Histopathological assessment of slides from same lesion was done. The overall diagnostic accuracy of fine needle aspiration was 76.1% and that of slit skin smear 50%. However, on adequate material diagnostic accuracy of slit skin smear was high, 100% as compared to 81.8% of fine needle aspiration smears. In cases of polar leprosy cytological findings paralleled histopathological diagnosis. Within the constraints of cytological interpretation the cases in borderline unstable spectrum of leprosy can be classified broadly.

Mycosis fungoides treated with Puva and Topical Corticosteroids.

An 89-year old patient had mycosis fungoides with extensive skin involvement and palpable but pathologically uninvolved lymph nodes. He was successfully treated with PUVA combined with topical 0.1% fluocinolone acetonide ointment. PUVA therapy is highly effective in the treatment of mycosis fungoides confined to the skin, especially in the elderly where more aggressive therapy may not be tolerated.

Syringocystadenoma papilliferum at unusual sites.

We describe two cases in which syringocystadenoma papilliferum was present in extremely unusual locations.