Leg ulcer in lepromatous leprosy - Case report.

In Brazil, leprosy is a widespread infectious and contagious disease. Clinicians and specialists view leprosy broadly as a systemic infection, since, in its manifestations, it mimics many conditions, such as rheumatic, vascular, ENT, neurological and dermatological diseases. There are few studies that characterize the factors associated with ulcers in leprosy. These injuries should be prevented and treated promptly to avoid serious problems like secondary infections, sepsis, carcinomatous degeneration and amputations. We describe a patient with ulcers on his legs, involving late diagnosis of lepromatous leprosy.

Leg ulcer in lepromatous leprosy - Case report

Abstract: In Brazil, leprosy is a widespread infectious and contagious disease. Clinicians and specialists view leprosy broadly as a systemic infection, since, in its manifestations, it mimics many conditions, such as rheumatic, vascular, ENT, neurological and dermatological diseases. There are few studies that characterize the factors associated with ulcers in leprosy. These injuries should be prevented and treated promptly to avoid serious problems like secondary infections, sepsis, carcinomatous degeneration and amputations. We describe a patient with ulcers on his legs, involving late diagnosis of lepromatous leprosy.

[Lucio's phenomenon in a patient with leprosy on Aruba]. / Luciofenomeen bij een patiënt met lepra op Aruba.

BACKGROUND: Lucio's phenomenon is a rare leprosy reaction characterised by bizarrely-shaped, purpuric skin lesions and ulceration. It occurs in diffuse lepromatous leprosy and it is mainly reported in patients from Mexico and the Caribbean. CASE DESCRIPTION: We describe the case of a 90-year-old Aruban man with recurrent leg ulcers and flexion contractures of the lower extremities. Occurrence of Lucio's phenomenon led to a diagnosis of diffuse lepromatous leprosy. Presence of Mycobacterium leprae was demonstrated in skin, bone marrow and lymph nodes. CONCLUSION: Lucio's phenomenon led to a diagnosis of leprosy. Leprosy is still endemic in Aruba.

Interventions for skin changes caused by nerve damage in leprosy.

BACKGROUND: More than three million persons are disabled by leprosy worldwide. The main complication of sensory nerve damage is neuropathic ulceration, particularly of the feet. In this review we explored interventions that can prevent and treat secondary damage to skin and limbs. OBJECTIVES: To assess the effects of self-care, dressings and footwear in preventing and healing secondary damage to the skin in persons affected by leprosy. SEARCH STRATEGY: We searched the Cochrane Skin Group Specialised Register (April 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2008), MEDLINE (from 2003 to April 2008), EMBASE (from 2005 to April 2008), CINAHL (1982-2006) and LILACS (1982- April 2008 ) as well as online registers of ongoing trials (April 2008). SELECTION CRITERIA: Randomised controlled trials involving anyone with leprosy and damage to peripheral nerves treated with any measures designed to prevent damage with the aim of healing existing ulcers and preventing development of new ulcers. DATA COLLECTION AND ANALYSIS: Two authors assessed trial quality and extracted data. MAIN RESULTS: Eight trials with a total of 557 participants were included. The quality of the trials was generally poor. The interventions and outcome measures were diverse. Although three studies that compared zinc tape to more traditional dressings found some benefit, none of these showed a statistically significant effect. One trial indicated that topical ketanserin had a better effect on wound healing than clioquinol cream or zinc paste, RR was 6.00 (95% CI 1.45 to 24.75). We did not combine the results of the two studies that compared topical phenytoin to saline dressing, but both studies found statistically significant effects in favour of phenytoin for healing of ulcer (SMD -2.34; 95% CI -3.30 to -1.39; and SMD -0.79; 95% CI -1.20 to 0.39). Canvas shoes were not much better than PVC-boots, and double rocker shoes did not promote healing much more than below-knee plasters. AUTHORS' CONCLUSIONS: One study suggested that topical ketanserin is more effective than clioquinol cream or zinc paste. Topical phenytoin (two studies) may be more effective than saline dressing regarding ulcer healing. For the other dressings the results were equivocal. Canvas shoes were a little better than PVC-boots, but not significantly, and the effect of double rocker shoes compared to below-knee plasters was no different in promoting the healing of ulcers. No side effects were documented. There is a lack of high quality research in the field of ulcer prevention and treatment in leprosy. New trials should follow the current standards for design and reporting of randomised controlled trials.

Leg ulcers due to hyperhomocysteinemia.

Chronic leg ulcers are rare in young adults and generally indicate a vascular cause. We report a case of a 26-year-old man with leg ulcers of eight months duration. Doppler study indicated venous incompetence and a postphlebitic limb. However, as the distribution and number of ulcers was not consistent with stasis alone and no features of collagen vascular disease were noted, a hyperviscosity state was considered and confirmed with significantly elevated homocysteine level in the serum. Administration of vitamins B1, B2, B6 and B12, trimethyl-glycine, mecobalamine, folic acid and povidone iodine dressings with culture-directed antibiotic therapy led to a satisfactory healing of ulcers over a period of one month. Hyperhomocysteinemia must be considered in the differential diagnosis of leg ulcers in young individuals.

Scar leishmaniasis.

A large spectrum of clinical presentations of cutaneous leishmaniasis (CL) have been reported including a scar presentation in many chronic cases. We report here a case where CL developed in a scar of healed lesion of tuberculoid leprosy. Initially, it was suspected as a relapse or reaction of the previous disease, but on histopathology, it proved to be a new disease (CL). On anti-leishmaniasis treatment, lesion healed satisfactorily in about a month time.

Leg ulcers in active lepromatous leprosy associated with cryoglobulinaemia.

A 40-year-old male agricultural labourer presented with active lepromatous leprosy and painful leg ulcers of 2 months' duration. Biopsy from the ulcer showed nonspecific changes. Raised erythrocyte sedimentation rate and positive rheumatoid factor made us suspect underlying cryoglobulinaemia. Presence of cryoprecipitate in the serum, demonstration of cryoglobulins by serum electrophoresis and raised cryocrit were compatible with cryoglobulinaemia as the cause of atypical leg ulcers in this case. The ulcers healed with bed rest, aspirin and specific anti-leprosy treatment. Though 95% of lepromatous leprosy patients can have cryoglobulinaemia, the presence of atypical ulcers as seen in our patient has not previously been related to the presence of cryoglobulinaemia.

Leg ulcers in active lepromatous leprosy associated with cryoglobulinaemia

A 40-year-old male agricultural labourer presented with active lepromatous leprosy and painful leg ulcers of 2 months' duration. Biopsy from the ulcer showed nonspecific changes. Raised erythrocyte sedimentation rate and positive rheumatoid factor made us suspect underlying cryoglobulinaemia. Presence of cryoprecipitate in the serum, demonstration of cryoglobulins by serum electrophoresis and raised cryocrit were compatible with cryoglobulinaemia as the cause of atypical leg ulcers in this case. The ulcers healed with bed rest, aspirin and specific anti-leprosy treatment. Though 95 per cent of lepromatous leprosy patients can have cryoglobulinaemia, the presence of atypical ulcers as seen in our patient has not previously been related to the presence of cryoglobulinaemia.

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part IV. Use of medial leg flap and medial knee flap.

The medial leg flap, based on the cutaneous branches of the posterior tibial artery is raised from the middle and lower regions of the medial aspect of the leg. It has a long pedicle, and it can be used as a free flap to reconstruct the distant soft tissue defects and also as an island flap. We have used this retrograde island flap for surfacing ulcerated areas in six leprosy patients. The flap survived in all cases. At 24 to 60 months follow-up examination, ulceration had not recurred in any of them. The medial knee flap consisting of the skin and subcutaneous tissue of the lower part of the medial side of the thigh and the upper part of the leg, is suitable for covering soft tissue cushion defects of the extremities because of the constant vessels, long pedicle, wide diameter, well-recognizable sensory nerves and less subcutaneous fat. We have used the medial knee flap for the resurfacing sizeable raw areas due to ulceration in three leprosy patients. The flap survived in all cases and there was no recurrence of ulceration during the 70-148 months follow-up period.

[Mutilating acrodystrophic neuropathy of alcoholic origin in the French West Indies]. / Acropathie ulcéromutilante d'origine alcoolique aux Antilles.

Among principal causes of acrodystrophic neuropathy-ie, leprosy, diabetes, amyloid neuropathy, hereditary sensory neuropathies-alcoholism is controversial since first descriptions (Bureau et al, 1957) incriminating heavy drinking. This retrospective review of 38 cases occurring in West-Indian rhum abusers, tends however to confirm its etiologic role. Patients present with three non specific signs or symptoms of the lower extremities: anaesthetic foot, plantar ulcers, and chronic, indolent, mutilating arthropathies. Motor function is spared. Male gender, massive (> or = 150 g pure alcohol daily) and prolonged (> or = 12 years) rhum intake, hygiene deficiency, poverty and social distress, exposition to repeated foot microtrauma and a protracted, non fatal, but disabling course leading to amputation, are the main features of this syndrome. The pathophysiology is poorly documented, and many questions remain unanswered including a genetic predisposition or a particular neuro-toxicity of West Indian rhum. However, the clinical and epidemiologic data presented here favour the concept of an "alcoholic foot" or true alcoholic acrodystrophic neuropathy, quite different from the most common sensory-motor form.

The most indolent ulcers of the skin treated with porcine xenografts and silver ions.

Cutaneous ulcers associated with Hansen's disease have long been recognized as among the most indolent of all ulcers. We have successfully treated such ulcers with porcine xenograft, achieving healing in ulcers which had been present for as much as three decades. These results suggest that this regimen may be applicable to other cutaneous ulcers wherever skin is missing. The newly available antibacterial effects of silver-impregnated porcine xenografts should have the result of increasing the effectiveness of the treatment still further.

[Epitheliomatous degeneration of wounds, ulcers and perforating plantar disorders in patients with leprosy]. / Dégénérescence épithéliomateuse des plaies, ulcères et maux perforants plantaires chez les lépreux.

Six cases of epitheliomatous degeneration, among which five spino-cellulars and one baso-cellular, happened among leprosy patients showing sores, ulcerations and planter ulcers, are quoted in this study. Here, the authors underline the favorable part of the defects of cellular immunity for the leprous pathogenesis, and the need of using histological exams systematically when noticing any continued delay of cicatrisation. An immuno-stimulating medication should be used for any leprosy patient showing obstinate trophical troubles.