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

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.

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.

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.

The flushing patient: differential diagnosis, workup, and treatment / The flushing patient: differential diagnosis, workup, and treatment

Cutaneous flushing-a common presenting complaint to dermatologists, allergists, internists, and family practitioners-results from changes in cutaneous blood flow triggered by multiple conditions. Most cases are caused by very common, benign diseases, such as rosacea or climacterum, that are readily apparent after a thorough taking of history and physical examination. However, in some cases, accurate diagnosis requires further laboratory, radiologic, or histopathologic studies to differentiate several important clinicopathologic entities. In particular, the serious diagnoses of carcinoid syndrome, pheochromocytoma, mastocytosis, and anaphylaxis need to be excluded by laboratory studies. If this work-up is unrevealing, rare causes, such as medullary carcinoma of the thyroid, pancreatic cell tumor, renal carcinoma, and others, should be considered. LEARNING OBJECTIVE: At the completion of this learning activity, participants should be familiar with the mechanisms of flushing, its clinical differential diagnosis, the approach to establish a definitive diagnosis, and management of various conditions that produce flushing.

A cirurgia de Smith na perda do movimento de aduçäo do polegar / Smith's surgery in the loss of the thumb adduction movement

Os autores analisam os resultados obtidos pela técnica cirúrgica descrita por Smith, que consiste na transferência do tendäo extensor radial curto do carpo para o tendäo do músculo adutor do polegar em sete pacientes com incapacidade da realizaçäo do movimento de aduçäo do polegar, devido à lesäo traumática do nervo ulnal (qatro casos) e neuropatia ulnal (três casos) causada pelo mal de Hansen.

A survey of antibodies to hepatitis C virus in Ethiopia.

Antibodies to hepatitis C virus (HCV) were measured in 1,580 Ethiopian subjects representing urban and rural populations. Sera found positive by a repeated second generation enzyme immunoassay (EIA) were subjected to three additional confirmatory tests. The overall confirmed seroprevalence was 2.0%. Less than 1% were confirmed to be seropositive in rural communities, with 1.4% positive among blood donors, 1.6% positive among patients with dermatologic disorders, 3.6% among leprosy patients, and 6.0% among patients attending a University Hospital clinic for neurologic disorders. The patients in the groups with leprosy and neurologic disorders have most likely been in ill health for many years and have sought relief by traditional healers or treatment at poorly equipped clinics. This group of patients demonstrated a high prevalence of antibodies to HCV. In Ethiopia, especially in small clinics, there is a shortage of syringes and needles and they have to be reused many times often with inadequate sterilization. Therefore, these syringes and needles may be contaminated, thus being a risk factor for HCV and HIV infection.

Classification of nerves is modified by the delayed recognition of Mycobacterium leprae.

Biopsies of 42 concurrent nerve and skin lesions across the spectrum of leprosy were classified and compared histologically and bacteriologically. Observations were made as follows: a) The bacterial load was higher in nerve than in skin lesions of the same histological classification, and it was higher in nerve than in concurrent skin lesions irrespective of classification, although not at the lepromatous pole. b) There was some discrepancy between the histological classification of nerve and skin lesions in half the cases. Skin classification appeared to represent the general tissue response and, insofar as discrepancies existed, the skin classification was thought to give the better evaluation. Nerve classification was subject to minor variations of a random nature which were thought to be the outcome of local reactions due to the build up of antigen as a result of delayed recognition in an immunologically protected situation. Upgrading or downgrading ensued locally, depending on the level of antigen at the time of its detection. In such cases, the corresponding skin classification was usually BT, which occupied a critical point in the spectrum. A certain autonomy of the response between lesions of skin and nerve suggests an explanation for downgrading reactions. Although Mycobacterium leprae, alone among mycobacteria, has some sort of affinity for Schwann cells, it is the role of the nerves as protected sites which is fundamental to the course of the disease.

Hypopigmentation in leprosy.

Hypopigmentation of macular leprosy lesions was not found to correlate with cellular infiltrate and AFB load in tissues. It is felt that hypopigmentation is in some way related to neural involvement.

[Acro-osteolysis in leprosy. Apropos of 19 personal cases]. / Acro-ostéolyses au cours de la lèpre. A propos de 19 observations personnelles.

Using their own personal series of 19 cases of leprosy complicated by massive osteolysis (AO), along with a comparison of these cases with data from previously published reports, the authors review the principal clinical and radiological findings of these manifestations which are not observed except in cases of leprosy where neuropathy is present, even though other factors (perforating plantar ulcers, poor hygiene, traumatisms) may play a contributing role independent of possible interference from non specific osteoarthritis or Hansen's bacilla, itself. After reviewing other causes of massive osteolysis and discussing the pathogeny of these manifestations during leprosy, the authors refer to the various therapies which can prevent or stabilize osteolysis or aid the patient to better tolerate its manifestations.

Acro-ostéolyses au cours de la lèpre. A propos de 19 observations personnelles

Using their own personal series of 19 cases of leprosy complicated by massive osteolysis (AO), along with a comparison of these cases with data from previously published reports, the authors review the principal clinical and radiological findings of these manifestations which are not observed except in cases of leprosy where neuropathy is present, even though other factors (perforating plantar ulcers, poor hygiene, traumatisms) may play a contributing role independent of possible interference from non specific osteoarthritis or Hansen's bacilla, itself. After reviewing other causes of massive osteolysis and discussing the pathogeny of these manifestations during leprosy, the authors refer to the various therapies which can prevent or stabilize osteolysis or aid the patient to better tolerate its manifestations

Thermography: an aid in the management of insensitive feet and stumps.

Infrared thermography contributes to the care of insensitive limbs. The inflammatory response of near damaged or damaged tissue presents areas of increased heat on the surface which can be detected and followed. Thermography was found to be a valuable aid to the established management methods used for insensitivity problems including management of healing and freshly healed ulcerations, management of neuropathic bone and joint problems and fitting of prosthetic devices and custom shoes. The most important contribution thermography offered was the detection of irritated tissue prior to frank breakdown often in time to prevent permanent injury if quick and effective management followed.

Bone changes in leprosy: a correlation of clinical and radiographic features

Characteristic bone lesions in leprosy affect the small bones of the face, hands, and feet. They are due directly to leprous infection imposed upon denervated tissues. The manifestations of leprous bone infection vary from the presence of bacilli in the bone to actual destruction. Distal absorption involves fingers and toes with the loss of digits. Combined absorption of lenght and width of bone often affects the metatarsophalangeal joints. Tarsal absorption patterns are determined by abnormal weight-bearing forces and infection.

Transtornos neurológicos associados ao mal perfurante plantar leprótico

Os autores analisam os distúrbios neurológicos sensitivos, motores e tróficos em 100 pacientes de lepra, 32 dos quais portadores de mal perfurante plantar. Concluem ser o m.p.p. complicação tardia do processo patológico hanseniano que se manifesta tôda vez que profundas modificações sensitivas, motoras e tróficas, devidas principalmente a transtornos da inervação profunda dos pés, alteram a arquitetura dos segmentos distais dos membros inferiores.