Neurological Complications of Leprosy.

Leprosy is a challenging international health concern. Despite tremendous efforts in reducing worldwide disease prevalence in the past decades, some countries remain endemic and are plagued by high levels of disability. The neurological complications of leprosy are varied and complex, with current research focused on evaluating tools for earlier diagnosis of neuropathy, especially in resource-limited countries. While treatment with multidrug therapy is highly effective, active research aims to simplify regimens to improve adherence, minimize adverse effects, and prevent antimicrobial resistance. Although promising progress has been made in the past decades, further efforts are needed to push the international community toward achieving worldwide elimination.

Bullous pemphigoid and antecedent neurological diseases: An association with dementia.

BACKGROUND: Bullous pemphigoid is the most common subepidermal immunobullous disorder. Studies have reported the association between bullous pemphigoid and various neurological diseases. AIMS: The aim of this study was to evaluate whether bullous pemphigoid is associated with pre-existent neurological diseases and whether specific diseases exhibit this association. METHODS: All dermatology inpatients from January 2010 to May 2015 were analyzed. Bullous pemphigoid cases were identified based on clinical features and consistent histopathologic and direct immunofluorescence findings. Patients with other autoimmune bullous skin disorders were excluded. An equal number of inpatients with other skin conditions were selected randomly as age- and sex- matched controls. RESULTS: Out of 3015 inpatients, 103 cases of bullous pemphigoid and 103 age- and sex-matched controls were included. Seventy six patients with bullous pemphigoid had a history of at least one neurological disease. After adjusting for age, gender, race, functional status and neuro-psychiatric medications, patients with bullous pemphigoid were found to be approximately thrice as likely to have a history of at least one neurological disease than were controls (odds ratio: 2.88; 95% confidence interval: 1.32-6.26; P = 0.008). Amongst the pre-existing neurological diseases, only dementia was statistically more prevalent in bullous pemphigoid cases compared to controls (adjusted odds ratio: 2.61; 95% confidence interval: 1.19-5.75; P = 0.017). Parkinson disease and psychiatric disorders demonstrated a higher adjusted risk among bullous pemphigoid patients but the difference was not statistically significant. LIMITATIONS: The limitations were potential referral and selection bias, as the patients were inpatients. There is a possible misclassification as the diagnosis of neurological diseases was performed using medical records. The duration from the diagnosis of neurological diseases to bullous pemphigoid could not be accurately determined as it was a retrospective review of records and most neurological diseases have a prolonged course. CONCLUSIONS: Pre-existent neurological disease, specifically dementia, was found to be associated with bullous pemphigoid.

Neurological diseases and bullous pemphigoid: A case-control study in Iranian patients.

INTRODUCTION: Neurological diseases are important co-morbidities found in association with bullous pemphigoid. Various neurological conditions (stroke, Parkinson's disease, dementia, epilepsy and multiple sclerosis) have been reported as associations of this bullous disease; whether these are significant has not been definitely proved. However, the presence of neurological conditions is a predictor of poorer prognosis. OBJECTIVES: Our aim was to examine the association of bullous pemphigoid and neurological diseases in Iranian bullous pemphigoid patients. METHODS: The medical records of one hundred and sixty consecutive bullous pemphigoid patients who presented to the Autoimmune Bullous Diseases Research Center, Tehran, Iran, from 2006 to 2011 were examined for evidence of any neurological disease. The control group comprised of 317 age- and sex-matched subjects. RESULTS: Neurological diseases were seen in 42 (26.4%) patients with bullous pemphigoid and in 29 (9.1%) controls (odds ratio: 3.53 (2.1-5.9), P< 0.001). Comparing cases to controls, stroke was seen in 17.5% versus 4.1%, odds ratio 4.96 (2.49-9.88); dementia in 5.6% versus 1.9%, odds ratio 3.09 (1.08-8.84); Parkinson's disease in 2.5% versus 2.2%, odds ratio 1.14 (0.33-3.94); epilepsy in 2.5% versus 0.6%, odds ratio 4.04 (0.73-22.3); and multiple sclerosis in 0 versus 0.3% odds ratio 1.00 (0.98-1.01). LIMITATIONS: The main limitations of our study were referral bias, retrospective design and a rather low sample size. CONCLUSIONS: Neurological diseases in general, and stroke and dementia in particular, were significantly associated with bullous pemphigoid in our study.

[Neurologic diseases in a rural tropical area: experience at a primary health care center in the Boeny region of Madagascar]. / Pathologies neurologiques en milieu tropical et rural : expérience malgache d'un centre de santé primaire de la région de Boeny.

There is, to our knowledge, no study reporting the demand for health care related to neurological diseases in rural tropical areas of developing countries. Neurology is nonetheless more or less closely related to the priority health issues in these countries. Over a 6-week period, 626 patients were seen at the primary health center in the town of Madirovalo, Madagascar. Neurological disorders accounted for 11.1% of the consultations. The neurological disorders most frequently leading to consultations were headaches (42.7%), with primary headaches accounting for 16%; next came leprosy neuropathy (14.7%), with a worrisome total of 8 new cases; other peripheral neuropathies (13.3%), and epilepsy (12%). The relatively low share of the latter seems likely related to families' frequent use of traditional healers rather than Western medicine. Neurological diseases appears to represent a significant part of the health-care demand of people living in rural tropical areas of developing countries, and specific support in this specialization is essential.

Rabies, tetanus, leprosy, and malaria.

The developing world is still endemic to rabies, tetanus, leprosy, and malaria. Globally more than 55000 people die of rabies each year, about 95% in Asia and Africa. Annually, more than 10 million people, mostly in Asia, receive postexposure vaccination against the disease. World Health Organization estimated tetanus-related deaths at 163000 in 2004 worldwide. Globally, the annual detection of new cases of leprosy continues to decline and the global case detection declined by 3.54% during 2008 compared to 2007. Malaria is endemic in most countries, except the US, Canada, Europe, and Russia. Malaria accounts for 1.5-2.7 million deaths annually. Much of the disease burden related to these four infections is preventable.

[Hans Schliack (1919 - 2008): a personal and professional appraisal]. / Hans Schliack (1919 - 2008): Eine persönliche und wissenschaftliche Würdigung.

Hans Schliack (1919 -2008) was one of the prominent post war neurologists who acted successfully for the emancipation of clinical neurology in the former western part of Berlin and Germany. His scientific work was destined to the theory of segments (dermatomes, myotomes, zones of Head, initially with Karl Hansen in Lübeck), sweat disturbances in neurological disorders and peripheral nerve lesions. The latter issue led - in cooperation with Marco Mumenthaler - to the textbook, which held its leading standard since its first edition in 1965. Schliack's founding editorship of the purely neurological journal "Aktuelle Neurologie" since 1974, his author- and editorship of neurological textbooks and his teaching of numerous coworkers in Berlin and Hannover stress his outstanding role over nearly five decades.

Evaluation of simplified tests for the diagnosis of nerve function impairment in leprosy: the Sensory Motor Screening (SMS) study.

OBJECTIVE: Rapid and simple tests for diagnosing nerve function impairment (NFI) in leprosy are required in integrated settings. We examined whether simplified tests performed by newly trained general health workers (GHWs) have comparable diagnostic accuracy to the reference test conducted by experienced physiotherapists. DESIGN: This multi-centre study from India and Bangladesh evaluated three simplified tests named: ILEP Learning Guide Two (M2), Indian dance (M3), and a questionnaire (M4) in 408 people affected by leprosy. Sensitivity (Se) and specificity (Sp) of the three tests were calculated using the full assessment (M1) as reference. Se and Sp were calculated at both whole body and individual nerve levels: whether any NFI and if single NFI (voluntary muscle testing of lid gap, eye closure, little finger out, thumb up and foot up, sensory testing of hands and of feet) was present. RESULTS: M2 had 83% Se and 69% Sp, M3 had 76% Se and 84% Sp and M4 had 85% Se and 46% Sp in diagnosing any NFI. At the level of single NFI, M2 was most or similarly accurate in diagnosing single NFIs with highest prevalence (ST feet, ST hands, little finger out, thumb up), compared to M3 and M4. CONCLUSIONS: ILEP Learning Guide Two (M2) and Indian dance (M3) were found to be the most accurate simplified tests for diagnosing the presence of NFI compared to the reference. M2 was the most useful test, because of greatest accuracy for most of the common types of NFI and inclusion of sensory testing of the hands. M2 is considered to be a useful tool in the hands of GHWs with time constraints in integrated settings.

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.

Intra- and inter-tester reliability of sensibility testing in leprosy.

We conducted an intra- and inter-tester agreement study of three sensory screening tests used in nerve function assessment of leprosy patients: the Semmes-Weinstein monofilament (SWM) test, moving 2-point discrimination (M2PD), and the pin prick test. The weighted kappa (Kw) statistic was used as the reliability coefficient. The SWM had intra-observer Kws ranging from 0.83 to 0.92 and inter-observer Kws ranging from 0.76 to 0.89. The M2PD had intra- and inter-tester Kws ranging from 0.75 to 0.82 and 0.54 to 0.82, respectively. Inter-tester agreement for the pin prick test ranged from 0.45 to 0.85. There was evidence that the main source of variability between testers was testing skill and experience. Among the experienced physiotechnicians there was no significant difference between intra- and inter-tester reliability. We conclude that reliability of the SWM test was very good, closely followed by the M2PD test. Reliability of the pin prick test was less good than that of the SWM and M2PD, making it less suitable for serial testing.

Un neurologo en el bosque / A neurologist in the forest

Para los que ya están formados y los que vendrán, las páginas que hoy presento en la esperanza de brindar por un lado ejemplos, episodios, anécdotas y por el otro enseñanzas que considero serán de utilidad. Se injertan en estas páginas conceptos teóricos y prácticos que están escritos algunos en textos de neurología, pero algunos no lo están por ser producto personal, resultado de la observación, de la intuición del médico, de las comparaciones. No pretendo ser completo sino simplemente quiero trasladar al papel ejemplos de curiosidades médicas, salpicado de comentarios diversos conducentes a contribuir con un granito de arena al conocimiento. Si vuestro tiempo gastado en la lectura, llega a ser, aunque más no sea una distracción pasajera, matizado de algún agregado al conocimiento, me sentiré satisfecho. Un cuadro psiquiátrico. Psicosis esquizofrénica. Crisis hipertensiva?. Parálisis general progresiva P.G.P. Dorsalgia y psicosis. Cefalea postraumática. Sinusitis. Cefalalgia por sinusitis: oxigenoterapia. Depresión reactiva. Arteriosclerosis cerebral?. Crisis convulsivas. Alucinaciones visuales. Psicosis progresiva. Cáncer terminal de origen desconocido. El paciente de Pavlov. Poliomielitis. Miastenia. Miscelaneas entre páginas (ref. fotomotor, midriasis, Claude Bernard Horner versus III par. Síndrome de las Tres A). Paraplejía aguda por arma de fuego. Síndrome de insuficiencia vertebral versus tumor cerebeloso. Reflejo radial. Variante. Sección del crural por arma blanca. El reflejo plantar patológico: Babinsky. Hematoma epidural. Notas del T. E. C. Miscelanea (lepra). El signo de la rueda dentada de Negro. Coma (curiosidades). Coma traumático con recuperación postquirúrgica incompleta. Raro diagnóstico. Cual es el turno siguiente?. Anticonceptivos. Anticonvulsivos. Uso discriminado. Líquido cefaloraquídeo. Miscelaneas (disfonia, insólito). Amaurosis bilateral. Amor propio y dignidad. Manuel de Falla. Paraplejía aguda

Un neurologo en el bosque / A neurologist in the forest

Para los que ya están formados y los que vendrán, las páginas que hoy presento en la esperanza de brindar por un lado ejemplos, episodios, anécdotas y por el otro enseñanzas que considero serán de utilidad. Se injertan en estas páginas conceptos teóricos y prácticos que están escritos algunos en textos de neurología, pero algunos no lo están por ser producto personal, resultado de la observación, de la intuición del médico, de las comparaciones. No pretendo ser completo sino simplemente quiero trasladar al papel ejemplos de curiosidades médicas, salpicado de comentarios diversos conducentes a contribuir con un granito de arena al conocimiento. Si vuestro tiempo gastado en la lectura, llega a ser, aunque más no sea una distracción pasajera, matizado de algún agregado al conocimiento, me sentiré satisfecho. Un cuadro psiquiátrico. Psicosis esquizofrénica. Crisis hipertensiva?. Parálisis general progresiva P.G.P. Dorsalgia y psicosis. Cefalea postraumática. Sinusitis. Cefalalgia por sinusitis: oxigenoterapia. Depresión reactiva. Arteriosclerosis cerebral?. Crisis convulsivas. Alucinaciones visuales. Psicosis progresiva. Cáncer terminal de origen desconocido. El paciente de Pavlov. Poliomielitis. Miastenia. Miscelaneas entre páginas (ref. fotomotor, midriasis, Claude Bernard Horner versus III par. Síndrome de las Tres A). Paraplejía aguda por arma de fuego. Síndrome de insuficiencia vertebral versus tumor cerebeloso. Reflejo radial. Variante. Sección del crural por arma blanca. El reflejo plantar patológico: Babinsky. Hematoma epidural. Notas del T. E. C. Miscelanea (lepra). El signo de la rueda dentada de Negro. Coma (curiosidades). Coma traumático con recuperación postquirúrgica incompleta. Raro diagnóstico. Cual es el turno siguiente?. Anticonceptivos. Anticonvulsivos. Uso discriminado. Líquido cefaloraquídeo. Miscelaneas (disfonia, insólito). Amaurosis bilateral. Amor propio y dignidad. Manuel de Falla. Paraplejía aguda

A comparison of sensory loss tests and histopathology in the diagnosis of leprosy.

Three different sensory loss tests, for anaesthesia to light touch, for diminished pain sensation and for loss of thermosensation, were compared with histopathological examination results in the diagnosis of suspected tuberculoid leprosy in 120 individuals with 126 lesions. Though none of the 3 tests used in this study was found to be strikingly superior to any of the others, the results indicate potentially important differences in their usefulness in different subgroups of suspected patients. The methodological problems inherent in such studies are discussed.