National Health Survey reveals high percentage of signs and symptoms of leprosy in Brazil. / Pesquisa Nacional de Saúde revela alto percentual de sinais e sintomas de hanseníase no Brasil.

Leprosy is a debilitating, infectious, systemic or localized dermato-neurological disease caused by Mycobacterium lepra. In Brazil, the magnitude and high disabling power keep the disease as a public health problem. Skin spotting and numbness are pathognomonic signs and symptoms in leprosy. The Instituto Brasileiro de Geografia e Estatística (IBGE) 2019 National Health Survey (PNS-2019) considered the following question as a proxy to estimate its magnitude in the country. "Do you have a spot with numbness or part of the skin with numbness?". In Brazil, 1,921,289 adults reported having a patch or part of the skin with numbness, with no regional differences. As for the age group, the older, the higher the prevalence, for example, between 18 to 29 years old (235,445) and 30 to 39 years old (236,485), 0.7% had the condition, between 40 to 59 years old (827,887), 1.5% and among the elderly, 1.8% (621,472). Being able to estimate, in population-based surveys, with statistical representativeness, a reported morbidity such as leprosy is essential to support the formulation of public policies, notably those related to primary health care actions. In this way, the IBGE fulfills its constitutional role of portraying the reality of the Brazilian population and today it is the main external evaluator of the Unified Health System (SUS) and of public policies developed by the federal level.

A hanseníase é uma doença dermato-neurológica, infecciosa, sistêmica ou localizada, debilitante, causada por Mycobacterium leprae. No Brasil, a magnitude e o alto poder incapacitante mantêm a doença como um problema de saúde pública. Mancha na pele e dormência são sinais e sintomas patognomônicos na hanseníase. A Pesquisa Nacional de Saúde de 2019 (PNS-2019), do Instituto Brasileiro de Geografia e Estatística (IBGE), considerou a seguinte pergunta como proxy para estimar sua magnitude no país. "O(a) sr(a). tem mancha com dormência ou parte da pele com dormência?". No Brasil, 1.921.289 adultos referiram ter mancha ou parte da pele com dormência, sem diferenças regionais. Com relação ao grupo etário, quanto mais velho, maior a prevalência. Por exemplo, entre os de 18 a 29 anos (235.445) e de 30 a 39 anos (236.485), 0,7% possuía a condição, entre 40 e 59 anos (827.887), 1,5%, e entre os idosos, 1,8% (621.472). Poder estimar, em pesquisas de base populacional, com representatividade estatística, uma morbidade referida tal como a hanseníase é fundamental para apoiar a formulação de políticas públicas, notadamente as relativas às ações da atenção primária à saúde. Dessa forma, o IBGE cumpre seu papel constitucional de retratar a realidade da população brasileira e hoje é o principal avaliador externo do Sistema Único de Saúde (SUS) e das políticas públicas instituídas no âmbito federal.

Disfiguring facial lesions and loss of sensation.

Hansen disease (leprosy) continues to be prevalent in some regions of Africa, Asia, and South America, and each year 100 to 300 cases are reported in the United States, especially in immigrants and patients exposed to armadillos. Treatment depends on patient presentation. Hansen disease remains highly stigmatized, though it is now clear that it is not readily transmitted through casual physical contact.

Lepra neural pura de 18 años de evolución / 18 years of pure neuritic leprosy

La lepra puede presentar dificultades diagnósticas, especialmente en la forma neural primaria. Un hombre de 38 años, exsoldado y trabajador rural, presentó durante más de 10 años hiperestesia supraclavicular y supraescapular izquierdas y anestesia progresiva escapular y en guante de la mano y brazo izquierdos, con reabsorción ósea de las falanges distales del primero y segundo dedos de la misma mano, cambios que le dificultaban realizar sus labores; no tenía lesiones cutáneas de lepra. El nervio cubital izquierdo presentaba engrosamiento epitroclear, por lo que se sospechó lepra neural pura. Las baciloscopias de moco, pabellones auriculares y codos fueron negativas, al igual que los anticuerpos IgM contra el glicolípido fenólico 1; dos biopsias de piel de zonas anestésicas fueron normales también. La electromiografía evidenció disminución notoria de los potenciales sensitivos de los nervios cubital, radial y mediano izquierdos, lo cual favoreció el diagnóstico de lepra neural primaria. Se inició tratamiento para lepra multibacilar por tener afección de más de un tronco nervioso, dos meses después comenzó a presentar mejoría notoria de los síntomas y logró reanudar sus actividades comunes y laborales. La lepra neural primaria cursa con zonas de hipoestesia y anestesia cutánea y engrosamiento neural troncular, puede permanecer sin diagnóstico durante años. La electromiografía, que demuestra disminución de los potenciales sensitivos, es una ayuda diagnóstica considerable, mientras la biopsia de piel anestésica ayuda al diagnóstico solo en la tercera parte de los casos. La sospecha clínica razonable es suficiente para iniciar tratamiento antileproso, cuando no se dispone de otros medios diagnósticos.

Leprosy can be difficult to diagnose, in particular the pure neuritic leprosy type. A 38-year-old male, former soldier and rural worker, presented with a 10-year history of supraclavicular and suprascapular hyperesthesia of the left side and progressive scapular left arm anesthesia, including the hand, associated with bone resorption in distal phalanges of the first and second finger. No typical leprosy skin changes were present. An examination of the skin revealed epitrochlear thickening of the left side cubital nerve, therefore primary neural leprosy was suspected. Skin smears from the routine sites were normal, as were two skin biopsies and the serologic assay specific for M leprae to detect phenolic glycolipid-1. Electromyography revealed an important reduction in the sensory action potential of the ulnar, radial and medial nerves, which favored the primary neural leprosy diagnosis. After two months of multibacillar leprosy treatment, the symptoms started to disappear and the patient could recommence his old job. Pure neuritic leprosy presents with skin areas of hypesthesia and anesthaesia associated with nerve thickening. It is a disease that is commonly misdiagnosed for several years before the correct diagnosis is made and effective treatment is started. Electromyography can be a helpful tool in the diagnosis, typically showing reduced sensory action potential, while a biopsy of anesthetic skin is only helpful in one-third of cases. Reasonable clinical suspicion is sufficient to initiate antileprosy treatment when no other diagnostic methods are available.

Novel presentation of lepromatous leprosy in an erythema gyratum repens-like pattern.

OBJECTIVES: Leprosy can have diverse cutaneous and occasionally perplexing presentations. We report an unusual case of lepromatous leprosy (LL) with annular lesions resembling erythema gyratum repens. REPORT: A 55-year-old man presented with a symmetrical, hypopigmented, and erythematous rash of bizarre appearance over the lateral aspect of the upper arm, and anterior and posterior aspects of the trunk of two months' duration. He gave a history of self-resolving episodes of bilateral pedal edema, and numbness and pricking sensations in both the hands and feet, which had occurred intermittently over the previous six years. An ulcer measuring 2 cm in size was present over the adjacent surface of the right first and second toes. The bilateral ulnar and radial cutaneous nerves were symmetrically thickened. RESULTS: Slit-skin smears revealed numerous acid-fast bacilli. Skin biopsy from the trunk showed collections of histiocytes, lymphocytes, and plasma cells in the dermis and around the blood vessels. The patient was diagnosed with LL and started on multibacillary multi-drug therapy. CONCLUSIONS: Lepromatous leprosy can have varied clinical manifestations and is often a great imitator. However, the skin smear positivity, even in normal skin, symmetrical cutaneous and peripheral nerve involvement, and histopathology in the present patient were indicative of LL. This report highlights a rare presentation of leprosy. Clinicians should be aware of these rare manifestations as lepromatous cases still occur in certain regions.

A case of Hansen Disease presenting as tinea versicolor.

Hansen Disease (leprosy) is an infectious disease that targets macrophages and Schwann cells, caused by the acid fast intracellular organism, Mycobacterium leprae. Clinically, it presents with a spectrum of findings that may include hypopigmented macules, erythematous plaques and nodules, and thickened or tender peripheral nerves. The most feared complication is mutilating damage to facial structures or digits resulting from loss of sensation in affected skin. In non-endemic areas, the diagnosis of leprosy is frequently delayed because it may mimic other more common skin conditions. We present a case of borderline/lepromatous leprosy in an otherwise healthy young Brazilian man that was initially diagnosed as tinea versicolor, but did not respond to appropriate treatment. This case highlights the importance of having a high index of suspicion for leprosy in patients from endemic areas who present with lesions that could be consistent with this disease.

Leprosy with ANA positive mistaken for connective tissue disease.

Leprosy is associated with the occurrence of various skin lesions such as macules, papules, plaques, nodules, and even diffused infiltration, depending on the patient's immune response. Its clinical presentation is often different from the usual pattern, leading to confusion in diagnosis. We present a case of leprosy with ANA positive that was mistaken for connective tissue disease. In this case, we want to tell that doctors should not only depend on laboratory index for diagnosis, the misdiagnosis may lead to delaying illness and aggravating illness.

Avaliação sensitiva de hansenianos pelos monofilamentos Semmes-Weinstein em serviço terciário de fisioterapia / Effectiveness of Semmes-Weinstein monofilaments in leprosy neuropathy in physiotherapy tertiary sevice

OBJETIVOS: Identificar a frequência das alterações da sensibilidade de mãos e pés de hansenianos através dos monofilamentos Semmes-Weinstein no hospital terciário.MÉTODO: Trinta pacientes do setor de fisioterapia do Hospital da Clínicas da FMRP-USP foram avaliados clinico-epidemiologicamente e submetidos ao teste por monofilamentos de agosto a dezembro de 2004.RESULTADOS: A média de idade dos pacientes foi de 48,4 anos, sendo 80% do sexo masculino e 70% oriundos da região de Ribeirão Preto. Classificavam-se como multibacilares 70% dos pacientes e 80% apresentavam-se com Grau I de incapacidade. Quanto ao teste nos membros superiores, o nervo ulnar foi o mais acometido nos paucibacilares (78%) e nos multibacilares (83%). Nos membros inferiores, o ramo plantar medial do nervo tibial posterior encontrou-se acometido em todos os pacientes do grupo multibacilar. A sensação protetora estava ausente nas mãos em 26% no grupo pauci e 46% no multibacilar, e nos pés 44% no paucibacilar e 56% no multibacilar. O diagnóstico foi tardio em 37% dos pacientes, apresentando no mínimo dois nervos com perda da sensação protetora.CONCLUSÃO: Os resultados evidenciaram que o acompanhamento da neuropatia da hanseníase pelos monofilamentos S-W, mostrou-se capaz de identificar alterações da sensibilidade em múltiplos nervos das extremidades, tanto nos pacientes paucibacilares quanto multibacilares, tornando-se evidente a gravidade dos pacientes atendidos nos serviço de atenção terciária à saúde.

OBJECTIVES: To identify the frequency of changes in the sensibility of hands and feet from leprosy patients through the Semmes-Weinstein monofilament in tertiary hospital.METHOD: Thirty patients of the Physiotherapy Service of Hospital das Clínicas FMRP-USP were evaluated from August to December 2004. The patients were clinically and epidemiologically evaluated. Afterwards, monofilaments were tested.RESULTS: The mean age was 48.4 years, 80% male and 70% came from the Ribeirão Preto region. Seventy percent of the patients were classified as multibacilary and 80% presented grade 1 of incapacity. Concerning to Semmes-Weinstein test on the upper limbs, the ulnar was the most impaired nerve on the paucibacillary patients (78%) and on the multibacillary (83%). On the lower limbs, the plantar medial branch from the tibial posterior nerve had been impaired in all patients. The protective sensation was absent on the hands in 26% on the paucibacillary group and 46% on the multibacillary, and on the feet in 44% on the paucibacillary and 56% on the multibacillary. Thirty seven percent of the patients have received late diagnosis, showing at least two nerves without protective sensation.CONCLUSIONS: The results showed the reliable use of Semmes-Weinstein monofilaments during the follow up of leprosy patients. This tool was able to identify sensitive changes in multiple nerves of the extremities, for paucibacilary and multibacilary patients, what clearly shows the severity of incoming patients in health tertiary care service.

Local corticosteroid treatment for carpal tunnel syndrome: a 6-month clinical and electrophysiological follow-up study.

OBJECTIVE: To evaluate the clinical and electrophysiological effects of local depo-methylprednisolone injection in patients with carpal tunnel syndrome (CTS) over a 6-months period. METHODS: Twenty one patients, of whom 7 were lost for follow-up (mean age 57.9 +/- 8.4) with clinical and electrophysiological evidence of CTS were treated by injection of depo-methylprednisolone 40 mg proximal to the carpal tunnel. Severity of pain (VAS), rates of numbness/paresthesias and nocturnal awakening, motor and sensory nerve conduction studies were used as outcomes. All tests were performed before, 1, 3 and 6 months after the injection. RESULTS: Severity of pain was significantly reduced at all follow-up time points (p < 0.001). Prior to injection all patients complained of night pain and awakening. On the first, third and sixth months, 0(0%), 4 (29%) and 7 (50%) of the patients, respectively, had night awakening. All patients complained of numbness before the treatment. This symptom disappeared in 81% of the patients after one month and reappeared in all after three months. Significant improvement was shown in the mean distal motor latency (DML) of the median nerve: 5.2 +/- 0.9 msec. before, 4.6 +/- 0.6 msec. and 4.7 +/- 0.6 msec. 1 and 3 months after the injection, respectively (p < 0.05). Mean values of motor muscle potential amplitudes, sensory latency and sensory amplitude did not change significantly after the treatment. CONCLUSIONS: Local corticosteroid injection for the treatment of CTS provides significant symptom improvement for three months. No electrophysiological parameters were improved after injection, except the improvement in distal motor latency of the median nerve.

Lepromatous leprosy.

Lepromatous leprosy is a form of chronic granulomatous disease that is caused by infection with Mycobacterium leprae. Early involvement is marked by widespread, ill-defined, erythematous papules and plaques. With early intervention, leprosy is a curable disease; however, if not recognized and treated promptly, permanent sequelae and disability result. We present a patient with long-standing lepromatous leprosy who exhibits many of these sequelae.