Comparing the clinical and histological diagnosis of leprosy and leprosy reactions in the INFIR cohort of Indian patients with multibacillary leprosy.

BACKGROUND: The ILEP Nerve Function Impairment in Reaction (INFIR) is a cohort study designed to identify predictors of reactions and nerve function impairment in leprosy. The aim was to study correlations between clinical and histological diagnosis of reactions. METHODOLOGY/PRINCIPAL FINDINGS: Three hundred and three newly diagnosed patients with World Health Organization multibacillary (MB) leprosy from two centres in India were enrolled in the study. Skin biopsies taken at enrolment were assessed using a standardised proforma to collect data on the histological diagnosis of leprosy, leprosy reactions and the certainty level of the diagnosis. The pathologist diagnosed definite or probable Type 1 Reactions (T1R) in 113 of 265 biopsies from patients at risk of developing reactions whereas clinicians diagnosed skin only reactions in 39 patients and 19 with skin and nerve involvement. Patients with Borderline Tuberculoid (BT) leprosy had a clinical diagnosis rate of reactions of 43% and a histological diagnosis rate of 61%; for patients with Borderline Lepromatous (BL) leprosy the clinical and histological diagnosis rates were 53.7% and 46.2% respectively. The sensitivity and specificity of clinical diagnosis for T1R was 53.1% and 61.9% for BT patients and 61.1% and 71.0% for BL patients. Erythema Nodosum Leprosum (ENL) was diagnosed clinically in two patients but histologically in 13 patients. The Ridley-Jopling classification of patients (n = 303) was 42.8% BT, 27.4% BL, 9.4% Lepromatous Leprosy (LL), 13.0% Indeterminate and 7.4% with non-specific inflammation. This data shows that MB classification is very heterogeneous and encompasses patients with no detectable bacteria and high immunological activity through to patients with high bacterial loads. CONCLUSIONS/SIGNIFICANCE: Leprosy reactions may be under-diagnosed by clinicians and increasing biopsy rates would help in the diagnosis of reactions. Future studies should look at sub-clinical T1R and ENL and whether they have impact on clinical outcomes.

History of medicine: the metamorphosis of scientific medicine in the ever-present past.

Hippocrates (460-370 BCE), the father of medicine, developed principles for medical diagnosis and treatment together with a code of ethics. When the first Ptolemy ruled Egypt, he created a great library of 700,000 rolls at Alexandria, which became a repository for the works of Socrates, Plato, Aristotle, Hippocrates, and all the writings of the known world, but it was destroyed by a great fire. Galen of Pergamum (129-216), who lived 500 years after Hippocrates, was well educated and studied anatomy, surgery, drugs and Hippocratic medicine. His ideas influenced medical thinking for the next 1500 years. The Arabic physician Ibn Sina (Avicenna) wrote a great medical work entitled Canon of Medicine. After the Dark Ages (500 to 1050), academic medicine was reestablished in Europe, especially at Salerno, Bologna, Padua, Paris, Montpellier, and Oxford. The greatest medical disaster of the Middle Ages was the Black Death. Other diseases of note were leprosy, smallpox, tuberculosis, typhus, measles, diarrhea, meningitis, and colic. As interest in human dissection increased, the study of anatomy became popular. With development of the printing press, medical knowledge became more widely disseminated and technical advances in science flourished. Advances in medicine occurred in concert with developments in technology. These included the microscope, the stethoscope, anesthetic agents, discoveries in bacteriology, a carbolic acid spray to reduce infection during surgery, the clinical thermometer, blood transfusions, electrocardiography, X-rays, and the sphygmomanometer. Johns Hopkins University was established at the end of the 19th century to train scientifically knowledgeable physicians. The first faculty included Welch, Osler, Halstead, Kelly, Mall, and Abel. Graduates of the new school carried scientific medicine to universities throughout America. More medical advances have been made during the 20th century than in all the other centuries combined. Advances in medical knowledge have resulted not only from developments in technology but from increased access to current information provided through libraries such as the National Library of Medicine in Bethesda, Maryland.