Asymmetric Nerve Enlargement: A Characteristic of Leprosy Neuropathy Demonstrated by Ultrasonography.

BACKGROUND: Neurological involvement occurs throughout the leprosy clinical spectrum and is responsible for the most feared consequences of the disease. Ultrasonography (US) provides objective measurements of nerve thickening and asymmetry. We examined leprosy patients before beginning multi-drug therapy aiming to describe differences in US measurements between classification groups and between patients with and without reactions. METHODOLOGY/PRINCIPAL FINDINGS: Eleven paucibacillary (PB) and 85 multibacillary (MB) patients underwent nerve US. Twenty-seven patients had leprosy reactions (type 1, type 2 and/or acute neuritis) prior to US. The ulnar (at the cubital tunnel-Ut-and proximal to the tunnel-Upt), median (M) and common fibular (CF) nerves were scanned to measure cross-sectional areas (CSAs) in mm2 and to calculate the asymmetry indexes ΔCSA (absolute difference between right and left CSAs) and ΔUtpt (absolute difference between Upt and Ut CSAs). MB patients showed greater (p<0.05) CSAs than PB at Ut (13.88±11.4/9.53±6.14) and M (10.41±5.4/6.36±0.84). ΔCSAs and ΔUtpt were similar between PB and MB. The CSAs, ΔCSAs and ΔUtpt were similar between PB patients with reactions compared to PB patients without reactions. MB patients with reactions showed significantly greater CSAs (Upt, Ut and M), ΔCSAs (Upt and Ut) and ΔUtpt compared to MB patients without reactions. PB and MB showed similar frequencies of abnormal US measurements. Patients with reactions had higher frequency of nerve thickening and similar frequency of asymmetry to those without reactions. CONCLUSIONS/SIGNIFICANCE: This is the first study to investigate differences in nerve involvement among leprosy classification groups using US before treatment. The magnitude of thickening was greater in MB and in patients with reactions. Asymmetry indexes were greater in patients with reactions and did not significantly differ between PB and MB, demonstrating that asymmetry is a characteristic of leprosy neuropathy regardless of its classification.

Degree of disability, pain levels, muscle strength, and electromyographic function in patients with Hansen's disease with common peroneal nerve damage.

INTRODUCTION: This study evaluated the degree of disability, pain levels, muscle strength, and electromyographic function (RMS) in individuals with leprosy. METHODS: We assessed 29 individuals with leprosy showing common peroneal nerve damage and grade 1 or 2 disability who were referred for physiotherapeutic treatment, as well as a control group of 19 healthy participants without leprosy. All subjects underwent analyses of degree of disability, electromyographic tests, voluntary muscle force, and the Visual Analog Pain Scale. RESULTS: McNemar's test found higher levels of grade 2 of disability (Δ = 75.9%; p = 0.0001) among individuals with leprosy. The Mann-Whitney test showed greater pain levels (Δ = 5.0; p = 0.0001) in patients with leprosy who had less extension strength in the right and left extensor hallucis longus muscles (Δ = 1.28, p = 0.0001; Δ = 1.55, p = 0.0001, respectively) and dorsiflexion of the right and left feet (Δ = 1.24, p = 0.0001; Δ = 1.45, p = 0.0001, respectively) than control subjects. The Kruskal-Wallis test showed that the RMS score for dorsiflexion of the right (Δ = 181.66 m·s-2, p = 0.001) and left (Δ = 102.57m·s-2, p = 0.002) feet was lower in patients with leprosy than in control subjects, but intragroup comparisons showed no difference. CONCLUSIONS: Leprosy had a negative influence on all of the study variables, indicating the need for immediate physiotherapeutic intervention in individuals with leprosy. This investigation opens perspectives for future studies that analyze leprosy treatment with physical therapeutic intervention.

Degree of disability, pain levels, muscle strength, and electromyographic function in patients with Hansen's disease with common peroneal nerve damage / Grau de incapacidade, níveis de dor, força muscular e função eletromiográfica em portadores de hanseníase com lesão do nervo fibular comum

INTRODUCTION: This study evaluated the degree of disability, pain levels, muscle strength, and electromyographic function (RMS) in individuals with leprosy. METHODS: We assessed 29 individuals with leprosy showing common peroneal nerve damage and grade 1 or 2 disability who were referred for physiotherapeutic treatment, as well as a control group of 19 healthy participants without leprosy. All subjects underwent analyses of degree of disability, electromyographic tests, voluntary muscle force, and the Visual Analog Pain Scale. RESULTS: McNemar's test found higher levels of grade 2 of disability (Δ = 75.9%; p = 0.0001) among individuals with leprosy. The Mann-Whitney test showed greater pain levels (Δ = 5.0; p = 0.0001) in patients with leprosy who had less extension strength in the right and left extensor hallucis longus muscles (Δ = 1.28, p = 0.0001; Δ = 1.55, p = 0.0001, respectively) and dorsiflexion of the right and left feet (Δ = 1.24, p = 0.0001; Δ = 1.45, p = 0.0001, respectively) than control subjects. The Kruskal-Wallis test showed that the RMS score for dorsiflexion of the right (Δ = 181.66 m·s-2, p = 0.001) and left (Δ = 102.57m·s-2, p = 0.002) feet was lower in patients with leprosy than in control subjects, but intragroup comparisons showed no difference. CONCLUSIONS: Leprosy had a negative influence on all of the study variables, indicating the need for immediate physiotherapeutic intervention in individuals with leprosy. This investigation opens perspectives for future studies that analyze leprosy treatment with physical therapeutic intervention.

INTRODUÇÃO: O objetivo do estudo foi avaliar o grau de incapacidade, níveis de dor, força muscular e a função eletromiográfica (RMS) em indivíduos portadores de hanseníase. MÉTODOS: A amostra foi composta de um grupo de 29 sujeitos portadores de hanseníase, apresentando lesão do nervo fibular comum e grau 1 ou 2 de incapacidade, com indicação ao tratamento fisioterapêutico, e um grupo controle de 19 indivíduos saudáveis, sem hanseníase. Os sujeitos foram submetidos à análise do grau de incapacidade, testes de eletromiografia, de força muscular voluntária e da Escala Visual Analógica (EVA) para a dor. RESULTADOS: O teste de McNemar mostrou maior prevalência do grau dois de incapacidade (Δ=75,9%; p=0,0001) entre os indivíduos com hanseníase. O teste de Mann-Whitney revelou maiores níveis de dor (Δ=5,0; p=0,0001) nos pacientes com hanseníase apresentando menores níveis de força muscular da extensão do hálux direito e esquerdo (Δ=1,28, p=0,0001; Δ=1,55, p=0,0001) e flexão dorsal do pé direito e esquerdo (Δ=1,24, p=0,0001; Δ=1,45, p=0,0001) do que os indivíduos sem hanseníase. O teste de Kruskal-Wallis revelou que os valores do RMS da flexão dorsal dos pés direito (Δ=181,66m.s-², p=0,001) e esquerdo (Δ=102,57m.s-2, p=0,002) apresentaram menores valores que o grupo controle em ambos os lados, mas as comparações intragrupos não mostraram diferenças. CONCLUSÕES: Conclui-se que a hanseníase altera todas as variáveis analisadas na pesquisa, indicando a necessidade de intervenção fisioterapêutica imediata nos sujeitos com Hanseníase. Esta investigação abre perspectivas de futuras pesquisas que analisem o tratamento da hanseníase com intervenção fisioterapêutica.

Infectious neuropathies.

Peripheral neuropathies can result from several infective agents, ranging from viruses, especially retroviruses, to parasites and bacilli. Leprosy, which often is considered a disorder of the past, still is common in dome geographic areas, especially in Africa, South America, and Asia. An increasing number of cases of neuropathies occurs in patients who have HIV or Lyme disease. The important point is that all these neuropathies are treatable and often preventable.

Ganglion cyst of the proximal tibiofibular joint causing foot drop-diagnostic problem of differentiating from neuritic leprosy.

A six-year old boy presented with pain around the knee joint and abnormal gait of one month duration. There was no history of hypopigmented anaesthetic patches, neuritis or family history of leprosy. Clinical examination revealed a localized cystic swelling of 1 x 1 cm in size in the region of left common peroneal nerve, with sensory loss on the lateral aspect of the left leg which was mistaken for a nerve abscess.

Isolated superficial peroneal nerve lesion in pure neural leprosy: case report.

Patients with leprosy may have only nerve involvement without skin changes. These cases are known as pure neural leprosy and can be seen in 10% of leprosy patients. Most patients have mononeuritic or multiple mononeuritic neuropathy patterns. The isolated lesion of the superficial peroneal nerve is uncommonly seen. We report a patient with involvement of this nerve in which there was no thickening of superficial nerves. The performed nerve biopsy showed inflammatory infiltration, loss of fibers and presence of Mycobacterium leprae. We believe that in prevalent leprosy countries we should take in mind the possibility of isolated pure neural leprosy in some patients without skin lesion. In these cases the diagnosis of leprosy is impossible on clinical grounds and nerve biopsy is mandatory.

Isolated superficial peroneal nerve lesion in pure neural leprosy: case report

Em alguns casos de lepra podemos encontrar acometimento de nervos periféricos sem manifestações cutâneas. É a denominada lepra neurítica pura que pode ocorrer em até 10% dos casos desta doença. Na maioria das vezes predominam quadros de mononeuropatia ou mononeuropatia múltipla. O acometimento isolado do nervo peroneiro superficial tem sido pouco relatado. Referimos a uma paciente com acometimento isolado deste nervo sem hipertrofia de troncos nervosos. A biópsia realizada mostrou presença de infiltrado inflamatório, perda moderada de fibras e presença do Mycobacterium leprae. Acreditamos que, em países onde a lepra é endêmica, diante de acometimento isolado de nervos periféricos, deve-se pensar na possibilidade de se tratar da forma neurítica pura desta moléstia, mesmo em pacientes sem alterações dermatológicas. Nestes casos o diagnóstico só será possível com a realização de biópsia de nervo superficial.

[Transposition of the tendon of M. tibialis posterior an effective treatment of drop foot; retrospective study with follow-up in 12 patients]. / Transpositie van de pees van de M. tibialis posterior effectief bij een klapvoet; retrospectief onderzoek met follow-up bij 12 patiënten.

OBJECTIVE: To evaluate the results of transposition of the tendon of the M. tibialis posterior in patients with a drop foot. DESIGN: Descriptive, retrospective and follow-up investigation. METHODS: Surgical treatment was carried out in 12 patients with a drop foot (9 women and 3 men, with an average age of 37 years) in the period 1986-1998. The aetiology of the drop foot was a traumatic or iatrogenic lesion of the peroneal nerve or sciatic nerve in 9 patients and in 3 patients spina bifida occulta, leprosy and a herniation of a lumbar disc respectively. None of the patients had important comorbidity. Treatment consisted of lengthening the Achilles tendon according to Huckstep, transposition of the tibial posterior tendon in two tails to the dorsomedial and dorsolateral side of the foot, and six weeks of immobilisation in plaster of Paris. RESULTS: The postoperative period was without complications. The treatment improved the heel-toe steppage gait in all patients. None of the 10 patients who had used an orthosis preoperatively still used it at the time of the follow up. Fifty per cent of the patients acquired a dorsiflexion of the foot of more than 0 degree. The results were in accordance with those in the literature. CONCLUSION: Transposition of the tibial posterior tendon is a worthwhile alternative for those patients with a drop foot (and without important comorbidity) who cannot walk satisfactorily with an ankle-foot orthosis.

Cytological needle aspiration of the nerve for the diagnosis of pure neural leprosy.

Pure neural (also called primary neuritic) leprosy manifests itself by involvement of only the nerve in the absence of skin lesions. Therefore, it sometimes can pose a diagnostic problem. Cytological needle aspiration of an affected nerve can be a valuable tool under such circumstances. The method as developed at Anandaban Leprosy Hospital, Nepal, is described and two cases are presented.

Experimental borderline lepromatous leprosy with intraneural erythema nodosum leprosum in a mangabey monkey (Cercocebus atys).

A sooty mangabey monkey (Cercocebus atys) was inoculated with Mycobacterium leprae and developed borderline lepromatous leprosy and intraneural erythema nodosum leprosum. Previously studied mangabeys have developed only disseminated lepromatous leprosy without reactions. This case broadens the spectrum of leprosy seen in experimentally inoculated animals and further characterizes the nonhuman primate model of leprosy.

Isolation and characterization of infiltrates in the nerves of patients with neuritic leprosy.

A study was done on the characteristics of infiltrating cells in the nerves of 9 patients with pure neuritic leprosy, by preparing a single cell suspension. The patients had no skin lesion. Histopathological examination revealed that 2 of the 9 nerves showed granulomas characteristics of tuberculoid leprosy, while the remaining 7 had features of lepromatous granulomas. In the nerves showing tuberculoid granulomas, a high proportion of lymphocytes were T cells as they formed rosettes with sheep erythrocytes and only a few percent were EAC rosette forming cells. On the other hand, the nerves showing lepromatous granulomas contained only occasional lymphocytes which formed E and EAC rosettes. Macrophages from the granulomas of all the nerves were esterase positive, peroxidase negative, contained M. leprae and did not exhibit C3 surface receptors.

Isolation and characterization of cells in granulomas of nerves of leprosy patients.

Single cell suspension from the granulomas in nerves of leprosy patients were prepared for an in vitro study of the properties of infiltrating cells. Nerve biopsies from 17 patients with tuberculoid (n = 9) and lepromatous (n = 8) leprosy cases were analysed. The granulomas were found to contain lymphocytes and macrophages. Lymphocytes were the predominant infiltrating cells in the tuberculoid nerves. In contrast, lepromatous nerves contained very few of these cells. The majority of lymphocytes in tuberculoid granulomas were activated T cells as they formed rosettes with sheep erythrocytes, exhibited esterase dots in the cytoplasm and expressed HLA-DR antigens. A small proportion of the lymphocytes also formed rosettes with EAC. Most macrophages from both the granulomas were mature macrophages as they were esterase positive, did not exhibit peroxidase activity and expressed HLA-DR antigens. The macrophages did not possess C3 surface receptors.

Diagnostic efficacy of cutaneous nerve biopsy in primary neuritic leprosy.

The role of nerve biopsy in the diagnosis of primary neuritic leprosy was evaluated in a study of 77 patients who had symptoms of peripheral neuropathy without hypopigmented patches, positive skin smears, or a skin biopsy consistent with leprosy. A biopsy of a representative cutaneous nerve near the site of the neurological deficit was taken for histopathological examination and acid-fast staining. Nearly half of the patients had leprosy confirmed by nerve biopsy, and the entire spectrum of leprosy was represented. No significant relationship was seen by age or sex or type of neuropathy. The duration of symptoms did not correlate with the severity of nerve damage as seen histologically. The probability of false-positive or false-negative results is discussed in light of clinical management. Being a relatively simple office procedure, a cutaneous nerve biopsy is strongly recommended as an important diagnostic tool, particularly for primary neuritic leprosy.