Pure neuritic leprosy: Current status and relevance.

Pure neuritic leprosy has always been an enigma due to its clinical and management ambiguities. Although only the Indian Association of Leprologist's classification recognizes 'pure neuritic leprosy' as a distinct sub group of leprosy, cases nonetheless are reported from various countries of Asia, Africa, South America and Europe, indicating its global relevance. It is important to maintain pure neuritic leprosy as a subgroup as it constitutes a good percentage of leprosy cases reported from India, which contributes to more than half of global leprosy numbers. Unfortunately, a high proportion of these patients present with Grade 2 disability at the time of initial reporting itself due to the early nerve involvement. Although skin lesions are absent by definition, when skin biopsies were performed from the skin along the distribution of the affected nerve, a proportion of patients demonstrated leprosy pathology, revealing sub-clinical skin involvement. In addition on follow-up, skin lesions are noted to develop in up to 20% of pure neuritic leprosy cases, indicating its progression to manifest cutaneous disease. Over the decades, the confirmation of diagnosis of pure neuritic leprosy has been subjective, however, with the arrival and use of high-resolution ultrasonography (HRUS) for nerve imaging, we have a tool not only to objectively measure and record the nerve thickening but also to assess the morphological alterations in the nerve including echo texture, fascicular pattern and vascularity. Management of pure neuritic leprosy requires multidrug therapy along with appropriate dose of systemic corticosteroids, for both acute and silent neuritis. Measures for pain relief, self-care of limbs and physiotherapy are important to prevent as well as manage disabilities in this group of patients.

Fatores preditivos de incapacidades em pacientes com hanseníase / Factores predictivos de incapacidades en pacientes con hanseníasis / Predictive factors of disability in patients with leprosy

OBJETIVO:Analisar os fatores preditivos na evolução do grau de incapacidade em pacientes com hanseníase. MÉTODOS:Foram analisados dados de coorte retrospectiva, que acompanhou 595 pacientes com incapacidades, registrados em uma unidade de saúde de Belo Horizonte (MG), de 1993 a 2003. Informações sociodemográficas e clínicas dos pacientes foram coletadas dos respectivos prontuários. Comparou-se o grau de incapacidade na admissão e no final do tratamento por meio do teste de homogeneidade marginal. Para identificar os fatores associados à evolução do grau de incapacidade foram utilizadas as análises univariada (teste qui-quadrado de tendência linear) e multivariada pelo algoritmo Chi-square Automatic Interaction Detector. RESULTADOS:Dos casos com registro de grau de incapacidade na admissão e na alta, observou-se que 43,2 por cento que tinham grau 1 na primeira avaliação evoluíram para grau 0. Dos que apresentavam grau 2, 21,3 por cento passaram a ter grau 0 e 20 por cento passaram a grau 1. Na análise univariada as variáveis que se mostraram estatisticamente associadas à evolução no grau de incapacidade foram: neurite, tempo até a ocorrência de neurite, número de nervos acometidos, tipo de tratamento fisioterápico e maior dose de prednisona. Na análise multivariada, o principal fator que se associou à evolução do grau de incapacidade foi o grau de incapacidade na admissão. CONCLUSÕES:Os resultados mostraram a importância do diagnóstico precoce de neuropatia, assim como da eficiente associação das intervenções medicamentosas e não-medicamentosas por meio das técnicas de prevenção de incapacidade e dosagens adequadas de corticoterapia.

OBJECTIVE:To analyze predictive factors in the progression of the disability grade in patients with leprosy. METHODS: A retrospective cohort study followed up 595 patients with disability registered at a healthcare unit in the city of Belo Horizonte (Southeastern Brazil) from 1993 to 2003. Patients' sociodemographic and clinical information was collected from the respective medical records. Comparisons were made between the disability grade upon admission and at the end of treatment using a marginal homogeneity test. To determine factors associated with progression in the disability grade, univariate analysis (linear trend chi-square test) was employed, as well as multivariate analysis by means of the algorithm Chi-square Automatic Interaction Detector. RESULTS:Among the cases in which the disability grade was recorded upon admission and upon discharge, 43.2 percent of the patients who had grade 1 in the first assessment progressed to grade 0. Among those who began with grade 2, 21.3 percent progressed to grade 0 and 20 percent progressed to grade 1. In the univariate analysis, the variables that proved to be statistically associated with progression in the disability grade were: neuritis, time elapsed until the occurrence of neuritis, number of damaged nerves, type of physiotherapy treatment and higher dose of prednisone. In the multivariate analysis, the main factor associated with the progression of disability was the disability grade upon admission. CONCLUSIONS: The results showed the importance of an early diagnosis of neuropathy as well as the efficient association of pharmacological and non-pharmacological treatment, through disability prevention techniques and adequate doses of steroid.

OBJETIVO: Analizar los factores predictivos en la evolución del grado de incapacidad en pacientes con hanseníasis. MÉTODOS: Fueron analizados datos de cohorte retrospectiva, que acompañó 595 pacientes con incapacidades, registrados en una unidad de salud de Belo Horizonte (Sureste de Brasil), de 1993 a 2003. Informaciones sociodemográficas y clínicas de los pacientes fueron colectadas de los respectivos prontuarios. Se comparó el grado de incapacidad en la admisión y en el final del tratamiento por medio de la prueba de homogeneidad marginal. Para identificar los factores asociados a la evolución del grado de incapacidad fueron utilizados los análisis univariado (prueba chi-cuadrado de tendencia linear) y multivariado por el algoritmo Chi-square Automatic Interaction Detector. RESULTADOS: De los casos con registro de grado de incapacidad en la admisión y en el alta, se observó que 43,2 por ciento que tenían grado 1 en la primera evaluación evolucionaron para el grado 0. De los que presentaban grado 2, 21,3 por ciento pasaron a tener grado 0 y 20 por ciento pasaron a grado 1. En el análisis univariado las variables que se mostraron estadísticamente asociados a la evolución en el grado de incapacidad fueron: neuritis, tiempo hasta la ocurrencia de la neuritis, número de nervios afectados, tipo de tratamiento fisioterapéutico y mayor dosis de prednisona. En el análisis multivariado, el principal factor que se asoció a la evolución del grado de incapacidad fue el grado de incapacidad en la admisión. CONCLUSIONES: Los resultados mostraron la importancia del diagnóstico precoz de neuropatía, así como de la eficiente asociación de las intervenciones medicamentosas y no medicamentosas por medio de las técnicas de prevención de incapacidad y dosis adecuadas de corticoterapia.

[Predictive factors of disability in patients with leprosy]. / Fatores preditivos de incapacidades em pacientes com hanseníase.

OBJECTIVE: To analyze predictive factors in the progression of the disability grade in patients with leprosy. METHODS: A retrospective cohort study followed up 595 patients with disability registered at a healthcare unit in the city of Belo Horizonte (Southeastern Brazil) from 1993 to 2003. Patients' sociodemographic and clinical information was collected from the respective medical records. Comparisons were made between the disability grade upon admission and at the end of treatment using a marginal homogeneity test. To determine factors associated with progression in the disability grade, univariate analysis (linear trend chi-square test) was employed, as well as multivariate analysis by means of the algorithm Chi-square Automatic Interaction Detector. RESULTS: Among the cases in which the disability grade was recorded upon admission and upon discharge, 43.2% of the patients who had grade 1 in the first assessment progressed to grade 0. Among those who began with grade 2, 21.3% progressed to grade 0 and 20% progressed to grade 1. In the univariate analysis, the variables that proved to be statistically associated with progression in the disability grade were: neuritis, time elapsed until the occurrence of neuritis, number of damaged nerves, type of physiotherapy treatment and higher dose of prednisone. In the multivariate analysis, the main factor associated with the progression of disability was the disability grade upon admission. CONCLUSIONS: The results showed the importance of an early diagnosis of neuropathy as well as the efficient association of pharmacological and non-pharmacological treatment, through disability prevention techniques and adequate doses of steroid.

La afectación neural en la lepra multibacilar; resultados de un estudio en Brasil

Este trabajo es un estudio retrospectivo de 103 pacientes de lepra multibacilar (18 por ciento BB, 48 por ciento BL y 34 por ciento LL) seguidos y controlados durante y después del tratamiento, en un centro especializado con clínica de tipo ambulatoria en una zona endémica de Brasil, durante un período promedio de 65 meses, desde el inicio de la farmacoterapia múltiple (24-dosis MDT). El objetivo es identificar el papel de la neuritis manifiesta (presencia de dolor en un tronco periférico neural, con o sin engrosamiento o afectación de la función neural) en el desarrollo y manifestación de las incapacidades. Se evaluaron mediante la escala de discapacitación de la Organización Mundial de la Salud, antes del tratamiento, al final del mismo y al final del período de seguimiento. El 34 por ciento de los pacientes presentó neuritis manifiesta durante la MDT y el 45 por ciento episodios de neuritis durante el período de seguimiento; los nervios normalmente más afectados son cubital, peroneo y tibial posterior y se tratan farmacológicamente estos episodios con esteroides y fisioterapia. Se asocian los deterioros con: nervios afectados (dolorosos y/o engrosados) en el diagnóstico (P < 0.005); retraso en el diagnóstico (P = 0.010); deterioros presentes en el momento de iniciar el tratamiento (P = 0.00041; al finalizar la MDT y P = 0.000013 al final del seguimiento); incidencias de episodios de neuritis manifiesta durante MDT (P = 0.0016) o durante todo el seguimiento (P = 0.015). Estos datos enfatizan la importancia del diagnóstico precoz y el correcto examen neurológico a través del seguimiento, y al mismo tiempo sugiere la importancia de la neuritis en la inducción de las afectaciones en la lepra multibacilar (AU)

A comparison of economic aspects of hospitalization versus ambulatory care in the management of neuritis occurring in lepra reaction.

Neuritis is one of the important causes of deformities and disabilities in leprosy. Neuritis has been managed both in the field and in hospital. This study was done to compare the economic aspects of cost of ambulatory vs in-patient management of neuritis in leprosy. The quality of life of the affected patients and the clinical improvement in the 2 groups were also studied. Twenty six patients fulfilling the study criteria were randomized into the ambulatory and in-patient group (13 in each group). The primary outcome examined was cost, in various categories; the secondary outcomes included pre- and post-treatment comparison of Quality of Life (QOL) scores and tests of sensory and motor function. The direct and indirect medical costs incurred by patients in the hospitalized group were higher than those patients in the ambulatory group. The difference in the direct medical costs between the two groups was Rs. 9110.5, and the extra direct non medical costs incurred by patients in the hospitalized group was Rs. 888.50 because of more frequent visits of family members. A greater percentage of ambulatory than in-patients returned to work in

Experiences from a collaborative project on the prevention of disability in leprosy patients in Shandong Province, the People's Republic of China.

Shandong Province (present population 89 million) in the People's Republic of China established a leprosy control programme in 1955. Between that year and the end of 1999, allowing for death and migration, the cumulative number of cases registered was 53,618, including 120 cases on multiple drug therapy (MDT) and 18,248 who had completed satisfactory courses of dapsone monotherapy and/or MDT. Of this latter group, 9500 cases (52%) suffered from visible disabilities (grade 2 of the WHO classification). Prevalence and incidence rates of leprosy have decreased dramatically since 1955 and, on average, only 50-70 new cases are now being detected annually in the entire province. Leprosy is thus no longer a public health problem, but the existence of such a large number of patients with grade 2 disabilities is clearly a matter of serious concern. This paper describes a pilot project to investigate the potential of health personnel in the leprosy programme and the dermatology and sexually transmitted diseases services to (a) prevent deterioration of existing disabilities in ex-patients through self-care and (b) prevent new neuritis in patients on MDT through early detection and the use of steroids.

Prevention of impairment in leprosy; results from a collaborative project in China.

OBJECTIVE: to evaluate programs of prevention and treatment of impairments due to leprosy in 8 geographical areas in the People's Republic of China. DESIGN: follow up of cohorts of leprosy patients receiving a range of different interventions. SETTING: 8 different geographical areas in China, varying in urban and rural characteristics from 6 provinces and 2 municipalities. SUBJECTS: leprosy patients who were receiving or had completed a course of antileprosy chemotherapy. INTERVENTIONS: a range of interventions, including steroids, self-care training, adapted footwear, surgery and provision of prostheses. MAIN OUTCOME MEASURES: changes in eye, hand and foot impairments between baseline assessment and assessment at 2 years. RESULTS: 232 out of 3571 patients assessed monthly over 2 years developed acute neuritis and, in most areas, were promptly and adequately treated. Regular self care of eyes was established in 238 out of 313 patients with lagophthalmos and was associated with reduction in the prevalence of conjunctivitis. Regular self care of hands was established in 730 out of 1010 patients with neurological impairment of the hand; this was associated with a reduction (80%) in hand cracks and wounds. Regular self care of feet was established in 745 out of 1094 patients with neurological impairment of the feet; this was associated with a 83% reduction in patients with cracks and a 33% reduction in patients with sole wounds. A footwear program was established in all 8 areas providing footwear to 4698 patients over the 2-year period; this was associated with a reduction of 61% and 21% in patients with cracks and wounds, respectively. Management of complicated sole wounds in 256 patients resulted in 69% of these patients being free of sole wounds at 2 years. Targets for reconstructive surgery and amputations were not fully attained, but lower limb prostheses were provided for 306 patients. CONCLUSIONS: leprosy is a chronic disease characterized by peripheral neuropathies which can result in increasing secondary impairments and disabilities. The emphasis, in countries such as China where the chemotherapy programs have been effectively implemented, is shifting to prevention and treatment of impairments. This innovative program in China has successfully demonstrated that it is possible to prevent and reverse impairments due to leprosy.

[Treatment of leprotic neuritis. Exclusive medical treatment or combined with decompression]. / Evolution du traitement des nevrites hanséniennes. Traitement médical exclusif ou associé à la décompression.

The authors consider the evolution of the treatment of leprotic neuritis based on homogenous series of numerous observations (a minimum of 250-300). These observations are well registered and documented with some results dimensioned by the classical A. L. E. R. T. tests carried out at intervals of time and verified by comparison between series only medical treatment and series of medico-surgical treatment. Considering some remote results and some comparative series, the indications of the exclusive medical treatment have been well defined, and the ones of the surgical decompression have been reduced. The early case finding of a leprotic neuritis by the mean of easy methods as well as its monitoring during its early specific treatment is essential. By this way we get an important proportion of functional results: satisfactory (50 p.c.) or interesting (20 p.c.). In the case of painful hypertrophia, the complementary decompression secure not only the functional recovery of mortricity, but also the epicritic sensibility.

Neuritis in pregnancy and lactation.

One hundred and forty-six women were studied during and after 153 pregnancies (31 healthy contacts: 34 pregnancies; 115 leprosy patients: 119 pregnancies). One healthy contact and 51 leprosy patients developed neuritis during the study period. All leprosy patients, including those who were considered to be cured and had stopped treatment, were at risk. Neuritis was accompanied by Type 1 and Type 2 lepra skin reactions and/or deterioration of the patients' leprosy status; this was particularly the case when neuritis was associated with nerve pain or tenderness (overt neuritis). Neuritis without nerve pain or tenderness (silent neuritis), preceded by the complaint of "rheumatism" and the clinical finding of enlarged peripheral nerves, was seen more frequently than overt neuritis (48:37 episodes). Insidious silent neuritis with loss of sensory and motor function during lactation was a particularly dangerous and hitherto undescribed risk of pregnancy.