Skin Lesions, Foot Drop, and Hand Contractures.

A previously healthy individual in his 20s had 3 months of annular skin lesions, with numbness and paresthesia in the affected areas. Physical examination revealed multiple tattoos, bilateral palpable thickened auricular and ulnar nerves, and claw-hand deformity; test results for rapid plasma reagin, antinuclear antibodies, rheumatoid factor, acid-fast bacilli, mycobacteria, and fungi were negative, and biopsy did not identify Mycobacterium leprae. What is the diagnosis and what would you do next?

Gait analysis of leprosy patients with foot drop using principal component analysis.

BACKGROUND: Peripheral nerve injury caused by leprosy can lead to foot drop, resulting in an altered gait pattern that has not been previously described using 3D gait analysis. METHODS: Gait kinematics and dynamics were analyzed in 12 patients with unilateral foot drop caused by leprosy and in 15 healthy controls. Biomechanical data from patients' affected and unaffected limbs were compared with controls using inferential statistics and a standard distance, based on principal components analysis (PCA). FINDINGS: Patients walked slower than controls (0.8 ± 0.2 vs. 1.1 ± 0.2 m/s, p = 0.003), with a reduced stance and increased swing percentage. The affected limb increased (p < 0.05) plantar flexion at the initial contact (-16.8o ± 8.3), terminal stance (-29.1o ± 11.5), and swing (-12.4o ± 6.2) in the affected limb compared to unaffected (-6.6o ± 10.3; -14.6o ± 11.6; 2.4o ± 7.6) and controls (-5.4o ± 2.5; -18.8o ± 5.8; -1.4o ± 3.9). Increased pelvic tilt and knee adduction/abduction range, with lower hip adduction, were observed. The second peak of ground reaction force (98.6 ± 5.2 %BW), ankle torque (0.99 ± 0.33 Nm/kg), and net ankle work in stance (-0.03 ± 5.4 J/Kg) decreased in the affected limb compared to controls (104.1 ± 5.5 %BW; 1.24 ± 0.4 Nm/kg; -4.58 ± 5.19 J/kg; p < 0.05). There were decreasing multivariate standard distances in the affected limb compared with the unaffected and controls. PCA loading factors highlighted the major differences between groups. INTERPRETATION: Leprosy patients with foot drop presented altered gait patterns in affected and unaffected limbs. There were remarkable differences in ankle kinematics and dynamics. Rehabilitation devices, such as ankle foot orthosis or tendon transfer surgeries to increase ankle dorsiflexion, could benefit these patients and reduce deviations from normal gait.

Pure Neuritic Leprosy with Bilateral Foot Drop and Central Nervous Involvement: A Clinical, Electrophysiological, and MR Correlation.

BACKGROUND: Central nervous system (CNS) involvement in leprosy is sparsely documented. Neurophysiological tests and magnetic resonance imaging (MRI) helps in demonstrating CNS involvement in the patient of pure neuritic leprosy. OBJECTIVES: To demonstrate CNS involvement in pure neuritic leprosy. METHODS: Detailed clinical presentation and skin lesions were evaluated. Sural nerve biopsy, MRI diffusion tensor imaging of spinal cord and optic nerve were performed. Visual evoked potential and tibial somatosensory evoked potential were done. Their clinical, electrophysiological, and MRI were done at follow-up visits. RESULTS: We report three patients of pure neuritic leprosy with bilateral foot drop as the initial presentation. MRI T2W sequence of cervico dorsal cord showed dorsal column hyperintensity in two patients. Diffusion-weighted MR revealed decrease fractional anisotropy and an increase in the apparent diffusion coefficient. Similar findings were also noted in the optic nerves. The patients were managed with multidrug therapy multibacillary regimen and steroid in tapering dose. At follow-up, they showed clinical improvement in vision and power of ankle dorsiflexor. CONCLUSIONS: Patients of pure neuritic leprosy may manifest with bilateral foot drop with the involvement of posterior column and cranial nerves.

A method used to access the functional outcome of tibial posterior tendon transfer for foot drop in leprosy.

OBJECTIVES: The aim of this study was to access the postoperative functional results of posterior tibial tendon transfer for foot drop as a consequence of nerve palsy in leprosy. MATERIAL AND METHODS: Thirteen patients (9 males and 4 females) with ages ranging from 9 to 69 years were submitted to posterior tibial tendon transfer by the circumtibial route to correct foot drop in leprosy. The length of postoperative follow-up ranged from 1 to 5 years. The Stanmore system was used as a method for evaluating the functional results of postoperative posterior tibial tendon transfer. This system is made up of 7 different categories and the total score is 100. RESULTS: According to the Stanmore system, the results were poor in 1 patient (7.6%), moderate in 2 feet (15.3%), good in 5 feet (38.4%), and excellent in 5 feet (38.4%). All the patients were satisfied with the final outcome. CONCLUSION: The posterior tibial tendon transfer for foot drop in leprosy was efficient in restoring normal function of the foot and gait without changing foot posture. In the absence of a standardized method for assessing the results of posterior tibial tendon transfer, the Stanmore system seems to be a good tool for an objective evaluation.

[Paresis of nervus peroneus after immobilization with range of motion walker]. / Parese af nervus peroneus efter bandagering med range of motion walker.

It is well known that cast immobilization can cause pressure on the common peroneal nerve. In this case a 64-year-old female patient had a fracture of the distal fibula (SU2, according to Lauge Hansens classification of angle fractures). This avulsion was conservatively treated and immobilized in a flexible cast. Unfortunately, the cast was too high, the metal plates inside it caused pressure on the common peroneal nerve and the patient sustained a peroneal palsy.

Electrophysiological evaluation of peripheral and autonomic involvement in leprosy.

OBJECTIVE: Motor and sensory nerve conductions, F responses, sympathetic skin responses and R-R interval variations (RRIV) were studied to determine the type of peripheral neuropathy among patients with leprosy. METHODS: Twenty-nine consecutive patients with leprosy (25 male, 4 female) hospitalized in the "Istanbul Leprosy Hospital" between January - December, 1999 were included in this study. Ten patients had borderline lepromatous leprosy, and 19 had lepromatous leprosy. None of the patients studied had the tuberculoid form. The mean age was 55 +/- 12 years. The control group consisted of 30 (26 male, 4 female) healthy volunteers (mean age: 58.1 +/- 7.8 years). All subjects included in the study underwent neurological examination and electrophysiological evaluation. Standard procedures were performed for evaluating sensory and motor conduction studies. Motor studies were carried out on both left and right median, ulnar, tibial and common peroneal nerves while median, ulnar, sural and superficial peroneal nerves were examined for sensory studies. Sympathetic skin response recordings on both hands and RRIV recordings on precordial region were done in order to evaluate the autonomic involvement. RESULTS: The lower extremity was found to be more severely affected than the upper, and sensory impairment predominated over motor. Of 58 upper limbs examined, no sympathetic skin responses was recorded in 46 (79.3%). Compared with the controls, the RRIVs of the leprosy patients were found to be reduced during both resting and deep forced hyperventilation. CONCLUSION: Our results indicate that leprosy causes a predominantly axonal polyneuropathy that is more severe in the lower extremities. Sensory nerve damage is accompanied by autonomic involvement.

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.