Case Report: Upper Thoracic Esophageal Paralysis Accompanying a Type 1 Leprosy Reaction.

Type 1 leprosy reactions (T1LRs) occur mainly in patients with borderline leprosy and an unstable immune status. The main symptoms of T1LRs include aggravated skin lesions and nerve damage. Nerve damage involving the glossopharyngeal and vagus nerves causes dysfunction of the nose, pharynx, larynx, and even the esophagus, which are innervated by these nerves. Here, we report a case of upper thoracic esophageal paralysis caused by vagus nerve involvement in a patient with T1LRs. Although infrequent, this serious emergency merits attention.

Factors affecting functional outcome of opponens replacement in median nerve paralysis in leprosy.

In this study, the factors affecting functional outcomes of opponens replacement in median nerve paralysis in leprosy, were investigated. Fifty six patients who underwent opponens transfer between 1995 and 2001 were included in the study. The average duration of follow up is 7.3 years with a range of 4-10 years. Functional assessments were done through assessment of grip strength, pinch strengths and fine manipulation and the results were interpreted using Sundararaj (1984) criteria. 76.6% had excellent or good results, 13.3% fair and 10.1% poor results. Pinch strength, grip strength and fine manipulation showed improvement after surgery. Logistic regression analysis showed that duration of paralysis had a significant independent effect on the outcome.

Reportable neurologic diseases in refugee camps in 19 countries.

BACKGROUND: Approximately one-third of refugees worldwide live in refugee camps. Selected neurologic diseases are actively reported in some refugee camps. METHODS: The United Nations High Commissioner for Refugees monitors health visits in refugee camps with the assistance of more than 25 partner organizations using standardized case definitions. Neurologic diseases were selected and searched for the years 2008 to 2011. The number of health care visits for a neurologic disease was calculated and divided by the aggregated number of reporting months available for each refugee camp ("visits per camp-month"). RESULTS: Five neurologic diseases were reported from 127 refugee camps in 19 countries. Visits for chronic, noncommunicable diseases including epilepsy (53,941 visits in 1,426 camp-months, 48% female) and cerebrovascular disease (4,028 visits in 1,333 camp-months, 51% female) far exceeded those for neurologic infectious diseases (acute flaccid paralysis/poliomyelitis, 78 visits in 3,816 camp-months, 42% female; leprosy, 74 visits in 3,816 camp-months, 66% female; meningitis, 477 visits in 3,816 camp-months, 51% female). In 2011, these diseases accounted for 31,349 visits globally with 91% of visits for epilepsy. CONCLUSIONS: Targeted programs addressing epilepsy and stroke among refugees in camps should become a priority and indicate that other chronic neurologic diseases that may be under- or misdiagnosed may also be common in refugee camps. Given that significant under-reporting is likely, our findings demonstrate the pressing need for coordinated preventive and interventional measures for epilepsy and stroke in refugee camps.

Correction of the claw hand.

Intrinsic paralysis can be the manifestation of a variety of pathologic entities (stroke, cerebral palsy, Charcot-Marie-Tooth, muscular dystrophy, leprosy, trauma, cervical disease, and compressive and metabolic neuropathies). Patients present with a spectrum of clinical findings dependent on the cause and severity of the disease. The 3 main problems caused by intrinsic weakness of the fingers are clawing with loss of synchronistic finger flexion, inability to abduct/adduct the digits, and weakness of grip. Clawing is defined as hyperextension of the metacarpophalangeal joints and flexion of the interphalangeal joints. This article describes the clinical evaluation and surgical treatment options for claw hand.

Factors affecting functional outcome of surgical correction of claw hand in leprosy.

The objective of this paper is to study the results and the factors that impact the results of claw hand surgery in leprosy. 110 patients who underwent claw hand correction between 2002 and 2006 were followed up and studied. Brand's criteria for objective assessment and a visual analog scale for subjective assessment were used. The factors studied were age, sex, clinical, duration of paralysis, long flexor tightness, degree of contracture and type of surgery. Objective assessment showed Excellent or Good results in 76.6%, Fair in 20% and Poor in 3.4%. Subjective assessment showed that 80.8% were fully satisfied or satisfied. Regression analysis showed that age, degree of contracture,duration of paralysis and long flexor contracture were seen as significant factors impacting results of claw hand correction.

Multiple grade II deformities in a child: tragic effect of leprosy.

Stigma is almost synonymous with visible deformity and this is what makes leprosy a dreaded disease for the common man. Deformities in children are more distressing, due to the limitation of their physical, academic and social life. An 11-year-old female child was presented with trophic ulceration of right foot and triple nerve paralysis (i.e. total claw hand with wrist drop) of the left hand of 2 years duration. In addition, she had multiple hypopigmented hypoaesthetic patches on the extremities and buttocks. She was diagnosed as a case of borderline tuberculoid leprosy and was started on WHO MB MDT therapy. Leprosy in children is an indicator for disease prevalence in general population and occurrence of deformities points towards the delay in making the diagnosis and the stigma associated with the disease.

[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.

Opponens plasty rehabilitation protocol--a case report.

In this case report of opponens plasty, we will attempt to accomplish two objectives: 1) to characterize some innovative modifications to the standard rehabilitation protocol for an opponens plasty and 2) to explain the role and advantages of a new muscle re-education splint in this modified protocol.

A study on the impact of FD-MDT on 200 leprosy patients.

A study was carried out from June 1999 to June 2001 to assess the impact of fixed duration multidrug therapy (FD-MDT) in newly detected cases of leprosy in terms of clinical and neurological improvement and changes in the bacillary index of skin smear for AFB. 200 new leprosy cases (both PB & MB) were started on FD-MDT. Of these 200 cases, 16 were of pure neuritic leprosy. After treatment, out of 184 cases with typical skin lesions of leprosy, all 26 PB cases showed inactivity of skin lesions, and, of the remaining 158 MB cases, 40.5% showed inactivity and 59.5% showed complete resolution of skin lesions. Out of 68 skin smear-positive cases, 42 cases with a BI of < or = 3 became smear-negative, while others showed gradual fall in the BI. Such heavily bacilliferous cases were continued with treatment for 1 more year to prevent relapse. As FD-MDT alone does not cure established sensory and motor impairment, it did not show any change in 19% of the patients presented with permanent sensory motor disturbance. FD-MDT prevents progression of sensory/motor disturbance.

Abductor pollicis longus deviation graft operation: modified for stabilizing CMC and MCP joints of 'intrinsic minus' thumb.

The original procedure abductor pollicis longus deviation graft operation by Beine (1996) was introduced to correct retroposition of the thumb and to balance the instability at the carpometacarpal (CMC) joint in cases of ulnar-cum-low median palsy in leprosy, so that bone-using procedures can be avoided to some extent. It provides an antagonistic force to the action of the abductor pollicis longus (abd. pol. long.) by giving this muscle a second insertion, with the result that the action of the abd. pol. long. now stabilises to a considerable extent the CMC joint in its mid-rotational position by a partial replacement of the action of the opponens pollicis (opp. pol.) and abductor pollicis brevis (abd. pol. brev.). Experience over five years with the original procedure showed us that it can make an ulnar deviation more visible at the MCP joint of the thumb. The modification of the procedure corrects this as well, as the results in 12 hands of 11 patients have shown. Interestingly, of the 11 patients who underwent operation, one was not a leprosy patient, but referred to us for partial triple palsy of the left hand and arm without sensory loss. It is shown that the indication of this procedure is wider than mentioned earlier.

Palsy of the rear limbs in Mycobacterium lepraemurium-infected mice results from bone damage and not from nerve involvement.

A small but relatively constant proportion (3-5%) of mice chronically infected with Mycobacterium lepraemurium (MLM) develops bilateral paralysis of the rear limbs. The aim of the study was to investigate whether or not the bilateral leg palsy results from nerve involvement. Direct bacterial nerve infection or acute/delayed inflammation might possibly affect the nerves. Therefore, palsied animals were investigated for the presence of: (a) histopathological changes in the leg tissues including nerves, bones and annexes, and (b) serum antibodies to M. lepraemurium and M. leprae lipids, including phenolic glycolipid I from M. leprae. Histopathological study of the palsied legs revealed that the paralysis was not the result of direct involvement of the limb nerves, as neither bacilli nor inflammatory cells were observed in the nerve branches studied. Antibodies to brain lipids and cardiolipin were not detected in the serum of the palsied animals, thus ruling out an immune response to self-lipids as the basis for the paralysis. Although high levels of antibodies to MLM lipids were detected in the serum of palsied animals they were not related to limb paralysis, as the nerves of the palsied legs showed no evidence of inflammatory damage. In fact, nerves showed no evidence of damage. Paralysis resulted from severe damage of the leg bones. Within the bones the bone marrow became replaced by extended bacilli-laden granulomas that frequently eroded the bone wall, altering the normal architecture of the bone and its annexes, namely muscle, tendons and connective tissue. Although this study rules out definitively the infectious or inflammatory damage of nerves in murine leprosy, it opens a new avenue of research into the factors that participate in the involvement or the sparing of nerves in human and murine leprosy, respectively.

Nerve thickening in leprosy patients and risk of paralytic deformities: a field based study in Agra, India.

This paper examines the extent of nerve thickening among leprosy patients detected in the field in Agra district. All the clinically diagnosed leprosy patients were examined in detailed for thickening of local cutaneous nerves and peripheral nerve trunks. In each case all the major nerve trunks in both upper and lower extremities, forehead and neck were examined for thickening. Nerve thickening was found in 94% of multibacillary (MB) patients and among 52% paucibacillary (PB) patients. Nerve thickening was found to be more in males, in prevalent cases than in new (untreated) cases and increased significantly with age and delay in diagnosis (P<0.001). Visible deformities of grade > or =2 were found in 10% (58/573) of the leprosy patients; paralytic deformity accounted for 78% (45/58). Claw hand alone or in combination was seen in 82% (37/45) of patients with paralytic deformities. Risk (odd ratio) for deformities was observed to be high (15-18 times) with increasing number of nerves among patients with neuritic leprosy but correlated with delay in diagnosis of over 5 years. Likewise, deformities were more often seen in those with skin lesions, provided they had > or =3 thickened nerves. Findings suggest that early detection and treatment is useful in preventing deformities.

Reactions and their management.

The uneventful response to chemotherapy in leprosy is marked by clinically disturbing episodes encountered in 20-30% of patients and these phenomena are called "reactions". Generally they are classified as reversal reaction (type-1) and erythema nodosum leprosum (type-2). The cutaneous menifestations are: (1) Type-2 reactions in LL, BL types constituting erythema nodosum leprosum, erythema multiforme, erythema necroticans, subcutaneous nodules, lepromatous exacerbation. (2) Type-1 reactions in borderline and tuberculoid leprosy. The other manifestations include: Acute neuritis, lymphadenitis, arthritis, oedema of the hands and feet, ocular lesions, etc. Sequelae of reactions are: Paralytic deformities, non-paralytic deformities, extensive scarring and renal damage. A simple guideline to identify the risk-prone cases has been narrated. Prednisolone in standard dosage schedule as recommended by WHO is now being widely used in control programmes.

Reconstruction of facial deformities in leprosy patients.

Almost all the parts of the face may be involved in deformities caused by leprosy. Reconstructive surgery can be undertaken after the disease is arrested by medical treatment. Reconstruction of nose can be done by augmentation with autogenous bone graft, retronasal inlay graft, etc. Loss of eyebrows can be reconstructed with hair bearing skin with hair follicles. Sagging face can be corrected by nasolabial face-lift with correction of glabellar folds. Blepharoplasty is done for correction of some conditions. The temporal muscle sling is a dynamic procedure to reconstruct facial nerve palsy.

Surgical reconstruction of irreversible ulnar nerve paralysis in leprosy.

Twenty-five patients with irreversible leprotic ulnar nerve palsy having undergone lumbrical replacement with two different tendon transfer techniques were assessed 6-120 months after surgery. Nineteen patients were reconstructed with the flexor digitorum four-tail procedure (FDS-4T), and six with Zancolli's lasso procedure (ZLP). Mean paralysis times were 103 months for FDS-4T, and 68 months for ZLP. Mean age of the patients was 36 years (21-57). Grip strength measurements, improvement in active range of motion at the PIP joints, patients' ability to open and close their hands fully, as well as sequence of phalangeal flexion, were noted. Mean grip strength measurements during follow-up were 76% of the contralateral extremity in the FDS-4T group and 82% in the ZLP group. Comparison of the follow-up grip strength with the preoperative value revealed 1% improvement in the FDS-4T group and 20% in the ZLP group. Claw hand deformity was completely corrected in 12 patients in FDS-4T group, and in five patients in the ZLP group. Residual flexion contracture remained in five patients after surgery. Swan-neck deformity subsequently developed in seven fingers. Age, sex, mean follow-up and surgical technique did not relate statistically to the functional outcome. However, preoperative extensor lag of the PIP joint and mean paralysis time significantly affected the functional outcome. ZLP was found to be a more effective procedure in restoring grip strength, whereas FDS-4T was more effective in correcting claw hand deformity.