The nail flag sign in heart transplant recipients: case reports and review of the patients with the flag sign of the nail.

The nail plate flag sign is a distinctive nail plate change that appears as white, red, white, and red sequential transverse bands beginning at the proximal nail fold. This distinctive nail change was initially described in patients with diabetes mellitus and leprosy; indeed, it was considered to be characteristic, but not diagnostic of leprosy. Subsequently, the flag sign was observed in patients with vitiligo. The flag sign has recently been noted in two men following heart transplantation. In summary, the flag sign is a unique nail change that has occurred in patients with autoimmune disorders, infection, and post transplantation surgery associated with immunosuppressive therapy to prevent organ rejection.

Severe type 1 upgrading leprosy reaction in a renal transplant recipient: a paradoxical manifestation associated with deficiency of antigen-specific regulatory T-cells?

BACKGROUND: Due to its chronic subclinical course and large spectrum of manifestations, leprosy often represents a diagnostic challenge. Even with proper anti-mycobacteria treatment, leprosy follow up remains challenging: almost half of leprosy patients may develop reaction episodes. Leprosy is an infrequent complication of solid organ transplant recipients. This case report illustrates the challenges in diagnosing and managing leprosy and its reactional states in a transplant recipient. CASE PRESENTATION: A 53-year-old man presented 34 months after a successful renal transplantation a borderline-tuberculoid leprosy with signs of mild type 1 upgrading reaction (T1R). Cutaneous manifestations were atypical, and diagnosis was only made when granulomatous neuritis was found in a cutaneous biopsy. He was successfully treated with the WHO recommended multidrug therapy (MDT: rifampicin, dapsone and clofazimine). However he developed a severe T1R immediately after completion of the MDT but no signs of allograft rejection. T1R results from flare-ups of the host T-helper-1 cell-mediated immune response against Mycobacterium leprae antigens in patients with immunologically unstable, borderline forms of leprosy and has been considered an inflammatory syndrome in many aspects similar to the immune reconstitution inflammatory syndromes (IRS). The T1R was successfully treated by increasing the prednisone dose without modifying the other immunosuppressive drugs used for preventing allograft rejection. Immunological study revealed that the patient had a profound depletion of both in situ and circulating regulatory T-cells and lack of expansion of the Tregs upon M. leprae stimulation compared to T1R leprosy patients without iatrogenic immunosuppression. CONCLUSIONS: Our case report highlights that leprosy, especially in the transplant setting, requires a high degree of clinical suspicion and the contribution of histopathology. It also suggests that the development of upgrading inflammatory syndromes such as T1R can occur despite the sustained immunosuppressors regimen for preventing graft rejection. Our hypothesis is that the well-known deleterious effects of these immunosuppressors on pathogen-induced regulatory T-cells contributed to the immunedysregulation and development T1R.

Meaning of leprosy for people who have experienced treatment during the sulfonic and multidrug therapy periods / Significado da hanseníase para pessoas que viveram o tratamento no período sulfônico e da poliquimioterapia / Significado de la lepra para personas que experimentaron el tratamiento en el período sulfónico y de poliquimioterapia

AbstractObjective: to analyze the meanings of leprosy for people treated during the sulfonic and multidrug therapy periods.Method: qualitative nature study based on the Vigotski's historical-cultural approach, which guided the production and analysis of data. It included eight respondents who have had leprosy and were submitted to sulfonic and multidrug therapy treatments. The participants are also members of the Movement for Reintegration of People Affected by Leprosy.Results: the meanings were organized into three meaning cores: spots on the body: something is out of order; leprosy or hanseniasis? and leprosy from the inclusion in the Movement for Reintegration of People Affected by Leprosy.Conclusion: the meanings of leprosy for people submitted to both regimens point to a complex construction thereof, indicating differences and similarities in both treatments. Health professionals may contribute to the change of the meanings, since these are socially constructed and the changes are continuous.

ResumoObjetivo:analisar significados da hanseníase para as pessoas que foram tratadas no período sulfônico e no período da poliquimioterapia.Método:estudo de natureza qualitativa fundamentado na abordagem histórico-cultural de Vigotski, a qual orientou a construção e análise dos dados. Foram incluídos oito entrevistados que já tiveram hanseníase e que realizaram tratamento no período sulfônico e da poliquimioterapia, sendo participantes do Movimento de Reintegração das Pessoas Atingidas pela Hanseníase.Resultados:os significados foram organizados em três núcleos de significação: manchas no corpo: alguma coisa está fora de ordem; lepra ou hanseníase? e hanseníase a partir da inserção no Movimento de Reintegração das Pessoas Atingidas pela Hanseníase.Conclusão:os significados de hanseníase para pessoas tratadas nos dois períodos apontam para a construção complexa dos mesmos, indicando diferenças e semelhanças nos dois períodos. Os profissionais de saúde podem contribuir para a mudança de significados, pois esses são socialmente construídos e as transformações são contínuas.

ResumenObjetivo:analizar los significados de la lepra para las personas que fueron tratadas en el período sulfónico y en el período de poliquimioterapia.Método:estudio de naturaleza cualitativa fundamentado en el abordaje histórico cultural de Vygotsky, el cual orientó la construcción y análisis de los datos. Fueron incluidos ocho entrevistados que ya tuvieron lepra y que realizaron tratamiento en el período sulfónico y de poliquimioterapia, siendo participantes del Movimiento de Reintegración de Personas Afectadas por la Lepra.Resultados:los significados fueron organizados en tres núcleos de significación: manchas en el cuerpo: alguna cosa está fuera de orden; ¿Lepra o enfermedad de Hansen?; y lepra a partir de la inserción en el Movimiento de Reintegración de Personas Afectadas por la Lepra. Conclusión: los significados de la lepra para las personas tratadas en los dos períodos apuntan para la construcción compleja de los mismos, indicando diferencias y semejanzas en los dos períodos. Los profesionales de la salud pueden contribuir para el cambio de significados, ya que estos son socialmente construidos y las transformaciones son continuas.

An uncommon presentation of an uncommon disease: leprosy in a heart transplant recipient.

The effect of solid-organ transplantation on the acquisition, presentation and course of leprosy is unknown. We present a case of leprosy in a heart transplant recipient with multiple unique features possibly attributed to altered immune function.

Thalidomide for autoimmune disease.

The therapeutic efficacy of thalidomide in erythema nodosum leprosum suggests that thalidomide might play a useful therapeutic role in other human immune-complex diseases. Thalidomide has shown anti-inflammatory or immunosuppressive actions in several animal models. Current evidence suggests that its rapid activity in ENL may result from suppression of neutrophil chemotaxis and phagocytosis. Scattered anecdotal clinical reports of apparent response to thalidomide in various autoimmune diseases are hardly conclusive, but underline the desirability of appropriate pilot trials of thalidomide in autoimmune diseases, particularly those in which immune complex deposition plays a prominent role. Provided that a contraindication in fertile women is strictly observed, thalidomide therapy appears to be quite safe.

Thalidomide for autoimmune disease

The therapeutic efficacy of thalidomide in erythema nodosum leprosum suggests that thalidomide might play a useful therapeutic role in other human immune-complex diseases. Thalidomide has shown anti-inflammatory or immunosuppressive actions in several animal models. Current evidence suggests that its rapid activity in ENL may result from suppression of neutrophil chemotaxis and phagocytosis. Scattered anecdotal clinical reports of apparent response to thalidomide in various autoimmune diseases are hardly conclusive, but underline the desirability of appropriate pilot trials of thalidomide in autoimmune diseases, particularly those in which immune complex deposition plays a prominent role. Provided that a contraindication in fertile women is strictly observed, thalidomide therapy appears to be quite safe.

The use of monoclonal anti-T cell antibodies to study T cell imbalances in human diseases.

Monoclonal antibodies are now available to evaluate human T cell subsets by direct counting using indirect immunofluorescence analysis. The critical use of these antibodies has already permitted the delineation of the T cell imbalances present in a number of immunologically mediated diseases such as autoimmune haemolytic anaemia, chronic active hepatitis, myasthenia gravis, glomerulonephritides, multiple sclerosis, leprosy, or immunodeficiency syndromes. The potential diagnostic and therapeutic application of this new methodology are emphasized.

Norwegian scabies: occurrence in a patient undergoing immunosuppression.

Norwegian scabies is rare yet distinctive. The majority of reported cases have been in patients with relatively small group of diseases, including Down syndrome and lepromatous leprosy. A case occurred in a patient on long-term immunosuppressive therapy following a kidney transplant. Altered host factors appear to be the prime determinants in the pathogenesis of the disease.

Immunological problems in leprosy research. 1.

This Memorandum reviews the present status of knowledge of the immunology of leprosy, with particular attention to developments since the publication of a similar review in 1970. The different types of lepromin reaction and their significance in healthy contacts and in patients with tuberculoid and lepromatous leprosy are discussed. The immunological responsiveness of patients with leprosy is also considered, with special attention to in vitro methods for evaluating this response. Part 2 of the Memorandum will cover possible mechanisms of altered immune response in leprosy (including a tentative scheme to explain the possible genesis of the lepromatous lesion); genetic, nutritional, and hormonal factors; the possibility of vaccination; attempts at immunotherapy; and areas in which further research is needed. A detailed protocol for evaluating the effect of transfer factor in leprosy will be included as an annex.