Nerve abscess in Hansen's disease as part of immune reconstitution inflammatory syndrome: a case report.

Immune reconstitution inflammatory syndrome is an inflammatory reaction in HIV-infected patients after initiation of antiretroviral therapy resulting from restored immunity to specific infectious or non-infectious antigens. A 36-year-old male patient on highly active antiretroviral therapy of six months duration, presented with reddish, tender lesions over medial aspect of arm and a single, anaesthetic patch. Tender fluctuant swellings were seen on the medial aspect of left forearm. A few of them had ruptured spontaneously discharging pus. A skin biopsy from the anaesthetic patch showed caseating epitheloid granulomas. A diagnosis of Hansen's disease borderline tuberculoid in type 1 reversal reaction, with formation of nerve abscess due to Immune Reconstitution Inflammatory Syndrome was made. The patient was started on multibacillary multidrug therapy as per WHO guidelines and highly active antiretroviral therapy was continued.

Variables affecting interpretation of skin prick test results.

BACKGROUND: Both performer- and device-dependent variabilities have been reported in sizes of wheal responses to skin prick tests. OBJECTIVE: We aimed to evaluate whether or not variabilities in sizes of wheal responses influence the final interpretation of skin prick tests; in other words, the decision on whether or not there is an allergy to a given antigen. METHODS: Skin prick tests with positive and negative controls and extracts of Dermatophagoides farinae and Dermatophagoides pteronyssinus were done for 69 patients by two different persons, using two different puncturing devices- disposable 22-gauge hypodermic needles and metal lancets. RESULTS: Among four different skin prick tests, the average coefficients of variation in sizes of wheal responses were near to or higher than 20% for all of them. On the other hand, in the final interpretation of results, kappa values indicated substantial or almost perfect agreements between these tests. However, the frequency of establishing allergy to the house dust mites widely ranged in these tests (20.8-35.8% for D. farinae and 20.8-28.3% for D. pteronyssinus). LIMITATIONS: The conduction of the study in a single center and the comparisons of results of only two performers. CONCLUSION: We feel that variabilities in sizes of wheal responses of skin prick test can influence its categorical results.

Complex Type 2 Reactions in Three Patients with Hansen's Disease from a Southern United States Clinic.

In non-endemic countries, leprosy, or Hansen's disease (HD), remains rare and is often underrecognized. Consequently, the literature is currently lacking in clinical descriptions of leprosy complications in the United States. Immune-mediated inflammatory states known as reactions are common complications of HD. Type 1 reactions are typical of borderline cases and occur in 30% of patients and present as swelling and inflammation of existing skin lesions, neuritis, and nerve dysfunction. Type 2 reactions are systemic events that occur at the lepromatous end of the disease spectrum, and typical symptoms include fever, arthralgias, neuritis, and classic painful erythematous skin nodules known as erythema nodosum leprosum. We report three patients with lepromatous leprosy seen at a U.S. HD clinic with complicated type 2 reactions. The differences in presentations and clinical courses highlight the complexity of the disease and the need for increased awareness of unique manifestations of lepromatous leprosy in non-endemic areas.

Insect bite reactions.

Insects are a class of living creatures within the arthropods. Insect bite reactions are commonly seen in clinical practice. The present review touches upon the medically important insects and their places in the classification, the sparse literature on the epidemiology of insect bites in India, and different variables influencing the susceptibility of an individual to insect bites. Clinical features of mosquito bites, hypersensitivity to mosquito bites Epstein-Barr virus NK (HMB-EBV-NK) disease, eruptive pseudoangiomatosis, Skeeter syndrome, papular pruritic eruption of HIV/AIDS, and clinical features produced by bed bugs, Mexican chicken bugs, assassin bugs, kissing bugs, fleas, black flies, Blandford flies, louse flies, tsetse flies, midges, and thrips are discussed. Brief account is presented of the immunogenic components of mosquito and bed bug saliva. Papular urticaria is discussed including its epidemiology, the 5 stages of skin reaction, the SCRATCH principle as an aid in diagnosis, and the recent evidence supporting participation of types I, III, and IV hypersensitivity reactions in its causation is summarized. Recent developments in the treatment of pediculosis capitis including spinosad 0.9% suspension, benzyl alcohol 5% lotion, dimethicone 4% lotion, isopropyl myristate 50% rinse, and other suffocants are discussed within the context of evidence derived from randomized controlled trials and key findings of a recent systematic review. We also touch upon a non-chemical treatment of head lice and the ineffectiveness of egg-loosening products. Knockdown resistance (kdr) as the genetic mechanism making the lice nerves insensitive to permethrin is discussed along with the surprising contrary clinical evidence from Europe about efficacy of permethrin in children with head lice carrying kdr-like gene. The review also presents a brief account of insects as vectors of diseases and ends with discussion of prevention of insect bites and some serious adverse effects of mosquito coil smoke.

Type I lepra reaction presenting as immune reconstitution inflammatory syndrome.

Immune reconstitution inflammatory syndrome (IRIS) is an unusual inflammatory reaction due to infectious and non-infectious causes occurring in human Immunodeficiency virus (HIV)-infected patients. IRIS occurs after the initiation of antiretroviral therapy. There are no reports of type I lepra reaction due to IRIS in published literature from India. We report two cases of HIV-infected males who presented with borderline tuberculoid leprosy in type 1 reaction after the initiation of highly active antiretroviral treatment (HAART). Case 1 presented with multiple, tender, erythematous and hypoesthetic plaques on the trunk and extremities after 3 months of antiretroviral therapy. In case 2, type I lepra reaction was observed 2 months after the initiation of HAART.

Retos del Deterioro neural en Lepra / No disponible

La base del deterioro neural en la lepra es la tendencia del Mycobacterium leprae de invadir las c¨¦lulas Schawann. El ¦Á¦Â-distroglicano sobre la membrana basal de las c¨¦lulas Schawann se une a la alminina ¦Á2, que a su vez se une a receptores situados sobre la superficie del M. leprae, incluyendo una prote¨ªna tipo histona y el glicol¨ªpido fen¨®lico-I. Cuando se observ¨® que este deterior neural durante las reacciones de reversi¨®n estaba asociado con el repentino incremento de la hipersensibilidad de tipo retardado frente a determinados ant¨ªgenos de M. leprae liberado por las c¨¦lulas Schawann, se postul¨® que se afecta el nervio como testigo inocente de la respuesta inmunol¨®gica. Esto favorece la administraci¨®n de terapia farmacol¨®gica basada en la inmunosupresi¨®n combinado con la anti-micobacteriana. La lisis xe las c¨¦lulas Schawann con determinantes antig¨¦nicos M.leprae por c¨¦lulas T CD4+ activadas y la interaci¨®n de los receptores tipo Toll de las c¨¦lulas Schawann con el M.leprae son mecanismos adicionales tambi¨¦n implicados en el deterioro neural. La persistencia de ant¨ªgenos M. Leprae en las lesiones locales despu¨¦s de la administraci¨®n de MDT es un factor de riesgo importante para las reacciones tard¨ªas. A pesar de los grandes adelantos en el suministro global de MDT, el diagn¨®stico precoz, junto al tratamiento eficaz de la enfermedad y el deterioro neural asociado con ¨¦l siguen constituyendo un desaf¨ªo para los servicios sanitarios. La disminuci¨®n de la prevalencia como consecuencia de la MDT no debe ser tomada como indicador de que los desaf¨ªos que presenta esta enfermedad est¨¢n disminuyendo ya que mientras no se controle el deterior neural y los ¨ªndices de nuevas detecciones no disminuyan hay que seguir en guardia

The basis of nerve damage in leprosy is the unique tendency of Mycobacterium leprae to invade Schwann cells. ¦¡¦Â-Dystroglycan on the basement membrane of Schwann cells binds to laminin ¦Á2 in turn binding to receptors on the M. leprae surface, comprising a histone-like protein and phenogly-1colipid-1. When never damage during reversal reactions was found tio be associated with an abrupt increase in delayed type hypersensitivy against M. leprae antigenic determinants relased form Schwann cells, it suggested that the nerve is damaged as an innocent bystander during the immune response. This strongly influenced the introduction of therapy based on immunosuppression combined with continued anti-mycobacterial medication. Lysis of Schwann cells presenting M. leprae antigenic determinants by activated CD4 + T cells and interaction of M. leprae with Toll-like receptors on Schawann cells are additional mechanisms implicated in nerve damage. Persistence of M. leprae antigen in local lesions after regular multiple drug therapy (MDT) is an important risk factor for late reactions. In spite of significant advances in the provision of MDT globally, early diagnosis, together with effective treatment of the disease and associated serve damage at initial presentation remains a major challenge for the health services. Reduced prevalence as a result of MDT should not to be taken to indicate that the challenges of leprosy control are diminished as long as nerve damage is not controlled and new case detection rates are not declining

Clinical recognition of leprosy: some factors leading to delays in diagnosis.

The case histories of eight patients in the United Kingdom admitted to hospital for the diagnosis of leprosy are examined in detail. Review of their early symptoms and signs showed that there had been delays in diagnosis, ranging from a few months to many years. Possible reasons for delay are discussed, and attention is called to the importance of nasal symptoms in the early diagnosis of lepromatous leprosy.