Ulcers in leprosy patients, an unrecognized clinical manifestation: a report of 8 cases.

BACKGROUND: Leprosy is a chronic granulomatous infection caused by Mycobacterium leprae. It is a polymorphic disease with a wide range of cutaneous and neural manifestations. Ulcer is not a common feature in leprosy patients, except during reactional states, Lucio's phenomenon (LP), or secondary to neuropathies. CASES PRESENTATION: We report eight patients with multibacillary leprosy who presented specific skin ulcers as part of their main leprosy manifestation. Ulcers were mostly present on lower limbs (eight patients), followed by the upper limbs (three patients), and the abdomen (one patient). Mean time from onset of skin ulcers to diagnosis of leprosy was 17.4 months: all patients were either misdiagnosed or had delayed diagnosis, with seven of them presenting grade 2 disability by the time of the diagnosis. Reactional states, LP or neuropathy as potential causes of ulcers were ruled out. Biopsy of the ulcer was available in seven patients: histopathology showed mild to moderate lympho-histiocytic infiltrate with vacuolized histiocytes and intact isolated and grouped acid-fast bacilli. Eosinophils, vasculitis, vasculopathy or signs of chronic venous insufficiency were not observed. Skin lesions improved rapidly after multidrug therapy, without any concomitant specific treatment for ulcers. CONCLUSIONS: This series of cases highlights the importance of recognizing ulcers as a specific cutaneous manifestation of leprosy, allowing diagnosis and treatment of the disease, and therefore avoiding development of disabilities and persistence of the transmission chain of M. leprae.

Diagnóstico tardío de lepra lepromatosa. A propósito de un caso / No disponible

La lepra es una enfermedad infecciosa crónica, que afecta piel y nervios periféricos, la mucosa de las vías respiratorias superiores y también los ojos, además de algunas otras estructuras, ocurre en personas de cualquier edad y de ambos sexos causadas por el Mycobacterium leprae. El diagnóstico precoz reviste gran importancia ya que cura al enfermo, interrumpe la cadena de transmisión y evita las discapacidades. Presentamos un paciente masculino de 46 años de edad, trabajador agrícola sin antecedentes epidemiológicos conocidos y sin percepción del riesgo de la enfermedad que ingresa en el hospital municipal de Florida con fiebre, dolores articulares y lesiones en piel, diagnosticándose una lepra lepromatosa, discapacidad grado 2 según clasificación de la OMS dado por la deformidad de manos y pies, la pérdida de la estructura y la rigidez, constituyendo un diagnóstico tardío

Leprosy is an infectious disease with a chronic evolution that affects skin, peripheral nerves, upper respiratory tract and other structures. It appears in individuals of any age or sex and its etiological agent is Mycobacterium leprae. An early diagnosis is essential for preventing incapacities and interrupting the chain of transmission. We present a case of a 46 year old male, field worker, with a previous clinical history and no reception of the risk of illness. He entered the general hospital in Florida with fever, joint pains and skin lesions and was diagnosed of lepromatous leprosy, with grade 2 disabilities according to the WHO classification of the hand, feet and eye deformities, all the cause of a late diagnosis

Trigeminal trophic syndrome complicating a case of borderline tuberculoid leprosy.

An example of trigeminal trophic syndrome presenting as ulceration of ala nasi in a case of borderline tuberculoid leprosy is reported. To the best of our knowledge, this is only the second case report of this manifestation in leprosy to be documented.

Multifocal cutaneous melanoacanthoma with ulceration: a case report with review of literature.

We report a case of a 58-year-old female patient who presented with multiple, asymptomatic, slowly-growing, raised pigmented lesions all over her body for the past 10 years with ulceration in one of the lesions on the trunk for the past five months. Histopathology of the lesion revealed features consistent with melanoacanthoma. Here, we report the first case of cutaneous melanoacanthoma presenting with an ulcerated plaque and the third case of cutaneous melanoacanthoma with multiple lesions. To the best of our knowledge, ulceration has not yet been reported as a feature of cutaneous melanoacanthoma in the medical literature.

Pityriasis lichenoides with ulceronecrosis and hyperthermia: a rare variant of pityriasis lichenoides et varioliformis acuta.

Pityriasis lichenoides with ulceronecrosis and hyperthermia (PLUH) is a severe variant of pityriasis lichenoides et varioliformis acuta that is characterized by high fever and papulo-necrotic skin lesions. We report the case of a 49-year-old male with typical features of PLUH along with an unusual manifestation of extensive skin necrosis including involvement of the intertriginous regions. Systemic administration of corticosteroids and antibiotics did not help to control the disease and the patient succumbed to death due to its fulminant nature.

Marjolin's ulcer: the importance of surgical management of chronic cutaneous ulcers.

Chronic cutaneous ulcers are commonplace in the developing world, especially in rural areas with poor living conditions and often result from the trauma of road-traffic injuries. Chronic cutaneous ulcers may also be due to vascular insufficiency, neuropathy, nodular leprosy, pressure, diabetes, or hemoglobinopathies, or they may be tropical ulcers. If poorly managed, these lesions may undergo malignant transformation. We evaluated the clinical histories and treatment outcomes of patients seen at the University of Calabar Teaching Hospital, between January 2000 and December 2004, who had histologic diagnosis of Marjolin's ulcer, in an attempt to identify risk factors for this problem. The six patients were men, age 30-70 years (mean, 42 years). Trauma was the leading cause of injury leading to ulceration: road-traffic accidents (four patients, 66.7%), fall (one patient, 16.7%), and flame burn (one patient, 16.7%). Most injuries involved the limbs: lower (four patients, 66.7%) and upper (one patient, 16.7%). The histologic diagnosis in all the cases were squamous cell carcinoma and mean latency period from injury to diagnosis of malignancy was 18.5 years. All the patients had been admitted because of poor results from topical treatment. Three patients (50%) were managed with wide excision and skin grafting with the lesions healed. Ignorance as well as economic and sociocultural factors were the underlying issues. Education concerning the risks associated with chronic wounds and the need for prompt and proper surgical management are recommended.

Reação reversa com vasculites granulomatosas e lesões cutâneas necrosantes e ulcerativas / Reversal reaction with granulomatous vasculities and necrotizing cutaneous lesions

Um indivíduo com 49 anos de idade recebe o diagnóstico de Hanseníase Virchoviana sub-polar. Ele referiu, durante os prévios 11 anos, sintomas, principalmente neurológicos, característicos de hanseníase, mas este diagnóstico não foi definido nos serviços médicos que freqüentou. Após 6 meses de poliquimioterapia passou a apresentar neurites que foram tratadas como reação tipo 2. Em um último episódio apresentou febre, mal estar, mialgias e lesões necróticas e ulcerativas nos membros, nádegas, dorso, pavilhão auricular esquerdo. O aspecto clínico destas lesões era semelhante as lesões observadas no fenômeno de Lúcio e no Eritema nodoso necrosante. As biópsias mostram alterações da microvasculatura superficial, necrose epidérmica e dérmica, similares a estas reações, mas as alterações básicas são vasculites granulomatosas no derma profundo e tecido celular sub-cutâneo. Estes aspectos clínicos e histopatológicos são interpretados e discutidos como reação tipo 1 (reação reversa) com envolvimento vascular predominante.

Topical phenytoin suspension and normal saline in the treatment of leprosy trophic ulcers: a randomized, double-blind, comparative study.

OBJECTIVE: To evaluate and compare two strengths of topical phenytoin sodium suspension (2% and 4%) with normal saline in the healing of acute trophic ulcers in leprosy patients. METHODS: A prospective, parallel, double-blind, randomized study was conducted in 45 leprosy inpatients with acute trophic ulcers. Patients were randomized to receive 2%, 4% or normal saline dressing on their ulcers once daily for 4 weeks. Efficacy parameters such as a reduction in the surface area of the ulcer, bacterial culture of the ulcer swab, appearance of healthy granulation tissue, cessation of ulcer discharge and overall gradation of clinical healing and safety were assessed at weekly intervals. RESULTS: The ulcer area reduction was greater in the 2% and 4% phenytoin groups compared with the normal saline group (p<0.001). Appearance of healthy granulation tissue and cessation of ulcer discharge was also observed earlier in the two phenytoin groups. At the end of 4 weeks, 11 ulcers each had healed completely in both the 2% and 4% phenytoin groups compared with none in the control group. There were no statistical differences between the 2% and 4% phenytoin groups. No side effects were reported by any patient. CONCLUSION: Topical phenytoin appears to be an effective, safe and cheap therapeutic option for the healing of trophic ulcers in leprosy patients.

Lepra de Lucio y eritema necrotizante / No disponible

Se comenta la historia y características de la lepra de Lucio y eritema necrotizante y su preferencia geográfica por México, aunque se han descrito en otros países. Se expone la experiencia personal de dos casos de Lucio y 22 eritemas necrotizantes en enfermos lepromatosos no difusos y la evolución mortal en dos pacientes (AU)

We coment the history and characteristics of the Lucio's Leprosy and the Necrotrisans erythema and it's geographical preference by Mexico even though it is also spread out other countries. We expuse our personal experience of two Lucio's cases and the 22 Necrotisans erythema in lepromatous patients not difused and the mortal evolution in two patients (AU)

Ulceraciones en la lepra. Tratamiento / Ulcerations in lepra. Management

Se estudian las úlceras en la lepra, su etiología, frecuencia y localización, la mayoría de carácter neurotrófico. Se describen diferentes tratamientos tópicos y quirúrgicos, resaltando las dificultades terapéuticas y la cronicidad (AU)

[How does one treat the osteitis and osteoarthritis of the extremities in older leprosy patients using granulated table sugar?]. / Comment guérir les ostéites et ostéo-arthrites des extrémités des anciens malades de la lèpre par le sucre cristallisé alimentaire?

A common problem of osteitis and septic arthritis is the recurrent bone infection after surgical debridement, a problem frequently encountered in patients with sequela leprosy. In these cases the authors propose the use of an ancient method of post surgical wound care based on the treatment with ordinary granulated sugar. The hyperosmolar climate created this way in the wounds inhibits the bacterial growth, enhances bacterial death and therefore permits the growth of granulation tissue in order to recover the debrided nude bones. At ILAD (Leprosy Institute of Dakar), 36 osteitis and septic arthritis were treated and healed during the last 2 years from March 1995 to March 1997 using this technic. All the wounds healed in the mean-time of 44 days. Only two of them needed a second debridement and healed afterwards. Up to now the method using ordinary sugar was applied in the treatment of infected wounds, eschars and postsurgical infections. Our experience shows that it also can be indicated to treat bone infections. This method is easy to apply also under often difficult field conditions and is very cheap.

The predictive value of sensation testing in the development of neuropathic ulceration on the hands of leprosy patients.

The early detection of the loss of protective sensation in leprosy patients is vital if neuropathic ulceration and subsequent disabilities are to be avoided. The aim of this study was to find protective value of sensory thresholds in the hands of leprosy patients. Thresholds for touch-pressure, vibration and temperature were assessed in areas on leprosy-affected hands near ulcers or ulcer scars (LU-group), in areas without lesions (LN-group), and in controls (N-group). Semmes-Weinstein monofilaments were used for testing the touch-pressure threshold (PST), a biothesiometer for the vibration threshold (VST) and a Thermo Sensation Tester for the temperature threshold (TST). The distribution of ulcers was about equal on palmar and dorsal aspects of the hands. In the LU-group there was a negative response to SWF of 2.0 g in all patients, while 74% could feel the 2.0 g in LN-areas and in N-areas 100% could detect the 2.0 g SWF. In the LU-group about 11% felt 8 V VST, in the LN-group about 60% and in the N-group 89%. Testing temperature sensation was given up prematurely because the results in controls were unsatisfactory. Both palmar and dorsal sides of the hands should be tested for sensation. The thresholds for protective sensation are 2.0 g SWF and 8 V for vibration sense. It is recommended that Semmes-Weinstein monofilaments should always be used for early detection of loss of protective sensation.

Squamous cell carcinoma in chronic ulcers in leprosy: a review of 38 consecutive cases.

The histories of 38 consecutive cases of squamous cell carcinoma (SCC) arising in chronic ulcers of leprosy patients treated between 1981 and 1990 at the McKean Rehabilitation Centre, Northern Thailand were analysed retrospectively. The study included 37 individual patients; 29 males and 8 females. The average age was 60 years, the average duration of leprosy was 34 years and the average duration of ulcers was 12 years. Most patients (76%) came from leprosy settlements. Patients with borderline-tuberculoid (BT) leprosy were most commonly affected (63%), followed by lepromatous (LL) leprosy (21%) and borderline-lepromatous (BL) leprosy (16%). Four patients (11%) had histories of SCC on other extremities. Metastatic spread was observed in 2 cases (5%), both instances leading to death. The commonest site of involvement of SCC was the foot, but it was seen on the knee in 1 patient and on the hand in 2 others. The incidence rate of SCC in the group at risk (leprosy patients with disability grading 1 and 2) is calculated as being 0.79:1000 per year. SCC was seen in 1.8% of all cases admitted for ulcer care at the Centre. Treatment is by radical amputation. SCC in chronic ulcers in leprosy patients cannot be considered rare and emphasizes the need for an active policy of disability prevention in leprosy programmes.