Health-related quality of life of adults with cutaneous leishmaniasis at ALERT Hospital, Addis Ababa, Ethiopia.

BACKGROUND: Cutaneous leishmaniasis (CL) is a growing public health threat in Ethiopia. Leishmania aethiopica is the predominant causative organism. Affected individuals develop chronic skin lesions on exposed parts of the body, mostly on the face, which are disfiguring and cause scarring. The effects of CL on the health-related quality of life (HRQoL) of affected individuals has not been assessed in Ethiopia. OBJECTIVE: To assess HRQoL in adults with active CL at ALERT Hospital, Addis Ababa, Ethiopia. METHODS: A cross-sectional study was done using the Amharic version of the Dermatology Life Quality Index (DLQI). Trained health staff administered the DLQI. RESULTS: Three hundred and two adults with active CL participated and all of them exhibited a reduced HRQoL. The median DLQI score was 10 (IQR 8). Almost half of the participants reported very poor HRQoL, 36.4% and 11.3% fell within the very large and extremely large effect categories respectively. DLQI scores were higher (median 18) in patients diagnosed with diffuse cutaneous leishmaniasis (DCL) compared to those with localized cutaneous leishmaniasis (LCL). The DLQI domain of 'work and school' was the most affected, scoring 73.3% and 66.6% of total possible score for female and male respectively, followed by that of 'symptom and feeling' (at 50.0% and 56.6% for female and male respectively). Men were more affected than women in the domains of 'leisure' (P = 0.002) and 'personal relationships' (P = 0.001). In the multivariate ordinal logistic regression site of lesion, clinical phenotype and age of participant remained associated with significantly poor HRQoL. CONCLUSION: The HRQoL impairment associated with CL is significant. Thus, patient-reported outcome measure should be used to assess the efficacy of treatments along with clinical outcome measures.

Methotrexate and prednisolone study in erythema nodosum leprosum (MaPs in ENL) protocol: a double-blind randomised clinical trial.

INTRODUCTION: Erythema nodosum leprosum (ENL) is an immunological complication of leprosy. ENL results in morbidity and disability and if it is not treated can lead to death. The current treatment consists of thalidomide or high doses of oral corticosteroids for prolonged periods. Thalidomide is not available in many leprosy endemic countries. The use of corticosteroids is associated with morbidity and mortality. Identifying treatment regimens that reduce the use of corticosteroids in ENL is essential. Methotrexate (MTX) is used to treat many inflammatory diseases and has been used successfully to treat patients with ENL not controlled by other drugs, including prednisolone and thalidomide. We present the protocol of the 'MTX and prednisolone study in ENL' (MaPs in ENL) a randomised controlled trial (RCT) designed to test the efficacy of MTX in the management of ENL. METHODS AND ANALYSIS: MaPs in ENL is an international multicentre RCT, which will be conducted in leprosy referral centres in Bangladesh, Brazil, Ethiopia, India, Indonesia and Nepal. Patients diagnosed with ENL who consent to participate will be randomly allocated to receive 48 weeks of weekly oral MTX plus 20 weeks of prednisolone or 48 weeks of placebo plus 20 weeks of prednisolone. Participants will be stratified by type of ENL into those with acute ENL and those with chronic and recurrent ENL. The primary objective is to determine whether MTX reduces the requirement for additional prednisolone. Patients' reported outcome measures will be used to assess the efficacy of MTX. Participants will be closely monitored for adverse events. ETHICS AND DISSEMINATION: Results will be submitted for publication in peer-reviewed journals. Ethical approval was obtained from the Observational/Interventions Research Ethics Committee of the London School of Hygiene & Tropical Medicine (15762); The Leprosy Mission International Bangladesh Institutional Research Board (in process); AHRI-ALERT Ethical Review Committee, Ethiopia; Ethics Committee of the Managing Committee of the Bombay Leprosy Project; and The Leprosy Mission Trust India Ethics Committee; the Nepal Health and Research Council and Health Research Ethics Committee Dr. Soetomo, Indonesia. This study is registered at www.clinicaltrials.gov. This is the first RCT of MTX for ENL and will contribute to the evidence for the management of ENL.Trial registration numberNCT 03775460.

Clinico-pathological features of erythema nodosum leprosum: A case-control study at ALERT hospital, Ethiopia.

BACKGROUND: Leprosy reactions are a significant cause of morbidity in leprosy population. Erythema nodosum leprosum (ENL) is an immunological complication affecting approximately 50% of patients with lepromatous leprosy (LL) and 10% of borderline lepromatous (BL) leprosy. ENL is associated with clinical features such as skin lesions, neuritis, arthritis, dactylitis, eye inflammation, osteitis, orchitis, lymphadenitis and nephritis. ENL is treated mainly with corticosteroids and corticosteroids are often required for extended periods of time which may lead to serious adverse effects. High mortality rate and increased morbidity associated with corticosteroid treatment of ENL has been reported. For improved and evidence-based treatment of ENL, documenting the systems affected by ENL is important. We report here the clinical features of ENL in a cohort of patients with acute ENL who were recruited for a clinico-pathological study before and after prednisolone treatment. MATERIALS AND METHODS: A case-control study was performed at ALERT hospital, Ethiopia. Forty-six LL patients with ENL and 31 non-reactional LL matched controls were enrolled to the study and followed for 28 weeks. Clinical features were systematically documented at three visits (before, during and after predinsolone treatment of ENL cases) using a specifically designed form. Skin biopsy samples were obtained from each patient before and after treatment and used for histopathological investigations to supplement the clinical data. RESULTS: Pain was the most common symptom reported (98%) by patients with ENL. Eighty percent of them had reported skin pain and more than 70% had nerve and joint pain at enrolment. About 40% of the patients developed chronic ENL. Most individuals 95.7% had nodular skin lesions. Over half of patients with ENL had old nerve function impairment (NFI) while 13% had new NFI at enrolment. Facial and limb oedema were present in 60% patients. Regarding pathological findings before treatment, dermal neutrophilic infiltration was noted in 58.8% of patients with ENL compared to 14.3% in LL controls. Only 14.7% patients with ENL had evidence of vasculitis at enrolment. CONCLUSION: In our study, painful nodular skin lesions were present in all ENL patients. Only 58% patients had dermal polymorphonuclear cell infiltration showing that not all clinically confirmed ENL cases have neutrophilic infiltration in lesions. Very few patients had histological evidence of vasculitis. Many patients developed chronic ENL and these patients require inpatient corticosteroid treatment for extended periods which challenges the health service facility in resource poor settings, as well as the patient's quality of life.

The prevalence and association with health-related quality of life of tungiasis and scabies in schoolchildren in southern Ethiopia.

BACKGROUND: The prevalence of skin disease in low and middle income countries is high and communicable skin diseases are a significant public health problem. Tungiasis is an ectoparasite infestation caused by the flea Tunga penetrans, which has a widespread geographical distribution. Tungiasis causes painful skin lesions and may affect activities of daily living. OBJECTIVE: We wished to determine the prevalence and impact of tungiasis and scabies in schoolchildren in southern Ethiopia. METHODS: A cross-sectional study was performed in which students were examined by dermatologists and the skin disorders recorded. Individuals with pyogenic skin infections, scabies and tungiasis were also invited to complete the Children's Dermatology Life Quality Index. RESULTS: There was a high burden of skin disease amongst this cohort with more than 40% having an ectodermal parasitic skin disease. The majority of these were due to tungiasis. Tungiasis was evident in more than a third of children and was associated with onychodystophy. There was a significant association between wearing "closed" footwear and a greater number of tungiasis lesions but not tungiasis per se. Dermatophyte infections, acne and plantar maceration secondary to occlusive footwear were also common. Scabies and tungiasis appeared to have a significant negative effect on quality of life. CONCLUSION: Tungiasis is highly prevalent in schoolchildren in the part of Ethiopia where the study was conducted and is associated with a deleterious effect on quality of life. The role of footwear in both preventing and possibly exacerbating cutaneous ailments in this setting requires further study.

A leprosy clinical severity scale for erythema nodosum leprosum: An international, multicentre validation study of the ENLIST ENL Severity Scale.

OBJECTIVES: We wished to validate our recently devised 16-item ENLIST ENL Severity Scale, a clinical tool for measuring the severity of the serious leprosy associated complication of erythema nodosum leprosum (ENL). We also wished to assess the responsiveness of the ENLIST ENL Severity Scale in detecting clinical change in patients with ENL. METHODS: Participants, recruited from seven centres in six leprosy endemic countries, were assessed using the ENLIST ENL Severity Scale by two researchers, one of whom categorised the severity of ENL. At a subsequent visit a further assessment using the scale was made and both participant and physician rated the change in ENL using the subjective categories of "Much better", "somewhat better", "somewhat worse" and "much worse" compared with "No change" or "about the same". RESULTS: 447 participants were assessed with the ENLIST ENL Severity Scale. The Cronbach alpha of the scale and each item was calculated to determine the internal consistency of the scale. The ENLIST ENL Severity Scale had good internal consistency and this improved following removal of six items to give a Cronbach's alpha of 0.77. The cut off between mild ENL and more severe disease was 9 determined using ROC curves. The minimal important difference of the scale was determined to be 5 using both participant and physician ratings of change. CONCLUSIONS: The 10-item ENLIST ENL Severity Scale is the first valid, reliable and responsive measure of ENL severity and improves our ability to assess and compare patients and their treatments in this severe and difficult to manage complication of leprosy. The ENLIST ENL Severity Scale will assist physicians in the monitoring and treatment of patients with ENL. The ENLIST ENL Severity Scale is easy to apply and will be useful as an outcome measure in treatment studies and enable the standardisation of other clinical and laboratory ENL research.

ENLIST 1: An International Multi-centre Cross-sectional Study of the Clinical Features of Erythema Nodosum Leprosum.

Erythema nodosum leprosum (ENL) is a severe multisystem immune mediated complication of borderline lepromatous leprosy and lepromatous leprosy. ENL is associated with skin lesions, neuritis, arthritis, dactylitis, eye inflammation, osteitis, orchitis, lymphadenitis and nephritis. The treatment of ENL requires immunosuppression, which is often required for prolonged periods of time and may lead to serious adverse effects. ENL and its treatment is associated with increased mortality and economic hardship. Improved, evidence-based treatments for ENL are needed; however, defining the severity of ENL and outcome measures for treatment studies is difficult because of the multiple organ systems involved. A cross-sectional study was performed, by the members of the Erythema Nodosum Leprosum International STudy (ENLIST) Group, of patients with ENL attending seven leprosy referral centres in Brazil, Ethiopia, India, Nepal, the Philippines and the United Kingdom. We systematically documented the clinical features and type of ENL, its severity and the drugs used to treat it. Patients with chronic ENL were more likely to be assessed as having severe ENL. Pain, the most frequent symptom, assessed using a semi-quantitative scale was significantly worse in individuals with "severe" ENL. Our findings will determine the items to be included in a severity scale of ENL which we are developing and validating. The study also provides data on the clinical features of ENL, which can be incorporated into a definition of ENL and used for outcome measures in treatment studies.

The mortality associated with erythema nodosum leprosum in Ethiopia: a retrospective hospital-based study.

BACKGROUND: Erythema nodosum leprosum (ENL) is a debilitating multisystem disorder which complicates leprosy. It is characterised by fever, malaise and painful erythematous cutaneous nodules. ENL is often recurrent or chronic in nature and frequently severe. Patients often require prolonged treatment with high doses of oral corticosteroids. There are no data on the mortality associated with treated ENL. METHODOLOGY: The notes of patients who were admitted, discharged, transferred to another facility or died with a diagnosis of leprosy or a leprosy-related complication for a five year period were reviewed. RESULT/DISCUSSION: 414 individuals were identified from the ward database. 312 (75.4%) patient records were located and reviewed. Ninety-nine individuals had ENL and 145 had a Type 1 reaction. The median age of individuals with ENLwas 25 years. Eight patients with erythema nodosum leprosum died compared with two diagnosed with Type 1 reaction. This difference is statistically significant (p = 0.0168, Fisher's Exact Test). There is a significant mortality and morbidity associated with ENL in this Ethiopian cohort. The adverse outcomes seen are largely attributable to the chronic administration of oral corticosteroids used to control the inflammatory and debilitating symptoms of the condition.

Sífilis em apresentação com fases sobrepostas: como conduzir? / Syphilis in presentation with overlapping phases: how to lead?

A sífilis é uma doença infectocontagiosa de alta prevalência, especialmente nos países em desenvolvimento, e costuma ser denominada a "grande imitadora",devido seu polimorfismo lesional. A divisão da doença em fases é apenas didática e tem importância no manejo terapêutico, entretanto a sífilis deve ser tratada como doença dinâmica, pela possibilidade de sobreposição de seus estágios. Os autores relatam dois casos em que há concomitância do primarismo com o secundarismo sifilítico e enfatizam a importância da avaliação global do paciente em DST.

Syphilis is an infectious disease of high prevalence, especially in underdeveloped countries, and is often called the "great imitator" due to its versatile andvaried disease presentations. The disease's division into stages is only didactic and has importance in the therapeutic management, however syphilis should be managed as a dynamic disease, due to its possibility of overlapping stages. The authors report two cases in which there is concomitance of primary and secondary syphilis and emphasize the importance of patient global assessment in STD.