Clofazimine-induced cutaneous hyperpigmentation as a source of stigma in the treatment of leprosy: A cross-sectional study.

OBJECTIVES: Cutaneous hyperpigmentation is one of the main adverse effects encountered in patients undergoing leprosy treatment with multidrug therapy (WHO-MDT). This adverse effect has been described as intolerable and capable of contributing to social stigma. The objectives of this study were to quantify the variation in skin colour induced by clofazimine during and after treatment and to assess the related stigma. METHODS: This observational cross-sectional study objectively measured skin colour in 51 patients by reading the individual typology angle (ITA°) with a spectrophotometer, followed by the application of the Stigma Scale of the Explanatory Model Interview Catalogue (EMIC). RESULTS: Skin hyperpigmentation was observed in 100% of the individuals. They showed more negative ITA° values in lesion areas than non-lesion areas, particularly in sun-exposed regions. Clofazimine-induced cutaneous hyperpigmentation was not homogeneous and seemed to follow the lesion locations. The mean EMIC score was 18.8 points. CONCLUSION: All patients presented skin hyperpigmentation caused by clofazimine, detectable through spectrophotometry. Hyperpigmentation strongly impacted the social domain, indicating the intersectionality of disease and skin colour stigma, contributing to the social isolation of these patients. Health authorities should consider the negative impact of clofazimine on treatment adherence.

Topical formulation containing chitosan-chamomile microparticles in cutaneous wound healing in rats.

Objective: The aim of this research was to evaluate the efficacy of a topical formulation containing chitosan-chamomile microparticles in cutaneous healing in rats. Method: Male Wistar rats (n=57) were randomly distributed into three groups: treatment; vehicle; and control. Evaluations were performed on days 2, 7 and 14 after the surgical procedure using skin lesion photography, and histological and biochemical analyses. Results: The results showed that there was no difference in the healing index and in the histological analysis of the inflammatory infiltrate among groups. Fibrogenesis was more significant in the group treated with the test formulation at day 7, and angiogenesis was greater in the vehicle and chamomile groups at day 2. The quantification of hydroxyproline showed a higher amount of collagen in the group treated with chamomile, mainly at day 14, although the histological quantification of collagen showed no difference between the groups. Conclusion: From the results of this study, it can be concluded that the formulation, although it had no effect on the healing time, improved the quality of the cicatricial tissue formed with a greater quantity of fibroblasts and collagen.

Leprosy in urban space, areas of risk for disability and worsening of this health condition in Foz Do Iguaçu, the border region between Brazil, Paraguay and Argentina.

BACKGROUND: Leprosy is a public health problem and a challenge for endemic countries, especially in their border regions where there are intense migration flows. The study aimed to analyse the dynamics of leprosy, in order to identify areas of risk for the occurrence of the disease and disability and places where this health condition is worsening. METHOD: This ecological study considered the new cases of leprosy reported in the municipality of Foz do Iguaçu from 2003 to 2015. Spatial and spatial-temporal scan statistics were used to identify the risk areas for the occurrence of leprosy, as well as the Getis-Ord Gi and Getis-Ord Gi* methods. Areas of risk for disabilities were identified by the scan statistic and kernel density estimation. RESULTS: A total of 840 cases were reported, of which 179 (21.3%) presented Grade 1 or 2 disabilities at the time of diagnosis. Leprosy risk areas were concentrated in the Southern, Eastern and Northeastern Health Districts of the municipality. The cases of Grade 2 disability were observed with higher intensity in regions characterized by high population density and poverty. CONCLUSION: The results of the study have revealed changes in the pattern of areas at risk of leprosy according to the investigated periods. In addition, it was possible to verify disabilities as a condition present in the investigated cases, or that may be related to the late diagnosis of the disease. In the areas of risk identified, patients have reported worse physical disability after diagnostic confirmation, or indicate inadequate clinical examination, reinforcing the need for structuring leprosy control services in a qualified manner.

Thermographic Characterization of Cutaneous Ulcers of Different Etiologies.

The characterization of the temperature of skin ulcers may provide preliminary diagnostic evidence. The aim of this study was to characterize cutaneous ulcers of different etiologies by infrared thermography. 122 cutaneous ulcers of 87 patients (age 60.1 ± 15.7 years) were evaluated, allocated into five groups: venous ulcers (VU) n = 26, arterial ulcers (AU) n = 20, mixed ulcers (MU) n = 25, pressure ulcers (PU) n = 29, and neuropathic ulcers (NU) n = 22. The cutaneous temperature was recorded by infrared thermography (FLIR-450™); we also evaluated the ulcer area, the ankle brachial index (ABI), the range of motion (ROM) of the ankle, and pain. For the different variables, the statistical analysis was performed using the Kruskal Wallis test, ANOVA, the chi-squared test, and the Spearman test (SPSS™ software version 20, p < 0.05). A significant difference was found between the temperatures of PU and NU. The ABI was significantly lower in the MU and AU groups, and pain was also higher in these groups. The ROM was decreased in all groups, and the MU and VU groups had the lowest ROM. There was no correlation between temperature and the clinical findings (ABI, ROM, and pain). There was a moderate correlation in the analysis between the temperature and the area of the ulcer in the PU group, as larger ulcers had lower temperatures. It is possible to characterize cutaneous ulcers by infrared thermography, and there are temperature differences among ulcers with different etiologies.

Novel polymeric dressing to the treatment of infected chronic wound.

Natural rubber latex (NRL) is a natural polymer which has arisen large interest in the biomedical field, mostly, due to its ability to facilitate angiogenesis and therefore, tissue repair. Moxifloxacin (MXF) is a broad-spectrum antibiotic orally administrated. Considering the biological properties of the NRL and its ability to deliver a wide range of compounds, the present study aimed to develop a novel device for infected chronic wound treatment. MXF-loaded NRL was obtained by a casting method. The results demonstrated that the incorporation of MXF in NRL did not promote any molecular interaction, preserving the integrity of the compounds. The mechanical properties of the biomaterial did not show any significant change, indicating enough elasticity for dermal application. The microbiological assays confirmed the ability of the polymer to deliver the drug without influencing its pharmacological properties. Moreover, it has expressed activity against major bacterial strains presented in wound infections. Finally, the biomaterial shown biocompatibility from the in vitro study. Thus, the present work has shown that MXF-loaded NRL membrane is a promising biomaterial to infected wound treatment.

Photobiomodulation effect on the proliferation of adipose tissue mesenchymal stem cells.

The use of mesenchymal stem cells (MSCs) in tissue engineering has been extensively investigated. The greater the proliferation of this cellular group, the greater the regenerative and healing capacity of the tissue to which they belong. In this context, photobiomodulation (PBM) is an efficient technique in proliferation of distinct cell types. However, its parameters and mode of action are still unclear and require further investigation. This study aimed to evaluate the PBM action with different energies in MSCs of adipose tissue (hASCs). We used hASCs, seeded in 24-well plates, with 3 × 104 cells per well, in culture media. We used a total of four experimental groups, one with hASCs and simulated PBM and three other groups, which received PBM irradiation at 24, 48, and 72 h, with a 660-nm laser and power of 40 mW and energy of 0.56, 1.96, and 5.04 J. We performed analyses of MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromidefor) and trypan blue to evaluate cell proliferation and viability, 1 h after PBM irradiation. Software Graph PadPrism 7.0 was used. Intergroup comparisons were performed with ANOVA two-way and we used the Tukey post hoc test. Mitochondrial activity evaluated by MTT revealed the statistical difference in the first 24 h for group with more high energy when compared to control group; and in the 72 h for two irradiated groups when compared to the control group. The trypan blue test showed significant differences at the end of the experiment for two irradiated groups LG1 (4.52 × 104 ± 0.2) and LG2 (4.85 × 104 ± 0.8), when compared to the control group (1.87 × 104 ± 0.7). Both tests failed to be statistically different at the end of the experiment for groups LG1 and LG2 and observed a reduction in cellular mitochondrial growth and activity for group LG3. We conclude that PBM with energy close to 0.56 and 1.96 J promote proliferation of hASCs, and higher energy, such as 5.04 J, can be harmful.

Th17 Response of Borderline-Lepromatous Leprosy Inhibits Rash Manifestation of Dapsone Hypersensitivity Syndrome: Case Report.

BACKGROUND: Dapsone hypersensitivity syndrome (DHS) is a rare, but potentially life-threatening reaction to dapsone. OBJECTIVE: Evaluation of immunological factors involved in the sparing of borderline-lepromatous (BL) leprosy patches by the severe exanthema related to DHS. METHODS: The authors describe a 19-year-old man with borderline-lepromatous leprosy with a recent diffuse rash, sparing only the hypochromic patches of leprosy, generalized lymphadenopathy, hepatomegaly, and jaundice 25 days after the start of multibacillary multidrug therapy. RESULTS: Laboratory testing was remarkable for leukocytosis with eosinophilia, atypical lymphocytosis, and elevated liver and canalicular enzymes. Immunohistopathology of the rash showed stronger expression of Th1 cytokines (IL1ß, TNFα, IFNγ, and iNOS), and limited expression of IL17, TGFb, IL4, and IL10. Whereas the hypochromic leprosy patches showed high expression of inflammatory cytokines IL1ß, TNFα, IFNγ, iNOS, and TGFß (Th1), and presented strong expression of IL17 and TGFß with no IL4 and IL10 expression, by the inflammatory infiltrate, characterizing a participation of Th17 response. CONCLUSION: Th17 response, coupled with the presence of subepidermal collagen band, seems to be directly related to the absence of DHS rash in these hypochromic leprosy patches.

Skin changes in streptozotocin-induced diabetic rats.

Diabetes can cause serious health complications, which can affect every organ of the body, including the skin. The molecular etiology has not yet been clarified for all diabetic skin conditions. Thus, this study aimed to investigate the changes of diabetes in skin compared to non-diabetic skin in rats. Fifteen days after establishing the diabetic status, skin samples from the dorsum-cervical region were harvested for subsequent analysis of alterations caused by diabetes. Our results demonstrate that diabetes stimulated higher inflammation and oxidative stress in skin, but antioxidant defense levels were lower compared to the non-diabetic group (p < 0.05). This could have been related to a decreased number of blood vessels and low expression of VEGF, eNOS and TGF-ß1. Finally, insulin signaling proteins IRS, Akt, Shc and ERK showed a low expression in the diabetic group. Thus, our study shows that the pathology of diabetes induced immunohistopathological and biochemical skin changes compared to non-diabetic skin in rats.

Leprosy with ulnar nerve abscess: ultrasound findings in a child.

We report the ultrasound findings of a typical case of nerve abscess due to leprosy in an 11-year-old boy. The patient had previously undergone pediatric multibacillary leprosy multidrug therapy (MDT) in accordance with World Health Organization guidelines. He presented to our service with bilateral ulnar neuritis with no response to prednisone (1 mg/kg). Right ulnar nerve ultrasound revealed nerve hypoechogenicity, fascicular pattern disorganization, marked fusiform thickening, and a round anechoic area suggestive of intraneural abscess. Intense intraneural power Doppler signal was detected, indicating active neuritis. Intravenous methylprednisolone had a poor response and the patient was submitted to ulnar nerve decompression, which confirmed nerve abscess with purulent discharge during surgery. As the patient weighed more than 40 kg, treatment with a pediatric dose was considered insufficient and adult-dose MDT was prescribed, with improvement of nerve pain and function. Although leprosy is rare in developed countries, it still exists in the USA and it is endemic in many developing countries. Leprosy neuropathy is responsible for the most serious complications of the disease, which can lead to irreversible impairments and deformities. Nerve abscess is an uncommon complication of leprosy and ultrasound can efficiently demonstrate this condition, allowing for prompt treatment. There is scant literature about the imaging findings of nerve abscess in leprosy patients. Radiologists should suspect leprosy in patients with no other known causes of neuropathy when detecting asymmetric nerve enlargement and nerve abscess on ultrasound.

Evidence of hidden leprosy in a supposedly low endemic area of Brazil.

OBJECTIVES: Show that hidden endemic leprosy exists in a municipality of inner São Paulo state (Brazil) with active surveillance actions based on clinical and immunological evaluations. METHODS: The study sample was composed by people randomly selected by a dermatologist during medical care in the public emergency department and by active surveillance carried out during two days at a mobile clinic. All subjects received a dermato-neurological examination and blood sampling to determine anti-PGL-I antibody titers by enzyme-linked immunosorbent assay (ELISA). RESULTS: From July to December 2015, 24 new cases of leprosy were diagnosed; all were classified as multibacillary (MB) leprosy, one with severe Lucio's phenomenon. Seventeen (75%) were found with grade-1 or 2 disability at the moment of diagnosis. Anti-PGL-I titer was positive in 31/133 (23.3%) individuals, only 6/24 (25%) were positive in newly diagnosed leprosy cases. CONCLUSIONS: During the last ten years before this study, the average new case detection rate (NCDR) in this town was 2.62/100,000 population. After our work, the NCDR was raised to 42.8/100,000. These results indicate a very high number of hidden leprosy cases in this supposedly low endemic area of Brazil.

Comparison of collagen content in skin wounds evaluated by biochemical assay and by computer-aided histomorphometric analysis.

CONTEXT: The quantification of total collagen is of major importance in a wide range of research areas, including the study of cutaneous wound healing and new drugs trials. OBJECTIVE: The total collagen content in skin biopsies was compared by biochemical hydroxyproline assay and by two computer-aided histomorphometric analyses of histological sections. MATERIALS AND METHODS: Two methods were used to evaluate collagen formation: the hydroxyproline assay, as the gold standard and histomorphometric image analysis of the filled areas by corresponding stained collagen fibres, using picrosirius and Gomori's trichrome staining. The image analyses were determined by digital densitometry recognition using computer-aided ImageJ software. One-way ANOVA, simple linear regression and ANCOVA were applied for the statistical analysis and correlation. RESULTS: In a simple linear regression analysis carried out on the 14th day period after the induction of skin injury, three techniques, picrosirius red (F = 33.57, p = 0.00), Gomori's trichrome (F = 81.61, p = 0.00) and hydroxyproline content (F = 16.85, p = 0.00) were able to detect collagen production. After scale adjustment, there were no significant differences among either the slopes (F = 1.17, p = 0.32) or the intercepts (F = 0.69, p = 0.51) of the estimated regression lines. It seems that a highly significant correlation exists between the histomorphometrical analysis and hydroxyproline assay. DISCUSSION AND CONCLUSION: The morphometric analysis proved to be adequate and can be used as a simple, rapid, low-cost technology for evaluating total collagen in cutaneous wound specimens, compared with the gold standard hydroxyproline assay.

Spatial epidemiology and serologic cohorts increase the early detection of leprosy.

BACKGROUND: Leprosy remains an important public health problem in some specific high-burden pockets areas, including the Brazilian Amazon region, where it is hyperendemic among children. METHODS: We selected two elementary public schools located in areas most at risk (cluster of leprosy or hyperendemic census tract) to clinically evaluate their students. We also followed anti-PGL-I seropositive and seronegative individuals and households for 2 years to compare the incidence of leprosy in both groups. RESULTS: Leprosy was detected in 11 (8.2 %) of 134 school children in high risk areas. The difference in the prevalence was statistically significant (p < .05) compared to our previous findings in randomly selected schools (63/1592; 3.9 %). The 2-year follow-up results showed that 22.3 and 9.4 % of seropositive and seronegative individuals, respectively, developed leprosy (p = .027). The odds of developing overt disease in seropositive people were 2.7 times that of negative people (p < .01), indicating that a follow-up of 10 seropositives has a >90 % probability to detect at least one new case in 2 years. The odds of clinical leprosy were also higher in "positive houses" compared to "negative houses" (p < .05), indicating that a follow-up of ten people living in households with at least one seropositive dweller have a 85 % probability to detect at least one new case in 2 years. CONCLUSIONS: Targeted screening involving school-based surveillance planned using results obtained by spatial analysis and targeted household and individual continuous surveillance based on serologic data should be applied to increase the early detection of new leprosy cases.

Human Skin as an Ex Vivo Model for Maintaining Mycobacterium leprae and Leprosy Studies.

The in vitro cultivation of M. leprae has not been possible since it was described as causing leprosy, and the limitation of animal models for clinical aspects makes studies on leprosy and bacteria-human host interaction a challenge. Our aim was to standardize the ex vivo skin model (hOSEC) to maintenance and study of M. leprae as an alternative animal model. Bacillary suspensions were inoculated into human skin explants and sustained in DMEM medium for 60 days. Explants were evaluated by RT-PCR-16SrRNA and cytokine gene expression. The viability and infectivity of bacilli recovered from explants (D28 and D60) were evaluated using the Shepard's model. All explants were RT-PCR-16SrRNA positive. The viability and infectivity of recovered bacilli from explants, analyzed after 5 months of inoculation in mice, showed an average positivity of 31%, with the highest positivity in the D28 groups (80%). Furthermore, our work showed different patterns in cytokine gene expression (TGF-ß, IL-10, IL-8, and TNF-α) in the presence of alive or dead bacilli. Although changes can be made to improve future experiments, our results have demonstrated that it is possible to use the hOSEC to maintain M. leprae for 60 days, interacting with the host system, an important step in the development of experimental models for studies on the biology of the bacillus, its interactions, and drug susceptibility.

New sonographic measures of peripheral nerves: a tool for the diagnosis of peripheral nerve involvement in leprosy.

To evaluate ultrasonographic (US) cross-sectional areas (CSAs) of peripheral nerves, indexes of the differences between CSAs at the same point (∆CSAs) and between tunnel (T) and pre-tunnel (PT) ulnar CSAs (∆TPTs) in leprosy patients (LPs) and healthy volunteers (HVs). Seventy-seven LPs and 49 HVs underwent bilateral US at PT and T ulnar points, as well as along the median (M) and common fibular (CF) nerves, to calculate the CSAs, ∆CSAs and ∆TPTs. The CSA values in HVs were lower than those in LPs (p < 0.0001) at the PT (5.67/9.78 mm2) and T (6.50/10.94 mm2) points, as well as at the M (5.85/8.48 mm2) and CF (8.17/14.14 mm2) nerves. The optimum CSA- receiver operating characteristic (ROC) points and sensitivities/specificities were, respectively, 6.85 mm2 and 68-85% for the PT point, 7.35 mm2 and 71-78% for the T point, 6.75 mm2 and 62-75% for the M nerve and 9.55 mm2 and 81-72% for the CF nerve. The ∆CSAs of the LPs were greater than those of the HVs at the PT point (4.02/0.85; p = 0.007), T point (3.71/0.98; p = 0.0005) and CF nerve (2.93/1.14; p = 0.015), with no difference found for the M nerve (1.41/0.95; p = 0.17). The optimum ∆CSA-ROC points, sensitivities, specificities and p-values were, respectively, 1.35, 49%, 80% and 0.003 at the PT point, 1.55, 55-85% and 0.0006 at the T point, 0.70, 58-50% and 0.73 for the M nerve and 1.25, 54-67% and 0.022 for the CF nerve. The ∆TPT in the LPs was greater than that in the HVs (4.43/1.44; p <0.0001). The optimum ∆TPT-ROC point was 2.65 (90% sensitivity/41% specificity, p < 0.0001). The ROC analysis of CSAs showed the highest specificity and sensitivity at the PT point and CF nerve, respectively. The PT and T ∆CSAs had high specificities (> 80%) and ∆TPT had the highest specificity (> 90%). New sonographic peripheral nerve measurements (∆CSAs and ∆TPT) provide an important methodological improvement in the detection of leprosy neuropathy.

Liquid crystalline nanoparticles enable a multifunctional approach for topical psoriasis therapy by co-delivering triptolide and siRNAs.

Liquid crystalline nanoparticles (LCNs) are an attractive drugs topical delivery system due to the great internal ordering, wide interfacial area and structural similarities with the skin. In this work, LCNs were designed to encapsulate triptolide (TP) and to complex on its surface small interfering RNAs (siRNA) targeting TNF-α and IL-6, aiming at topical co-delivery and regulating multi-targets in psoriasis. These multifunctional LCNs showed appropriate physicochemical properties for topical application, such as a mean size of 150 nm, low polydispersion, TP encapsulation greater than 90% and efficient complexation with siRNA. The internal reverse hexagonal mesostructure of LCNs was confirmed by SAXS while their morphology was assessed by cryo-TEM. In vitro permeation studies revealed an increase of more than 20-fold in the distribution of TP through the porcine epidermis/dermis was achieved after the application of LCN-TP or LCN TP in hydrogel. In cell culture, LCNs showed good compatibility and rapid internalization, which was attributed to macropinocytosis and caveolin-mediated endocytosis. Anti-inflammatory potential of multifunctional LCNs was assessed by reducing of TNF-α, IL-6, IL-1ß and TGF-ß1 levels in LPS-stimulated macrophages. These results support the hypothesis that the co-delivery of TP and siRNAs by LCNs may be a new strategy for psoriasis topical therapy.

A Review of Software and Mobile Apps to Support the Clinical Diagnosis of Hansen Disease.

This scoping review indicates a lack of scientific articles that specifically explore software and mobile applications designed to assist in the clinical diagnosis of leprosy, and our findings have provided insights into the available tools, their usage methods, and the benefits offered by health technologies.

Serological testing for Hansen's disease diagnosis: Clinical significance and performance of IgA, IgM, and IgG antibodies against Mce1A protein.

Hansen's disease (HD) is an infectious, treatable, and chronic disease. It is the main cause of infectious peripheral neuropathy. Due to the current limitations of laboratory tests for the diagnosis of HD, early identification of infected contacts is an important factor that would allow us to control the magnitude of this disease in terms of world public health. Thus, a cross-sectional study was conducted in the Brazilian southeast with the objective of evaluating humoral immunity and describing the accuracy of the immunoassay based on IgA, IgM, and IgG antibodies against surface protein Mce1A of Mycobacterium, the predictive potential of these molecules, the clinical significance of positivity, and the ability to segregate new HD cases (NC; n = 200), contacts (HHC; n = 105), and healthy endemic controls (HEC; n = 100) as compared to α-PGL-I serology. α-Mce1A levels for all tested antibodies were significantly higher in NC and HHC than in HEC (p < 0.0001). The performance of the assay using IgA and IgM antibodies was rated as highly accurate (AUC > 0.85) for screening HD patients. Among HD patients (NC), positivity was 77.5% for IgA α-Mce1A ELISA, 76.5% for IgM, and 61.5% for IgG, while α-PGL-I serology showed only 28.0% positivity. Multivariate PLS-DA showed two defined clusters for the HEC and NC groups [accuracy = 0.95 (SD = 0.008)] and the HEC and HHC groups [accuracy = 0.93 (SD = 0.011)]. IgA was the antibody most responsible for clustering HHC as compared to NC and HEC, evidencing its usefulness for host mucosal immunity and as an immunological marker in laboratory tests. IgM is the key antibody for the clustering of NC patients. Positive results with high antibody levels indicate priority for screening, new clinical and laboratory evaluations, and monitoring of contacts, mainly with antibody indexes ≥2.0. In light of recent developments, the incorporation of new diagnostic technologies permits to eliminate the main gaps in the laboratory diagnosis of HD, with the implementation of tools of greater sensitivity and accuracy while maintaining satisfactory specificity.

Specialized active leprosy search strategies in an endemic area of the Brazilian Amazon identifies a hypermutated Mycobacterium leprae strain causing primary drug resistance.

Introduction: Leprosy, an infectious disease caused by Mycobacterium leprae, remains a public health concern in endemic countries, particularly in Brazil. In this study, we conducted an active surveillance campaign in the hyperendemic city of Castanhal in the northeastern part of the state of Pará using clinical signs and symptoms combined with serological and molecular tools to diagnose new cases and to identify drug resistance of circulating M. leprae strains and their distribution in the community. Methods: During an active surveillance of one week, we enrolled 318 individuals using three different strategies to enroll subjects for this study: (i) an active survey of previously treated cases from 2006 to 2016 found in the Brazil National Notifiable Disease Information System database (n = 23) and their healthy household contacts (HHC) (n = 57); (ii) an active survey of school children (SC) from two primary public schools in low-income neighborhoods (n = 178), followed by visits to the houses of these newly diagnosed SC (n = 7) to examine their HHC (n = 34) where we diagnosed additional new cases (n = 6); (iii) and those people who spontaneously presented themselves to our team or the local health center with clinical signs and/or symptoms of leprosy (n = 6) with subsequent follow-up of their HHC when the case was confirmed (n = 20) where we diagnosed two additional cases (n = 2). Individuals received a dermato-neurological examination, 5 ml of peripheral blood was collected to assess the anti-PGL-I titer by ELISA and intradermal earlobe skin scrapings were taken from HHC and cases for amplification of the M. leprae RLEP region by qPCR. Results: Anti-PGL-I positivity was highest in the new leprosy case group (52%) followed by the treated group (40.9%), HHC (40%) and lowest in SC (24.6%). RLEP qPCR from SSS was performed on 124 individuals, 22 in treated cases, 24 in newly diagnosed leprosy cases, and 78 in HHC. We detected 29.0% (36/124) positivity overall in this sample set. The positivity in treated cases was 31.8% (7/22), while in newly diagnosed leprosy cases the number of positives were higher, 45.8% (11/23) and lower in HHC at 23.7% (18/76). Whole genome sequencing of M. leprae from biopsies of three infected individuals from one extended family revealed a hypermutated M. leprae strain in an unusual case of primary drug resistance while the other two strains were drug sensitive. Discussion: This study represents the extent of leprosy in an active surveillance campaign during a single week in the city of Castanhal, a city that we have previously surveyed several times during the past ten years. Our results indicate the continuing high transmission of leprosy that includes fairly high rates of new cases detected in children indicating recent spread by multiple foci of infection in the community. An unusual case of a hypermutated M. leprae strain in a case of primary drug resistance was discovered. It also revealed a high hidden prevalence of overt disease and subclinical infection that remains a challenge for correct clinical diagnosis by signs and symptoms that may be aided using adjunct laboratory tests, such as RLEP qPCR and anti-PGL-I serology.

High rates of undiagnosed leprosy and subclinical infection amongst school children in the Amazon Region.

Leprosy in children is correlated with community-level factors, including the recent presence of disease and active foci of transmission in the community. We performed clinical and serological examinations of 1,592 randomly selected school children (SC) in a cross-sectional study of eight hyperendemic municipalities in the Brazilian Amazon Region. Sixty-three (4%) SC, with a mean age of 13.3 years (standard deviation = 2.6), were diagnosed with leprosy and 777 (48.8%) were seropositive for anti-phenolic glycolipid-I (PGL-I). Additionally, we evaluated 256 house-hold contacts (HHCs) of the students diagnosed with leprosy; 24 (9.4%) HHC were also diagnosed with leprosy and 107 (41.8%) were seropositive. The seroprevalence of anti-PGL-I was significantly higher amongst girls, students from urban areas and students from public schools (p < 0.0001). Forty-five (71.4%) new cases detected amongst SC were classified as paucibacillary and 59 (93.6%) patients did not demonstrate any degree of physical disability at diagnosis. The results of this study suggest that there is a high rate of undiagnosed leprosy and subclinical infection amongst children in the Amazon Region. The advantages of school surveys in hyperendemic areas include identifying leprosy patients at an early stage when they show no physical disabilities, preventing the spread of the infection in the community and breaking the chain of transmission.

Ultrasound reference values for peripheral nerve cross-sectional areas and indices in a sample of healthy individuals in Brazil.

Objective: To establish peripheral nerve cross-sectional area (CSA) reference values (absolute values, measures of asymmetry, and measures of focality) for healthy individuals in Brazil. Materials and Methods: Sixty-six healthy volunteers underwent high-resolution ultrasound of the peripheral nerves. We obtained CSA measurements for three peripheral nerves, at specific locations: the median nerve, in the carpal tunnel (MT); the ulnar nerve, at the cubital tunnel site (UT) and at the pre-tunnel site (UPT); and the common fibular nerve, near the fibular head (FH). We calculated the CSA indices between the same sites on different sides (ΔCSAs) and between the ulnar nerve tunnel and pre-tunnel sites on the same side (ΔTPT). Results: A total of 132 neural sites were analyzed, and the following CSA values (mean ± SD, median) were obtained: MT (6.3 ± 1.9 mm2, 6.0 mm2); UT (6.2 ± 1.6 mm2, 6.1 mm2); UPT (5.6 ± 1.7 mm2, 5.4 mm2); and FH (10.0 ± 3.7 mm2, 9.9 mm2). The ΔCSA values (mean ± SD, median) were as follows: MT (0.85 ± 0.7 mm2, 0.95); UT (0.81 ± 0.62 mm2, 0.95); UPT (0.61 ± 0.51 mm2, 0.5); and FH (1.0 ± 0.77 mm2, 1.0). The ΔTPT (mean ± SD, median) was (1.0 ± 0.8 mm2, 1.0). Conclusion: Among individuals in Brazil, peripheral nerve CSA values tend to be higher among males and to increase with aging. However, the same does not appear to hold true for the ΔCSA or the ΔTPT, the exception being the difference between the right and left UT. Differences in CSA values greater than 2.5 mm2 between sides or between sites along the same nerve can indicate asymmetry or focal thickening in neuropathy, respectively.

Objetivo: Estabelecer valores de referência da área de secção transversa (AST) dos nervos periféricos (valores absolutos e medidas de assimetria e de espessamento focal) para amostra de indivíduos brasileiros saudáveis. Materiais e Métodos: Sessenta e seis voluntários brasileiros saudáveis foram submetidos a ultrassonografia de alta resolução de nervos periféricos. As medidas da AST dos seguintes nervos periféricos foram obtidas em: mediano no túnel do carpo (MT), ulnar no túnel cubital (UT), pré-túnel ulnar (UPT) e fibular comum na cabeça da fíbula (FH). Os índices CSA foram obtidos entre os mesmos sítios em lados diferentes (ΔCSA) e entre os sítios distal e proximal do nervo ulnar (ΔTPT). Resultados: As seguintes médias ± desvio-padrão e mediana da AST foram obtidas para os 132 sítios dos nervos periféricos analisados: MT (6,3 ± 1,9 mm2; 6,0 mm2), UT (6,2 ± 1,6 mm2; 6,1 mm2), UPT (5,6 ± 1,7 mm2; 5,4 mm2) e FH (10,0 ± 3,7 mm2; 9,9 mm2). A média ± desvio-padrão e as respectivas medianas do ΔCSA em mm2 foram: 0,85 ± 0,7 [0,95] para MT, 0,81 ± 0,62 [0,95] para UT, 0,61 ± 0,51 [0,5] para UPT, 1,0 ± 0,77 [1] para FH, e 1,0 ± 0,8 [1,0] para ΔTPT. Conclusão: Os valores de AST tendem a ser maiores no sexo masculino, aumentando os valores absolutos das medianas das ASTs com o envelhecimento, mas não nos seus índices, ΔCSA e ΔTPT, exceto a diferença entre a AST dos nervos ulnares nos lados direito e esquerdo. Diferenças de valores de AST entre lados ou pontos no mesmo nervo maior que 2,5 mm2 podem significar neuropatia com assimetria e espessamento focal.