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Volume - 84, Issue - 3

Original Papers
Pages 176 - 185
  • Wade histoid Leprosy: histological and immunohistochemical analysis

    • Daniela A.M. da Costa
    • Mílvia M.S.S. Enokihara
    • Suely Nonogaki
    • Solange M. Maeda
    • Adriana M. Porro
    • Jane Tomimori
    Volume 84, Issue 3

    | Published on September 2013

    Histoid leprosy is a rare multibacillary form that presents with disseminated papule-nodular cutaneous lesions. To study the inflammatory infiltrate of the histoid form and to compare it with other lepromatous forms, we performed histological and immunohistochemical analysis on skin biopsies. Fifteen patients were included for histopathological analysis (10 histoid and five lepromatous) via the haematoxylin-eosin and Ziehl-Neelsen-Faraco stains. Thus, immunohistochemical techniques using immunoperoxidase assay were performed for: anti-BCG, anti-M.leprae, anti-CD8, anti-CD3, anti-CD20, anti-S100, anti-CD1a, anti-CD68 and anti-vimentin. Spindle cells were present in all histoid patients. A pseudocapsule was observed in half of both studied forms. A comparison using the Ziehl-Neelsen-Faraco stain to evaluate anti-BCG and anti-M.leprae showed no major differences. The CD3+ cells were more pronounced in the histoid form than the lepromatous form. There was greater immunoreactivity toward CD8+ cells in the histoid form, as well as the CD20+ cell count. A similar count of S100+ cells in the epidermis of both leprosy forms was observed. There was a slight increase of dendritic cells in the histoid patients in the superficial and deep dermis. For CD1a marker, we observed expression in the epidermis and superficial dermis in both forms. A diffuse and intense infiltrate of CD68+ cells was also observed in the histoid and lepromatous forms. The high positivity for vimentin did not allow for a positive cell count. We concluded that the activation of both the cellular and humoral response is more pronounced in the histoid form because the T and B cells showed greater infiltration than those in the lepromatous form. The activation of dendritic and Langerhans cells is similar in both forms. The spindle cells likely belong to the macrophage population, thus maintaining phagocytic ability. The quantities of pseudocapsules and bacilli are similar and cannot serve as criteria for diagnosis.

Original Papers
Pages 186 - 193
  • Peroneal strength as an indicator in selecting route of tibialis posterior transfer for foot drop correction in leprosy

    • Premal Das
    • Julius Kumar
    • G Karthikeyan
    • PSS Sundar Rao
    Volume 84, Issue 3

    | Published on September 2013

    Objectives:

    Tibialis posterior tendon transfer (TPT) technique, using either the Circum-tibial (CT) or Inter-osseus (IO) route is the standard surgical technique to correct foot drop. The selection of the route of transfer is usually dependent on the surgeon’s preference. This study aims to identify criteria to help make that selection.

    Subjects and Methods:

    A study was carried out on 381 feet during the period 1999 to 2010. All the patients operated during this period were included in the study. The CT route was used for those with peronei power 4 or 5, while the IO route was used when peronei power was 3 or less.

    Results:

    In this case series the mean effective range of motion (above 90°) was 11 and 12 degrees in CT and IO routes, respectively. The results were comparable in terms of rest position, active dorsiflexion and effective range of motion. All patients had a post-operative heel to toe gait, except for one of the 381 operated feet. Only three of the 381 feet had a reduction in navicular height of more than 2 cm, the medial arch being maintained in the others.

    Conclusions:

    TPT is a standard procedure to correct foot drop deformity in leprosy. Pre-selection for route of transfer, CT or IO, based on peronei strength avoids the complication of iatrogenic inversion. The technique of insertion and routine tendo-achilles lengthening provides a good range of movement. The deep tunnelling has not compromised the results, while giving excellent cosmetic appearance.

Original Papers
Pages 194 - 198
  • Facial sensory loss in multi-bacillary leprosy patients

    • Ebenezer Daniel
    • PSS Rao
    • Paul Courtright
    Volume 84, Issue 3

    | Published on September 2013

    Sensation over the face was estimated using the Semmes-Weinstein’s monofilament (target force 0.05 gms) in a cohort of multi-bacillary (MB) patients whose clinical and ocular characteristics were available at the time of leprosy diagnosis. Among the 190 MB patients examined, 56 (30%) had areas of sensory impairment somewhere on the face and 43 (23%) had sensory deficit over the lids and/or the malar area. Lagophthalmos (adjusted OR 8.96, 95% CI 0.96–83.50), Type 1 reaction (aOR 2.47, 95% CI 1.11–5.52), history of reactions (aOR 6.36, 95% CI 2.40–16.85) and glove and stocking anaesthesia (aOR 3.49, 95% CI 1.40–8.70) were associated with impaired facial sensation. Hypoesthesia restricted to areas over the lids and/or malar area showed a stronger association with lagophthalmos (aOR 17.5, 95% CI 1.98–154.36). Loss of facial sensation appears to be associated with lagophthalmos in MB patients.

Original Papers
Pages 199 - 208
  • Enhancing counselling strategies for leprosy patients through the Participation Scale

    • Neelmani Bense
    • Premal Das
    • Pamidipani Samuel Sundar Rao
    • Annamma Succinda John
    Volume 84, Issue 3

    | Published on September 2013

    Background & Objectives

    Counsellors provide psychological support, appropriate education and coping skills to persons affected by adverse events. Counselling of leprosy patients is essential to enable them to cope with perceived stigma as well as managing severe enacted stigma at home, place of work or elsewhere. Professional counselling was instituted at the Leprosy Mission Community Hospital in Naini, Allahabad District, India, in 2004. In this paper we describe how the use of the Participation Scale helped in developing Counselling strategies for a variety of leprosy patients.

    Material & Methods

    A random sample of 250 leprosy patients visiting the hospital for the first time during 2011–2012 were chosen, 50 each from those with only hidden patches (Grade 0a), patients with visible patches (Grade 0b), those with only anaesthesia or weakness (Grade I), patients with paralytic deformities (Grade 2a), and patients with visible disabilities and ulcers Grade 2b). The P-scale consisting of 18 items was administered in the local language (Hindi) and used by the Counsellor along with relevant clinical and socioeconomic details.

    Results

    There were 84 women and 166 men, distributed in all the five categories. Overall, 142 patients out of 250 (56.8%) had no participation restrictions; 39 (15.6%) had mild social restrictions; 20 (8.0%) had moderate, 28 (11.2%) had severe and 21 (8.4%) had extreme participation restrictions. Paradoxically, there were some cases without severe deformity who are also subjected to restrictions. Patients in Grades 0a and 0b, had practically no severe or even moderate restrictions in their social participation, but their perceived stigma was high, requiring suitable leprosy education, family counselling and coping skills to feel confident that they were capable of normal work like any of their peers. Counselling became more intensive in Grade 1 and for almost all in Grade 2, who experienced moderate to severe restrictions in meeting new people, participating in social activities and indulging in socioeconomic activities. Counselling for such groups of patients required multiple approaches, including in-depth leprosy education for regular treatment, self-care measures, mobilisation of coping skills, self-confidence and acceptance counselling, and follow-up counselling for those released from treatment after multidrug therapy.

    Conclusions & Recommendations

    The P-scale provides essential information to enable a Counsellor to offer more meaningful and balanced counselling to leprosy-affected people, especially in coping with enacted stigma. Education oriented counselling and psychological supportive counselling are necessary adjuncts for clinical care and treatment. Client-oriented counselling allows clients to freely express their fears and anxieties, and promotes coping skills and confidence.

Original Papers
Pages 209 - 218
  • Intolerance to Leprosy Multi-Drug Therapy: More Common in Women?

    • Kathryn Margaret Dupnik
    • Fernando José Ramos Cardoso
    • Ana Luiza Braga Brito de Macêdo
    • Igor Leonardo Cardoso de Sousa
    • Renata Cristina Barros Leite
    • Selma Maria Bezerra Jerônimo
    • Mauricio Lisboa Nobre
    Volume 84, Issue 3

    | Published on September 2013

    Objectives:

    The objective was to characterise and identify potential risk factors for intolerance to multi-drug leprosy therapy (MDT) which prompted a medication change in a leprosy referral centre in northeastern Brazil.

    Design:

    A retrospective chart review of leprosy patients treated at a state referral centre for leprosy in Natal, Rio Grande do Norte, Brazil was completed. Chart review focus was on adverse effects necessitating modification of MDT regimen.

    Results:

    Six hundred and twelve records were reviewed with detection of 91 (14.8%) adverse effects with associated change in MDT regimen. The most common recorded causes of medication intolerance were anemia (8.7%), headache (4.2%), cyanosis (1.8%), and gastrointestinal symptoms (1.6%). Both female gender (OR = 2.63) and age less than 42 years old (OR = 2.7) remained risk factors for MDT intolerance in a multivariate model including gender, age, and WHO regimen type. With intolerance due to anemia as the outcome, female gender (OR = 2.36) and age less than 42 years (OR = 1.86) were associated.

    Conclusions:

    In this study, female gender and younger age were associated with greater risk of medication intolerance and medication intolerance related to anemia. These findings have important operational implications for drug intolerance monitoring during therapy for leprosy.

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