Perforating dermatoses: a review and report of four cases

Perforating dermatoses, an often overlooked entity comprised of Kyrle's disease, perforating folliculitis, reactive perforating collagenosis, elastosis perforans serpiginosa, and acquired perforating dermatosis, are succinctly described, focusing attention on their clinical features, histopathology, treatment, and pathogenesis. The literature on these facets has been extensively reviewed. In addition, three fresh cases of Kyrle's and one of perforating folliculitis have been incorporated to illustrate these conditions.

Leprosy in children: a prospective study

BACKGROUND

Leprosy has been identified as an important health problem in the pediatric age group. The study of leprosy in children is imperative as it may unravel the missing links in the natural evolution of the disease and dispel the uncertainty of the precise incubation period.

METHODS

The study was undertaken on patients attending the Urban Leprosy Centre. There were 161 children in the age group of 0 to 14 years, amongst 3184 cases of leprosy, detected between 1981 and 1991. The diagnosis in each was formed after meticulously recording the clinical features, slit-skin smear examination, and histopathologic characteristics. In addition, a detailed history of duration of the disease was elicited by complement recall method.

RESULTS

The study revealed an incidence of 5.06% amongst leprosy patients, in an urban setting. The boys:girls ratio was 2.6:1. The mean duration of the disease was 1.2 years in paucibacillary and 2.8 years in multibacillary. History of intra- or extrafamilial contact was elicited in 8.7%. The typical lesion was a "hypopigmented macule," either of indeterminate, tuberculoid, borderline tuberculoid, or borderline borderline leprosy. Borderline lepromatous, lepromatous, and polyneuritic leprosy were uncommon.

CONCLUSIONS

Leprosy in children is a well-established distinct entity. Any hypopigmented macule in pediatric age group should arouse suspicion of leprosy. The diagnosis is clinical. Other investigative parameters, namely slit-skin smear, and histopathology may supplement but not supplant the diagnosis.

Secondary syphilis mimicking borderline (BL) leprosy

A young woman with syphilids resembling borderline lepromatous (BL) leprosy is being described. This is yet another addition to its already well-documented manifestations. The high prevalence of leprosy and syphilis augments the epidemiological significance of the case.

Dyskeratosis congenita: a case report

Dyskeratosis congenita, an uncommon situation in females, is described in a 30-year-old woman. The expression of the disease was partial and was characterized by mottled pigmentation, nail dystrophy, palmoplantar keratoderma, and hyperhidrosis.

Evaluation of phenolic glycolipid-I (PGL-I) antibody as a multidrug therapy (MDT) monitor

Since phenolic glycolipid-I (PGL-I) is an unequivocal marker for Mycobacterium leprae, this antigen has been a good candidate for the serodiagnosis and monitoring of the effectiveness of leprosy chemotherapy. The present study, a continuation of an earlier report, was undertaken to estimate PGL-I antibody titers in 40 leprosy patients 3 and 6 months after starting MDT. All the leprosy groups showed significant declines in anti PGL-I reactivity after 6 months. There was a good correlation between bacteriological indices (BI) and anti PGL-I antibody levels. Thus, PGL-I based serology may be useful in monitoring the response to multidrug therapy.

Significance of antibodies to phenolic glycolipid-I in leprosy diagnosis

A gelatin particle agglutination assay for the detection of anti PGL-I antibodies in 40 clinically diagnosed and variously classified groups of leprosy cases revealed elevated PGL-I antibody titers in 85% of cases. In contrast, the slit-skin smear examination was positive in only 30% of cases. It was further observed that, out of 28 cases with Bacteriological Index (B.I.) zero, 22 cases (78.5%) had significant levels of PGL-I antibodies. There was no case in which the slit skin smear was positive and the PGL-I antibody titer was not significant. The elevated titers of PGL-I antibody better correlated (84%) with histopathological findings than did B.I. Thus it was concluded that estimation of PGL-I antibody titer is a better supplement to clinical diagnosis than B.I. Significant levels of PGL-I antibody were seen in 85% of cases who had no earlier chemotherapy or were treated for less than 2 months. Similar findings were observed in 12 patients who were on MDT for more than 5 months but for less than 2 years. In order to determine the significance of anti PGL-I antibodies in monitoring the response of patients to chemotherapy, a longer follow up with a greater number of cases should be contemplated.

Reconstruction of anti-leprosy drug depleted complement haemolytic activity by addition of zymosan-treated sera (a source of C142) and CratEDTA (a source of C3-C9)

This paper describes the mechanism of in vitro interaction of human serum complement system with anti-leprosy drugs (dapsone and clofazimine) and anti-lepra reaction drugs such as chloroquine. These drugs could inhibit the complement-mediated lysis of erythrocytes both via direct and alternative pathways, but only at hypertherapeutic doses. Attempts were made to restore the drug depleted complement-mediated lysis of erythrocytes by adding zymosan-treated guinea-pig sera (a source of C142) and also by adding Crat-EDTA sera (a source of C3-C9). Destroyed complement-mediated haemolytic activity by dapsone could be restored by early complement (C142) components, while complement-mediated haemolytic activity blocked by clofazimine could be regenerated by adding both late (C3-C9) and early (C142) complement component. However, chloroquine-mediated inhibition of the complement-mediated haemolysis activity could not be appreciably restored by adding both early and late complement reagents.

Tuberous sclerosis and spina bifida occulta

An interesting occurrence of tuberous sclerosis and spina bifida occulta is described, highlighting their unique and previously undescribed association in a 5-year-old boy.

Reaction in leprosy: acute phase reactant response during and after remission

Sera from 25 patients with type 1 (Lepra), upgrading and downgrading, and type 2 (erythema nodosum leprosum [ENL]) reactions were assayed, during the reaction and after its clinical remission, for changes in levels of alpha-1-antitrypsin (A1A) and C-reactive protein (CRP). The results were compared with those from normal healthy adults and patients of leprosy without history and/or clinical evidence of reaction. The A1A levels correlated better with changes in status of type 1 reaction; whereas CRP levels correlated well with alterations in type 2 reactions and were definitely superior to A1A in this situation for monitoring the course of these episodes.

In vivo effects of anti-leprosy drugs on the rat peritoneal macrophages and lymphocyte subpopulations

The present study describes the in vivo effects of anti-leprosy drugs on rat peritoneal macrophages and T-cell homeostasis. It was observed that BCG-elicited rat peritoneal macrophages produced more H2O2 and expressed more Ia antigen on their cell surfaces compared with resident peritoneal macrophages. Furthermore, elicited macrophages isolated from rats administered multidrug therapy (MDT), consisting of dapsone, clofazimine and rifampicin in high dose (10 x MDT) released more O2-. On the contrary, there was a significant decrease in the Ia antigen expression on these macrophages. Anti-leprosy drug treatment in high dose (10 x MDT) decreased the total number of blood T-helper (W3/25+) cells and increased the total number of blood T-suppressor (OX-8+) cells which resulted in a significant decrease in a W3/25: OX-8 ratio. Electron microscopy of elicited macrophages isolated from 10 x MDT treated rats showed development of many filipodia compared with control macrophages. These data show that 10 x MDT treatment in rats for 1 month alters the homeostasis of blood T-cell subpopulations which perhaps decreases the Ia expression on macrophages. However, the increase in O2- production and the appearance of filipodia on the macrophages is due to a direct effect of drugs on the macrophages. MDT treatment for 1 month in a therapeutic dose has no effect on the above-mentioned parameters.

Anti-leprosy drugs inhibit the complement-mediated solubilization of pre-formed immune complexes in vitro

Incubation of pre-formed immune complexes (IC) (125I-HSA--anti-HSA) with normal human serum resulted in solubilization of IC. When various anti-leprosy drugs were added to human sera, solubilization of IC was fairly explicit with clofazimine, whereas this effect was marginal with dapsone. Rifampicin hardly displayed this effect. Aspirin, chloroquine, and prednisolone, the drugs used in addition to multi-drug therapy to control reactions in leprosy, were in a position to inhibit the solubilization of 125I HSA--anti-HSA by normal serum only at a very high dose. From the current data of the inhibition of solubilization of pre-formed IC along with our earlier observations on the modulation of complement-mediated haemolysis by these drugs, it may be possible to postulate that clofazimine as well as chloroquine affect early complement components. This may in turn be responsible for preventing the deposition of C3 complement onto IC.

Peripheral T lymphocytes and their subsets in cutaneous tuberculosis

Fifty-four patients with cutaneous tuberculosis, consisting of 23 with lupus vulgaris, 22 with scrofuloderma, and nine with verrucosa cutis, were investigated for cell-mediated immunity, through estimation of peripheral total T lymphocytes (CD3+), CD4+ (helper/inducer), and CD8+ (cytotoxic/suppressor) lymphocytes, by immunohistochemical staining of peripheral blood smears, using specific monoclonal antibodies and the alkaline phosphatase-antialkaline phosphatase (APAAP) method. Absolute values of total T lymphocytes (CD3+), and CD4+ and CD8+ subsets, were found to be significantly raised in scrofuloderma, but the percentage values and the CD4+/CD8+ ratio remained unaltered. In tuberculosis verrucosa cutis, only the percentage of the CD8+ subset of T lymphocytes was found to be significantly lowered, and this altered the CD4+/CD8+ ratio. No significant change was observed in the peripheral blood T cells and their subpopulations in patients suffering from lupus vulgaris.

Inoculation lupus vulgaris

An 11-years-old girl with lupus vulgaris on the right buttock following inoculation is described. The diagnosis was formed by the history, morphological characteristics, Mantoux test, histopathology, and was supported by an affirmative response to short course intensive chemotherapy (6 months). This route of infection acquires special significance with the worldwide-spread of HIV infection.

Lymphocyte adenosine deaminase activity (L-ADA) in leprosy, during and after treatment of reactions

Twenty-five patients with type 1 (lepra) and type 2 (E.N.L.) leprosy reactions were studied for lymphocyte adenosine deaminase activity (L-ADA), during and after treatment of the reactions, using a standard technique, in order to establish its pattern and if possible, its value in assessing the course of reactions. The results were compared with those from 30 control subjects, comprising 10 normal healthy adults, 10 patients with borderline tuberculoid (BT) leprosy, four patients with borderline lepromatous (BL) leprosy and six patients with lepromatous (LL) leprosy. The level of L-ADA in the leprosy controls was higher than that of normal healthy subjects. The L-ADA values in patients with different types of reactions were about 10-fold higher than those obtained from leprosy controls, emphasizing a possible role in assessing reactions in leprosy. However, there was no significant variation in L-ADA levels, either between the various leprosy controls or reaction groups, before and after treatment.

Tissue level lymphocyte subpopulations in donovanosis

Total T-, B-, T4-, and T8-lymphocyte populations were estimated in tissue sections of ulcers from 22 donovanosis patients, comprising 17 ulcerogranulomatous, four hypertrophic, and one sclerotic variants, using monoclonal antibodies and immunohistochemical technique (PAP). T- and B-lymphocytic infiltrations in the tissues were almost identical, without any significant difference in ulcerogranulomatous and hypertrophic variants. The T4:T8 ratio in ulcerogranulomatous variants, however, was 1.41, which was significantly higher than that of hypertrophic variants (1.28), indicating a greater cell-mediated immune response in the former than in the latter. This is substantiated by the documentation of a paucity of Donovan bodies, both in the tissue smear and slow (overnight) Giemsa-stained tissue sections, in the ulcerogranulomatous variant.

Characterization of circulating lymphocytes by monoclonal antibodies in childhood and adult leprosy

Peripheral blood lymphocyte assays using monoclonal antibodies were done in 66 patients with leprosy, consisting of 25 children and 41 adults. The results were statistically analyzed for correlations, if any, among the different age groups and matched controls. The results, however, failed to show any significant correlation, nor was it possible to draw any conclusion as to why the disease spectrum in children tends to be incomplete (ie, there is a low incidence of the highly bacilliferous form of disease expression).

Soluble interleukin-2 receptors: levels in leprosy, and during and after type 1 (lepra) and type 2 (ENL) reactions

Twenty-five patients with Type 1 (lepra) and Type 2 (ENL) reactions, were assayed for SIL-2R in serum--before and after treatment for their acute condition--and the results were compared with 10 normal healthy adults and 20 patients of leprosy per se. Classification of each subject into different leprosy groups, and into various types and subtypes of reactions, was done according to standard criteria, prior to inclusion into the study. Detailed statistical evaluation of the data revealed significantly higher levels of SIL-2R in all leprosy patients, as compared to normal controls, with higher levels in the multibacillary groups as compared to the paucibacillary group. SIL-2Rs appeared higher in Type 1 upgrading reaction than in other forms of reaction, though this was not statistically significant. There was no significant change in levels following treatment and clinical remission.