An update on the diagnosis and treatment of leprosy

Artificial Intelligence on Diagnostic Aid of Leprosy: A Systematic Literature Review

Leprosy is a neglected tropical disease that can cause physical injury and mental disability. Diagnosis is primarily clinical, but can be inconclusive due to the absence of initial symptoms and similarity to other dermatological diseases. Artificial intelligence (AI) techniques have been used in dermatology, assisting clinical procedures and diagnostics. In particular, AI-supported solutions have been proposed in the literature to aid in the diagnosis of leprosy, and this Systematic Literature Review (SLR) aims to characterize the state of the art. This SLR followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) framework and was conducted in the following databases: ACM Digital Library, IEEE Digital Library, ISI Web of Science, Scopus, and PubMed. Potentially relevant research articles were retrieved. The researchers applied criteria to select the studies, assess their quality, and perform the data extraction process. Moreover, 1659 studies were retrieved, of which 21 were included in the review after selection. Most of the studies used images of skin lesions, classical machine learning algorithms, and multi-class classification tasks to develop models to diagnose dermatological diseases. Most of the reviewed articles did not target leprosy as the study's primary objective but rather the classification of different skin diseases (among them, leprosy). Although AI-supported leprosy diagnosis is constantly evolving, research in this area is still in its early stage, then studies are required to make AI solutions mature enough to be transformed into clinical practice. Expanding research efforts on leprosy diagnosis, coupled with the advocacy of open science in leveraging AI for diagnostic support, can yield robust and influential outcomes.

Pathogenesis, Clinical Considerations, and Treatments: A Narrative Review on Leprosy

Hansen disease, known as Leprosy, is an infectious disease caused by Mycobacterium leprae. The disease was once thought to be highly contiguous, and patients with leprosy were treated poorly and had to face discrimination due to the gruesome disease's complications. Mycobacterium leprae, the bacterium causative of leprosy, can generally be found in the nine-banded armadillo. The bacterium is transmitted via aerosol droplets and broken skin-to-skin contact. Once M. leprae enters the body, it will target peripheral nerves and the lining mucosa of the skin and eyes, thus causing inflammation and tenderness of the affected area. Over time, this will lead to peripheral neuropathy and weakness of the affected body parts. Treatment of leprosy involves multi-drug combinations such as dapsone, rifampin, and clofazimine. Even though leprosy is curable, early detection and treatment are crucial to preventing irreversible damage and disabilities. Prevention measures include early detection, treatment regimen adherence, close contact prophylaxis, contact tracing, and community awareness. This review aims to provide the latest diagnostic and therapeutic recommendations for leprosy. It outlines the epidemiology, microbiology, clinical treatment, and immunological methods used to detect leprosy.

Leprosy in an Adopted Woman Diagnosed by Molecular Tools: A Case Report from a Non-Endemic Area

Coupled with its rarity in non-endemic areas, the clinical heterogeneity of leprosy makes diagnosis very challenging. We report a diagnosis of multibacillary leprosy in a 22-year-old Indian woman, adopted at the age of 10 and living in Italy. The patient presented with painful skin lesions on the face, trunk, and lower and upper extremities, associated with dysesthesia and a motor deficit in her left leg following corticosteroid therapy interruption. Histopathology results from the skin lesions suggested leprosy, but no acid-fast bacilli were identified. Molecular biology in a center specializing in tropical diseases confirmed the diagnosis, allowing prompt and adequate treatment. Genotype analysis allowed the identification of a genotype 1D of M. leprae, facilitating the epidemiological investigation of the plausible infection origin. No resistances to rifampicin, dapsone, or ofloxacin were detected. Leprosy will continue to exist in high-income nations, and the incidence may rise over time due to increasing migration and globalization. CARE guidelines were followed.

Leprosy: A Review of Epidemiology, Clinical Diagnosis, and Management

Leprosy is a neglected infectious disease caused by acid-fast bacillus Mycobacterium leprae. It primarily affects the skin and then progresses to a secondary stage, causing peripheral neuropathy with potential long-term disability along with stigma. Leprosy patients account for a significant proportion of the global disease burden. Previous efforts to improve diagnostic and therapeutic techniques have focused on leprosy in adults, whereas childhood leprosy has been relatively neglected. This review aims to update the diagnostic and therapeutic recommendations for adult and childhood leprosy. This review summarizes the clinical, bacteriological, and immunological approaches used in the diagnosis of leprosy. As strategies for the diagnosis and management of leprosy continue to develop better and more advanced knowledge, control and prevention of leprosy are crucial.

The Prevalence of Ocular Manifestations in the Various Types of Common Skin Disorders at Tertiary Hospital in Ahmedabad, India

Aim

The article aims to study the prevalence and ocular manifestations of the various types of common skin disorders at a tertiary hospital in Ahmedabad, India. 

Materials and methods

Five hundred patients were studied in the ophthalmology department from September 2017 to September 2019.

Results

Out of the 500 patients that were included in our study, 312 were males, and 188 were females. In our study, lid involvement was seen most commonly in patients with herpes zoster ophthalmicus (HZO). Plexiform neurofibroma was seen in eight (14.5%) patients with neurofibromatosis (NF). Cicatricial ectropion was found in half of the patients with ichthyosis. Lagophthalmos was present in 10 (20.4%) patients with leprosy. Conjunctivitis was seen commonly in HZO patients. Papillary conjunctivitis was seen in half of the atopic dermatitis cases. Steven Johnson's syndrome (SJS) was associated with pseudomembranous conjunctivitis. Conjunctival xerosis was seen only in patients with Sjogren's syndrome. The cornea was most commonly involved in patients of HZO. Decreased corneal sensation was seen in leprosy and HZO. Lisch nodules were seen in NF cases. Anterior uveitis was found in seven (6.3%) patients with HZO. Glaucoma was seen most commonly in patients with Sturge Weber syndrome (SWS), followed by leprosy. Facial nerve palsy was seen in patients with leprosy. Episcleritis was seen in patients with leprosy and SWS.

Conclusion

We conclude that ocular involvement in skin disease is a common feature and could be a major component of the development of various systemic skin disorders.

Erythema nodosum leprosum (type 2 reaction) in a patient with neurofibromatosis type 1

Being a region endemic for leprosy, clinical practitioners in India often encounter myriad manifestations and diverse complications of the disease. However, the masking of the obvious clinical presentations due to the coexistence of a closely resembling unrelated disorder, a 'mimicker', would indeed pose a serious diagnostic predicament unless a high degree of clinical suspicion is maintained. Leprosy, also known as Hansen's disease is a chronic infectious disease caused by Mycobacterium leprae complex that involves the skin and peripheral nerves. Neurofibromatosis type 1 (NF1) also known as von Recklinghausen's disease is an autosomal dominant genetic disorder that presents with skin changes and benign peripheral nerve sheath tumours called neurofibromas. Here, we present the case of a 35-year-old man with NF1 who presented with type 2 lepra reaction (erythema nodosum leprosum, ENL) and the skin biopsy unmasked ENL nodule among the group of NF1 nodules.

Laboratory diagnosis of leprosy: Two staining methods from bacilloscopy and rapid ml flow test

Background

The diagnosis of leprosy is based on the characteristic signs and symptoms of the disease, subsidized by laboratory tests. When positive, the bacilloscopy closes the diagnosis for leprosy. Phenolic glycolipid-I, or PGL-I, is a molecule in the bacillus cell wall that confers a greater immune response. The ML Flow test is an immunochromatographic test for the detection of anti-PGL-I IgM in human blood or serum.

Methods

A prospective study with data collection and biological materials in patients with suspected leprosy from August 2020 to May 2021. For microscopy, intradermal smears were stained with Auramine O, and after reading under a fluorescence microscope, reviewed by Ziehl-Neelsen. The ML flow test was performed according to the Bührer-Sékula protocol. To assess the agreement between the methods, the Kappa index was estimated.

Results

Of the 94 suspected leprosy patients, 31 (32.9%) were diagnosed with leprosy. There was moderate agreement between the results of the ML Flow and Auramine O tests (Kappa = 0.58) and substantial agreement between the ML Flow and Ziehl-Neelsen microscopy (Kappa = 0.72). In paucibacillary cases, serology was positive in 100% of patients.

Conclusions

This study concluded that the Ziehl-Neelsen technique remains the best option for standard leprosy staining, and the ML flow test is more positive among the three techniques evaluated and can be an effective tool in the early diagnosis of leprosy cases.

Challenging diagnosis of leprosy in a psychotic homeless patient with atypical clinical manifestations: an interesting case report

Background

A decision to diagnose certain skin diseases in patient undergoing psychotic break is challenging; this includes establishing the diagnosis of leprosy. Diagnosis of leprosy is established if there is at least one of the three cardinal signs of leprosy. Histopathological examination is not a gold standard, but remains useful in atypical or clinically suspicious cases.

Case presentation

We report for the first time, an interesting case of leprosy with atypical clinical manifestations in a psychotic homeless male with unknown history of present illness. Upon examination, hypopigmented macules, hyperpigmented macules, and plaques were observed, with unclear sensation impairment. Peripheral nerve thickening and acid-fast bacilli from slit-skin smear were not found. Histopathological examination from hypopigmented macule on the upper right limb showed no granulomatous reaction and other histopathological features of leprosy. Although the condition did not fulfill the cardinal signs of leprosy, we found lagophthalmos, claw hands, pseudomutilation of fingers and toes. Therefore, the diagnosis of suspected leprosy was established. The patient was hospitalized and attempts to administer oral rifampicin and clofazimine were made. Several days after treatment, annular erythematous macules appeared on the patient’s face, abdomen, and back. Histopathological examination results on sample taken from erythematous macule and right sural nerve were consistent with the diagnosis of leprosy with reversal reaction.

Conclusion

In certain conditions, histopathological examination of the skin and nerves are a highly rewarding test in establishing a diagnosis of leprosy.

Sonographic evaluation of leprosy of ulnar nerve

Leprosy is a chronic granulomatous infection caused by Mycobacterium Leprae that predominantly affects the skin and peripheral nerves. The disease is prevalent in developing countries of Asia and Africa, with occasional cases reported from United States. In this case report we highlight a 33-year-old man from Qatar, who presented with symptoms of progressive weakness in his left wrist and hand for six months and was later found to have a granuloma of the ulnar nerve secondary to leprosy. We will discuss the etiopathogenesis, clinical features, role of imaging, and management of neuropathy due to leprosy. Our case provides an excellent learning example of the utility of ultrasonography to characterize leprosy granulomas of the ulnar nerve.

Sensitivity and specificity of multibacillary and paucibacillary leprosy laboratory tests: A systematic review and meta-analysis

This systematic review (number register: CRD42018112736) was performed to compare the sensitivity and specificity of leprosy diagnostic methods. The search was conducted in 3 electronic databases in January 2021. Studies evaluating leprosy diagnostic tests were included according the eligibility criteria. Meta-analysis was performed to calculate the sensibility and specificity of the groups. We included 36 studies. The test sensitivity for paucibacillary patients was 0.31 (95%CI: 0.29-0.33) and the specificity was 0.92 (95%CI: 0.92-0.93). In multibacillary patients, the sensitivity was 0.78 (95%CI: 0.77-0.80) and specificity was 0.92 (95%CI: 0.92-0.93). Comparing the sensitivity and specificity of the different techniques included, it should be noted that polymerase chain reaction (PCR) test presented the highest sensitivity for paucibacillary patients, while the western blot technique showed the highest sensitivity for multibacillary patients. However, further studies are needed to optimise the diagnosis of leprosy, requiring research with a larger number of samples and more uniform protocols.

Leprosy: Clinical aspects and diagnostic techniques

Leprosy, also known as Hansen's disease, is a curable infectious disease that remains endemic in >140 countries around the world. Despite being declared "eliminated" as a global public health problem by the World Health Organization in the year 2000, approximately 200,000 new cases were reported worldwide in 2017. Widespread migration may bring leprosy to nonendemic areas, such as North America. In addition, there are areas in the United States where autochthonous (person-to-person) transmission of leprosy is being reported among Americans without a history of foreign exposure. In the first article in this continuing medical education series, we review leprosy epidemiology, transmission, classification, clinical features, and diagnostic challenges.

Peripheral nerve injuries in the pediatric population: a review of the literature. Part III: peripheral nerve tumors in children

INTRODUCTION

Peripheral nerve tumors type, inciedence and treatment in the pediatric population should be analyzed.

METHODS

We have performed an extense literature review of this subject.

RESULTS

incidence and distribution are similar to those observed in adults. The most common peripheral nerve tumors in children are neurofibromas and schwannomas. Malignant peripheral nerve sheath tumors are also observed, specially associated with genetic syndromes, like neurofibromatosis and Carney complex.

CONCLUSION

In this review, peripheral nerve tumors have been divided into three categories to aid with understanding: reactive and hyperplastic lesions, benign tumors, and malignant tumors. The most frequent lesions have been described.

Acquired disorders with hypopigmentation: A clinical approach to diagnosis and treatment

Acquired hypopigmented skin changes are commonly encountered by dermatologists. Although hypopigmentation is often asymptomatic and benign, occasional serious and disabling conditions present with cutaneous hypopigmentation. A thorough history and physical examination, centered on disease distribution and morphologic findings, can aid in delineating the causes of acquired hypopigmented disorders. The second article in this 2-part continuing medical education series focuses on conditions with a hypopigmented phenotype. Early diagnosis and appropriate management of these disorders can improve a patient's quality of life, halt disease progression, and prevent irreversible disability.

Correlation between therapy and lipid profile of leprosy patients: is there a higher risk for developing cardiovascular diseases after treatment?

BACKGROUND

The impact of leprosy reduces health-related quality of life of affected patients, interfering with different factors such as nutrition. This study investigated the lipid profile, nutritional status, and risk for cardiovascular disease (CVD) in patients who underwent leprosy treatment in Brazil.

METHODS

Eighty-four adult patients of both genders ranging in age from 20 to 60 years and diagnosed with paucibacillary (PB) or multibacillary (MB) leprosy were selected after undergoing multidrug treatment. The following data were collected: sociodemographic and clinical data; food intake; anthropometric measures (weight, height, and waist circumference); and lipid profile components (total cholesterol, high-density lipoprotein cholesterol [HDL-c], low-density lipoprotein cholesterol [LDL-c], and triglycerides).

RESULTS

Among the study population, there was a predominance of males (65.48%) aged 50 to 60 years, patients with an income of 248-496 American dollars (63.10%), patients who completed elementary school (65.48%), inactive patients (76.19%), non-smokers (46.43%), and non-drinking patients (69.05%). The levels (mean ± standard deviation) of total cholesterol were 193.8 ± 29.4 mg/dL in the PB form and 203.5 ± 41.7 mg/dL in the MB form. The mean LDL-c was 116.9 ± 22.7 mg/dL in PB patients and 121 ± 31.3 mg/dL in MB patients. Mean triglyceride levels were 123.4 ± 45.2 mg/dL in the PB form and 147.4 ± 88.9 mg/dL in the MB form. The evaluation of nutritional status showed that 41.67% of the patients were eutrophic, while 55.96% had excess weight. Food intake was significantly associated with HDL-c in male patients (P = 0.0264) and with triglycerides in patients above the ideal weight (P = 0.0049).

CONCLUSIONS

The risk of acquiring CVDs was observed to be high due to patients' excess weight and increased waist circumference. This study will guide clinicians in the adequate treatment of patients with leprosy in order to avoid adverse cardiovascular events.

Borderline Tuberculoid Leprosy Masquerading as Granuloma Annulare: A Clinical and Histological Pitfall

INTRODUCTION

Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae, an intracellular acid-fast bacillus that tends to infect the skin and peripheral nerves. Because of the wide array of cutaneous manifestation, diagnosis is not always straightforward, especially in nonendemic regions of the world such as the United States.

CASE REPORT

The authors report an unusual case of borderline tuberculoid leprosy in an 80-year-old white woman from California. Clinical examination revealed multiple nonscaly annular plaques, with central clearing and absence of lesional anesthesia, distributed over the trunk and extremities initially clinically diagnosed as granuloma annulare (GA). After 2 years of unsuccessful treatment with topical corticosteroid, biopsy revealed a palisaded and interstitial granulomatous infiltrate with necrobiosis, without discrete granulomas, compatible with GA. However, the presence of perineural lymphocytes in the reticular dermis prompted a Fite stain, which revealed acid-fast bacilli within the Schwann cells of a small peripheral nerve, pathognomonic for leprosy.

CONCLUSION

This is the first reported case of leprosy masquerading both clinically and histologically as GA. Dermatopathologists should be aware of the possibility of leprosy given the presence of perineural lymphocytes amidst any pattern of granulomatous infiltrate and obtain a Fite stain.

Leprosy in Puerto Rico: insight into the new millennia

BACKGROUND

Leprosy, or Hansen's disease, is a chronic infectious disease caused by the bacillus Mycobacterium leprae. In 2000, the World Health Organization (WHO) defined the elimination of the disease as a global prevalence of less than one case per 10,000 population. However, disease transmission is an ongoing worldwide public health concern, as evidenced by the more than 220,000 new cases diagnosed each year.

METHODS

This study is an update of the incidence and prevalence of leprosy in Puerto Rico for the period of 2000-2014. A retrospective analysis of data was obtained from the Tropical Disease Clinic (TDC) of the University of Puerto Rico School of Medicine.

RESULTS

Sixty-three new cases of leprosy are detailed in this study. Disease incidence and prevalence were 1.65 and 5.26 per 100,000 inhabitants (of the island of Puerto Rico), respectively, and an average of 4.2 new cases per year. Most of the male patients in the study suffered from lepromatous leprosy (P = 0.026). In all, 47 (74.6%) patients had been born in Puerto Rico, and 29 (46%) had an affected family member or were in close contact with someone with leprosy.

CONCLUSIONS

Compared to those of previous studies, these results demonstrate a decrease in both the incidence and prevalence of leprosy in Puerto Rico over the past 15 years. The relatively high prevalence of leprosy in Puerto Rico means that it remains endemic on the island. Concerted efforts must be undertaken to achieve the goal of the elimination of this old and stigmatized disease.

Inflammatory and Infectious Lesions of the Sinonasal Tract

The sinonasal tract is frequently affected by nonneoplastic inflammatory diseases. Inflammatory lesions of the sinonasal tract can be divided into 3 main categories: chronic rhinosinusitis, which encompasses a heterogeneous group of entities, all of which result in mucosal inflammation with or without polyps-eosinophils; infectious diseases; and autoimmune diseases and vasculitides, which can result in midline necrosis and facial deformities. This article reviews the common inflammatory lesions of the sinonasal tract with emphasis on infectious diseases, vasculitis, iatrogenic, and diseases of unknown cause. Many of these lesions can result in midline destruction and result in facial deformity.

The oral cavity in leprosy: what clinicians need to know

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, a bacillus that has a tropism for skin and peripheral nerves. Leprosy treatment is based on a multidrug therapy established by the World Health Organization in 1982 and, despite its widespread use, Brazil ranks second worldwide in numbers of cases. Oral involvement in leprosy has been poorly described in the literature, and few studies have shown that although the bacillus is found in mucosa, specific leprosy lesions are rare and affect patients with advanced stages of the disease. This review aimed to assess the literature on oral manifestations in leprosy and the aspects involving oral cavity in leprosy pathogenesis.

Differential Diagnosis of Necrotizing Sinonasal Lesions

CONTEXT

A number of entities may result in necrosis in the sinonasal tract and lead to significant morbidity and mortality. These include infections, necrotizing vasculitis, neoplastic processes, and drug dependency. This review will concentrate on the differential diagnosis of sinonasal necrotizing lesions.

OBJECTIVE

To review the differential diagnoses of necrotizing destructive lesions of the sinonasal tract.

DATA SOURCES

The current literature was reviewed to provide updated information regarding the differential diagnosis of sinonasal necrotizing lesions, including infectious disease processes; antineutrophilic cytoplasmic antibody-associated vasculitides; neoplastic processes, particularly natural killer/T-cell lymphomas; and drug abuse.

CONCLUSIONS

The differential diagnosis of necrotizing sinonasal lesions is broad, with often overlapping diagnostic features that lead to diagnostic challenges. Ancillary tests such as special stains and immunohistochemical studies can offer significant assistance.

Leprosy profiles in post-elimination stage: a tertiary care hospital experience

BACKGROUND

Most countries that were previously highly endemic for leprosy have achieved elimination at the national level.

OBJECTIVES

To find out the pattern, prevalence, and trends of leprosy in the post-elimination stage.

METHODS

A descriptive retrospective cross-sectional study was carried out using the registered records of patients attending the leprosy clinic in Chittagong Medical College Hospital between the periods 2001 and 2011.

RESULTS

The new case detection rate was declining. The prevalence rate was 0.75 at the end of 2011. Of a total of 789 patients, males (74%) outnumbered the females (26%). The age of the patients in the study group ranged from 6 years to 87 years with mean age 35.58 years ± 0.05 SEM. Paucibacillary (PB) and multibacillary (MB) cases were 314 (39.80%) and 475 (60.20%), respectively. MB percentage was increasing more among new cases in the study period, and 119 (15.08%) patients presented with grade 2 deformities. Smear positive cases were 141 (17.87%). Leprosy reaction comprised of 193 (24.46%) type 1, 68 (8.62%) type 2, and 97 (12.29%) neuritis cases.

LIMITATIONS

This is a retrospective study from a single tertiary health center.

CONCLUSION

MB cases with grade 2 deformities are in an upward trend, and rates of children are declining. Developing reinforced new therapies to curb reactions, deformities are very important and contact tracing, especially of children, is essential. Domiciliary treatment needs to be made available to ensure early diagnosis.

Quantiferon-Gold Tuberculosis Test Cannot Detect Latent Tuberculosis in Patients With Leprosy

Five of 10 paucibacillary leprosy patients were Quantiferon Gold (Q-G) positive with negative chest X-rays. Forty multibacillary leprosy patients were negative. Reports have shown 100% cross-reactivity of ESAT6 and CFP10 between Mycobacterium leprae and Mycobacterium tuberculosis. The Q-G test cannot detect latent tuberculosis in patients with leprosy.

Leprosy in the 21st century

Despite significant improvements in leprosy (Hansen's disease) treatment and outlook for patients since the introduction of multidrug therapy (MDT) 3 decades ago, the global incidence remains high, and patients often have long-term complications associated with the disease. In this article, we discuss recent findings related to genetics, susceptibility, and disease reservoirs and the implications of these findings for Hansen's disease control and health outcomes for patients. We describe the continued difficulties associated with treatment of inflammatory episodes known as "leprosy reactions," which cause much of the disability associated with the disease and can affect people for many years after MDT is complete. We also discuss some of the contemporary challenges for physicians and patients, including international and internal migration of people affected by the disease. We suggest some important areas of focus for future Hansen's disease research.

Sleep, Hansen's disease and the immune system--a not so harmonic triad

Hansen's disease is one of the oldest skin diseases in the world characterized by a spectrum of clinical manifestations that are associated with stigmatization and poor quality of life. It is also considered a model disease for investigating the human immune system because of its association with immune reactions, which are thought to be a reflection of the host's immunological response, promoting intense cellular activity or humoral secretion. This relationship between the cellular and microbial components of skin and their regulation by local immune responses may be modulated by a currently neglected behavior: sleep. Recent studies have demonstrated that sleep deprivation may aggravate the progression of chronic dermatological diseases, which in turn can lead to a non-restorative sleep pattern. Indeed, sleep is essential for immune and skin integrity. Thus, we propose here a hypothesis linking Hansen's disease, sleep and immunity in a bidirectional relationship. Hansen's disease patients may demonstrate a worse sleep quality than the general population through the modulation of immunological environment; and sleep restriction, a hallmark of modern society, being a possible predictor of the disease progression.

Leprosy: a review of laboratory and therapeutic aspects--part 2

Leprosy is a chronic infectious condition caused by Mycobacterium leprae(M. leprae). It is endemic in many regions of the world and a public health problem in Brazil. Additionally, it presents a wide spectrum of clinical manifestations, which are dependent on the interaction between M. leprae and host, and are related to the degree of immunity to the bacillus. The diagnosis of this disease is a clinical one. However, in some situations laboratory exams are necessary to confirm the diagnosis of leprosy or classify its clinical form. This article aims to update dermatologists on leprosy, through a review of complementary laboratory techniques that can be employed for the diagnosis of leprosy, including Mitsuda intradermal reaction, skin smear microscopy, histopathology, serology, immunohistochemistry, polymerase chain reaction, imaging tests, electromyography, and blood tests. It also aims to explain standard multidrug therapy regimens, the treatment of reactions and resistant cases, immunotherapy with bacillus Calmette-Guérin (BCG) vaccine and chemoprophylaxis.

The molecular genetics of inflammatory, autoimmune, and infectious diseases of the sinonasal tract: a review

CONTEXT

The sinonasal tract is frequently affected by a variety of nonneoplastic inflammatory disease processes that are often multifactorial in their etiology but commonly have a molecular genetic component.

OBJECTIVE

To review the molecular genetics of a variety of nonneoplastic inflammatory diseases of the sinonasal tract.

DATA SOURCES

Inflammatory lesions of the sinonasal tract can be divided into 3 main categories: (1) chronic rhinosinusitis, (2) infectious diseases, and (3) autoimmune diseases/vasculitides. The molecular diagnosis and pathways of a variety of these inflammatory lesions are currently being elucidated and will shed light on disease pathogenesis and treatment.

CONCLUSIONS

The sinonasal tract is frequently affected by inflammatory lesions that arise through complex interactions of environmental, infectious, and genetic factors. Because these lesions are all inflammatory in nature, the molecular pathology surrounding them is most commonly due to upregulation and down-regulation of genes that affect inflammatory responses and immune regulation.

Understanding the type 1 reactional state for early diagnosis and treatment: a way to avoid disability in leprosy

A type 1 reaction or reversal reaction is expressed clinically by inflammatory exacerbation of the skin lesions and nerve trunks, consequently leading to sensory and motor alterations. It occurs in non-polar forms of leprosy, although it can occur in a small percentage of sub-polar LL treated patients. Disabilities, deformities and morbidity, still present in leprosy, are mainly caused by these acute episodes. The recognition of reactional states is imperative for an early approach and efficient management, to avoid the emergence of disabilities that stigmatize the disease. This review aims to describe the clinical aspects, immunopathogenesis, epidemiology, histopathological features and therapeutics of type 1 reactions.

Leprosy. An update: definition, pathogenesis, classification, diagnosis, and treatment

Leprosy is a chronic granulomatous disease caused by the bacillus Mycobacterium leprae. It primarily affects the skin and peripheral nerves and is still endemic in various regions of the world. Clinical presentation depends on the patient's immune status at the time of infection and during the course of the disease. Leprosy is associated with disability and marginalization. Diagnosis is clinical and is made when the patient has at least 1 of the following cardinal signs specified by the World Health Organization: hypopigmented or erythematous macules with sensory loss; thickened peripheral nerves; or positive acid-fast skin smear or skin biopsy with loss of adnexa at affected sites. Leprosy is treated with a multidrug combination of rifampicin, clofazimine, and dapsone. Two main regimens are used depending on whether the patient has paucibacillary or multibacillary disease.

Degree of skin denervation and its correlation to objective thermal sensory test in leprosy patients

Background

Leprosy is an infectious disease affecting skin and peripheral nerves resulting in increased morbidity and physical deformities. Early diagnosis provides opportune treatment and reduces its complications, relying fundamentally on the demonstration of impaired sensation in suggestive cutaneous lesions. The loss of tactile sensitivity in the lesions is preceded by the loss of thermal sensitivity, stressing the importance of the thermal test in the suspicious lesions approach. The gold-standard method for the assessment of thermal sensitivity is the quantitative sensory test (QST). Morphological study may be an alternative approach to access the thin nerve fibers responsible for thermal sensitivity transduction. The few studies reported in leprosy patients pointed out a rarefaction of thin dermo-epidermal fibers in lesions, but used semi-quantitative evaluation methods.

Methodology/Principal Findings

This work aimed to study the correlation between the degree of thermal sensitivity impairment measured by QST and the degree of denervation in leprosy skin lesions, evaluated by immunohistochemistry anti-PGP 9.5 and morphometry. Twenty-two patients were included. There were significant differences in skin thermal thresholds among lesions and contralateral skin (cold, warm, cold induced pain and heat induced pain). The mean reduction in the density of intraepidermal and subepidermal fibers in lesions was 79.5% (SD = 19.6) and 80.8% (SD = 24.9), respectively.

Conclusions/Significance

We observed a good correlation between intraepidermal and subepidermal fibers deficit, but no correlation between these variables and those accounting for the degree of impairment in thermal thresholds, since the thin fibers rarefaction was homogeneously intense in all patients, regardless of the degree of sensory deficit. We believe that the homogeneously intense denervation in leprosy lesions should be objective of further investigations focused on its diagnostic applicability, particularly in selected cases with only discrete sensory impairment, patients unable to perform the sensory test and especially those with nonspecific histopathological finds.

Our study has addressed objectively the rarefaction of cutaneous thin nerve fibers density and its correlation with quantitative thermal sensory test in leprosy patients. Thermal sensitivity evaluation is crucial to the early diagnosis of leprosy, since it is the first type of cutaneous sensitivity lost in the lesions. However, some patients are unable to perform thermal tests, like children and patients with cognitive impairment. The pathological study of those lesions is also fundamental and it is the gold standard method to diagnose and classify leprosy patients. However, it may also be unspecific, especially in the indeterminate form of leprosy. Our findings show that even in lesions with slight thermal sensitivity impairment, there is a homogeneously intense denervation, specifically in the superficial skin layers. We believe that our findings pave the way to future studies focused on the diagnostic applicability of the cutaneous thin nerve fibers density quantification in leprosy suspected lesions.

Current approaches and future directions in the treatment of leprosy

This review surveys current treatments and future treatment trends in leprosy from a clinical perspective. The World Health Organization provides a multidrug treatment regimen that targets the Mycobacterium leprae bacillus which causes leprosy. Several investigational drugs are available for the treatment of drug-resistant M. leprae. Future directions in leprosy treatment will focus on: the molecular signaling mechanism M. leprae uses to avoid triggering an immune response; prospective studies of the side effects experienced during multiple-drug therapy; recognition of relapse rates post-completion of designated treatments; combating multidrug resistance; vaccine development; development of new diagnostic tests; and the implications of the recent discovery of a genetically distinct leprosy-causing bacillus, Mycobacterium lepromatosis.

A delayed diagnosis of lepromatous leprosy: pitfalls and clues to early recognition

PURPOSE

To remind special attention to atypical symptoms of Hansen's disease, we report a case of an atypical case due to a delayed diagnosis.

BACKGROUND

Clinical features of leprosy are well known, cutaneous lesions and involvement of the peripheral nerves being the cardinal clinical signs. Among these presentations, systemic involvement, including mucous membranes of the upper respiratory tract and eyes, is rarely reported even if it is still commonly seen in endemic areas, in particular lepromatous leprosy.

CASE REPORT

We describe here a new case of Hansen's disease in a 51-year-old Tunisian woman with an atypical presentation and a delayed diagnosis. The early symptoms of the disease were different from the main clinical signs of Hansen's disease since they involved the upper respiratory tract and the eyes. A nasal smear was positive for acid-fast bacilli, thus confirming the diagnosis of bacilliferous leprosy. Histological findings suggested the diagnosis of leprosy and were somewhat more characteristic of the borderline lepromatous type.

CONCLUSION

Diagnosis of Hansen's disease in patients with neither apparent skin lesions nor neurological signs is still problematic. Clinicians should not only pay attention to the more obvious signs in their own fields of expertise but should be aware of the possible systemic involvement of leprosy.

Cutaneous Manifestations of Infectious Diseases

Skin infections account for a significant portion of ­dermatologic diseases. Infections of the skin and subcutaneous tissues are highly diverse in respect to incidence, ­etiologic organisms, and clinical manifestations. Most cases are potentially treatable, thus, it is vital for the clinician to become familiar with the cutaneous expression of local and systemic processes. This chapter covers the clinical presentation, diagnosis, and treatment of the most common bacterial, viral, and fungal mucocutaneous infections encountered in internal medicine.