Mycobacterium leprae and leprosy: a compendium

Toxoplasma gondii infection and high levels of IgE are associated to erythema nodosum leprosy (ENL)

Leprosy is a chronic infectious disease caused by the bacillus Mycobacterium leprae. The disease may evolve for inflammatory reactions, reversal reaction (RR) and erythema nodosum leprosum (ENL), the major cause of irreversible neuropathy in leprosy, which occur in 1 in 3 people with leprosy, even with effective treatment of M. leprae. Leprosy remains persistently endemic in our region where it predominantly affects lowest socioeconomic conditions people, as Toxoplasma gondii infection in the municipality studied. Previously, we have shown T. gondii coinfection as a risk marker for leprosy, mainly in its severe form. This present study assessed whether T. gondii infection is also a risk factor for leprosy reactions and the predictive value of immunoglobulin production prior to development of leprosy reactions. Patients with leprosy (n = 180), co-infected or not with T. gondii, had their serum investigated for levels of IgA, IgE, IgG1, IgG2, IgG3 and IgG4 anti-PGL-1 by ELISA prior to development of leprosy reactions. The serologic prevalence for T. gondii infection was 87.7% in leprosy reaction patients reaching 90.9% in those with ENL. The leprosy reaction risk increased in T. gondii seropositive individuals was two-fold ([OR] = 2.366; 95% confidence interval [CI 95%]: 1.024-5.469) higher than those seronegative, and considering the risk of ENL, this increase was even more evident (OR = 6.753; 95% CI: 1.050-72.85) in coinfected individuals. When evaluated the prediction of anti-PGL-1 immunoglobulin levels for development of leprosy reactions in patients coinfected or not with T. gondii, only the increase IgE levels were associated to occurrence of reactional episodes of leprosy, specifically ENL type, in patients coinfected with T. gondii, compared to those not coinfected or no reaction. Thus, the immunomodulation in co-parasitism T. gondii-M. leprae suggest increased levels of IgE as a biomarker for early detection of these acute inflammatory episodes and thereby help prevent permanent neuropathy and disability in leprosy patients.

The role of neurotrophin polymorphisms and susceptibility to neural damage in leprosy

OBJECTIVES

Mycobacterium leprae is able to infect Schwann cells leading to neural damage. Neurotrophins are involved in nervous system plasticity and impact neural integrity during diseases. Investigate the association between single nucleotide polymorphisms in neurotrophin genes and leprosy phenotypes, especially neural damage.

DESIGN

We selected single nucleotide polymorphisms in neurotrophins or their receptors genes associated with neural disorders: rs6265 and rs11030099 of brain-derived neurotrophic factor (BDNF), rs6330 of BDNF, rs6332 in NT3 and rs2072446 of P75NTR. The association of genetic frequencies with leprosy phenotypes was investigated in a case-control study.

RESULTS

An association of the BDNF single nucleotide polymorphism rs11030099 with the number of affected nerves was demonstrated. The "AA+AC" genotypes were demonstrated to be protective against nerve impairment. However, this variation does not affect BDNF serum levels. BDNF is an important factor for myelination of Schwann cells and polymorphisms in this gene can be associated with leprosy outcome. Moreover, rs11030099 is located in the binding region for micro-RNA (miRNA) 26a that could be involved in control of BDNF expression. We demonstrated different expression levels of this miRNA in polar forms of leprosy.

CONCLUSION

Our findings demonstrate for the first time an association between the polymorphism rs11030099 in the BDNF gene and neural commitment in leprosy and may indicate a possible role of miRNA-26a acting synergistically to these genetic variants in neural damage development.

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.

Pathogenicity and virulence of Mycobacterium leprae

Leprosy is caused by Mycobacterium leprae (M. leprae) and M. lepromatosis, an obligate intracellular organism, and over 200,000 new cases occur every year. M. leprae parasitizes histiocytes (skin macrophages) and Schwann cells in the peripheral nerves. Although leprosy can be treated by multidrug therapy, some patients relapse or have a prolonged clinical course and/or experience leprosy reaction. These varying outcomes depend on host factors such as immune responses against bacterial components that determine a range of symptoms. To understand these host responses, knowledge of the mechanisms by which M. leprae parasitizes host cells is important. This article describes the characteristics of leprosy through bacteriology, genetics, epidemiology, immunology, animal models, routes of infection, and clinical findings. It also discusses recent diagnostic methods, treatment, and measures according to the World Health Organization (WHO), including prevention. Recently, the antibacterial activities of anti-hyperlipidaemia agents against other pathogens, such as M. tuberculosis and Staphylococcus aureus have been investigated. Our laboratory has been focused on the metabolism of lipids which constitute the cell wall of M. leprae. Our findings may be useful for the development of future treatments.

Leprosy Relapse: a Retrospective Study on Epidemiological, Clinical and Therapeutics Aspects at a Brazilian Referral Center

OBJECTIVES

We aim to characterize the profile of patients diagnosed with leprosy relapse and understand the influence of different multidrug therapy (MDT) treatments and initial disease presentation.

METHODS

This retrospective study included patients diagnosed with leprosy relapse at a referral center in Brazil from 2013-2018. We analyzed their clinical-epidemiological characteristics, laboratory, and bacilloscopic tests. Survival analysis was used to determine the time elapsed until relapse, according to the previous treatment and the disease clinical forms.

RESULTS

126 cases of relapse were analyzed, which comprised 11.89% (126/1059) of the cases. The median time elapsed until relapse was 10 years, and most patients had previously undergone 12 doses of MDT (40.48%; 51/126). Undergoing 24 doses of MDT was associated with a better prognosis regarding relapse over time compared to six or 12 doses of MDT therapy. Most of the cases of relapse were classified as multibacillary (96.03%; 121/126).

CONCLUSION

The incidence of relapse was greater than observed in other studies. The high percentage of multibacillary patients who had negative bacillary indices demonstrated that the bacillary index cannot be considered to be an essential criterion for relapse, especially with regard to making an early diagnosis.

Role of diffusion tensor imaging in the evaluation of ulnar nerve involvement in leprosy

OBJECTIVE

Early detection of peripheral neuropathy is extremely important as leprosy is one of the treatable causes of peripheral neuropathy. The study was undertaken to assess the role of diffusion tensor imaging (DTI) in ulnar neuropathy in leprosy patients.

METHODS

This was a case-control study including 38 patients (72 nerves) and 5 controls (10 nerves) done between January 2017 and June 2019. Skin biopsy proven cases of leprosy, having symptoms of ulnar neuropathy (proven on nerve conduction study) were included. MRI was performed on a 3 T MR system. Mean cross-sectional area, fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values of ulnar nerve at cubital tunnel were calculated. Additional ancillary findings and appearance of base sequences were evaluated.

RESULTS

Ulnar nerve showed thickening with altered T₂W signal in all the affected nerves, having an average cross-sectional area of 0.26 cm². Low FA with mean of 0.397 ± 0.19 and high ADC with mean of 1.28 ± 0.427 x 10 ^-3 mm²/s of ulnar nerve in retrocondylar groove was obtained. In the control group, mean cross-sectional area was 0.71cm² with mean FA and ADC of 0.53 ± 0.088 and 1.03 ± 0.24 x 10 ^-3 mm²/s respectively. Statistically no significant difference was seen in diseased and control group. Cut-off to detect neuropathy for FA and ADC is 0.4835 and 1.1020 × 10 ^-3 mm²/s respectively.

CONCLUSION

DTI though is challenging in peripheral nerves, however, is proving to be a powerful complementary tool for assessment of peripheral neuropathy. Our study validates its utility in infective neuropathies.

ADVANCES IN KNOWLEDGE

1. DTI is a potential complementary tool for detection of peripheral neuropathies and can be incorporated in standard MR neurography protocol.2. In leprosy-related ulnar neuropathy, altered signal intensity with thickening or abscess of the nerve is appreciated along with locoregional nodes and secondary denervation changes along with reduction of FA and rise in ADC value.3. Best cut-offs obtained in our study for FA and ADC are 0.4835 and 1.1020 × 10 ^-3 mm²/s respectively.

Active case detection methods for crusted scabies and leprosy: A systematic review

BACKGROUND

Crusted scabies is endemic in some remote Aboriginal communities in the Northern Territory (NT) of Australia and carries a high mortality risk. Improvement in active case detection (ACD) for crusted scabies is hampered by a lack of evidence about best practice. We therefore conducted a systematic review of ACD methods for leprosy, a condition with similar ACD requirements, to consider how findings could be informative to crusted scabies detection.

METHODS AND PRINCIPLE FINDINGS

We conducted systematic searches in MEDLINE, CINAHL, Scopus and the Cochrane Database for Systematic Reviews for studies published since 1999 that reported at least one comparison rate (detection or prevalence rate) against which the yield of the ACD method could be assessed. The search yielded 15 eligible studies from 511. Study heterogeneity precluded meta-analysis. Contact tracing and community screening of marginalised ethnic groups yielded the highest new case detection rates. Rapid community screening campaigns, and those using less experienced screening personnel, were associated with lower suspect confirmation rates. There is insufficient data to assess whether ACD campaigns improve treatment outcomes or disease control.

CONCLUSION

This review demonstrates the importance of ACD campaigns in communities facing the highest barriers to healthcare access and within neighbourhoods of index cases. The potential benefit of ACD for crusted scabies is not quantified, however, lessons from leprosy suggest value in follow-up with previously identified cases and their close contacts to support for scabies control and to reduce the likelihood of reinfection in the crusted scabies case. Skilled screening personnel and appropriate community engagement strategies are needed to maximise screening uptake. More research is needed to assess ACD cost effectiveness, impact on disease control, and to explore ACD methods capable of capturing the homeless and highly mobile who may be missed in household centric models.

Uveitic Glaucoma and Hansen's disease, A case report

Background

The number of Hansen's disease cases in Latin America and the Caribbean has decreased in the last decade; nevertheless, the region is still struggling with infections caused by Mycobacterium leprae. This is a case report that portrays the diagnostic and management challenges associated with atypical uveitic glaucoma that is due to Hansen's disease.

Case presentation

A 62-year-old female was referred with a 2-year history of anterior uveitis of unknown etiology and ocular hypertension. Past medical history and general physical examination were unremarkable. Upon ocular examination, her best-corrected visual acuity (BCVA) was 20/25 in the OD and 20/60 in the OS. Tonometry showed intraocular pressures (IOPs) of 29 mmHg and 22 mmHg in her right and left eyes, respectively. The slit-lamp examination showed clinical signs of bilateral granulomatous anterior uveitis and cataracts; gonioscopy revealed open angles with some peripheral anterior synechiae for both eyes. Fundus examination and glaucoma tests revealed mild glaucomatous damage in the right eye. Given the presentation of uveitis, the respective questionnaire was completed by internal medicine and rheumatology. Four months later, after bilateral cataract surgery, the patient developed skin plaques on the face, neck, upper back, and extremities, which were biopsied and identified as positive for tuberculoid leprosy.

Conclusion

This is the first case report in Ecuador of atypical glaucoma triggered by infectious uveitis produced by Mycobacterium leprae. We describe a female patient's clinical presentation with several ocular signs of leprosy and other nonspecific and rarely seen symptoms. Uveitis is a condition that often requires a multidisciplinary team of ophthalmologists and clinicians because of the possible manifestation of an underlying systemic disease, creating a challenge for all the medical personnel involved in the management of the case.

Impurity profiling of dapsone using gradient HPLC method

The quality control of active pharmaceutical ingredients (APIs) is a very important aspect for drug products entering the market. However, also for the well-established drugs, there ought to be a state-of-the-art impurity control. Some of the pharmacopoeial tests for related substances still make use of thin layer chromatography, even though selectivity and sensitivity are suboptimal. Here, we report on the development of a new gradient high performance liquid chromatography (HPLC) method for dapsone in order to replace the currently described pharmacopoeial TLC method. The separation of all relevant components was achieved on a C18 stationary phase (Waters XTerra® RP₁₈ 5 μm 4.6 × 250 mm) using a water-acetonitrile gradient. A limit of detection (LOD) of 0.02% was registered for all specified impurities. Additionally, within this study an "impurity of an impurity" was identified by means of LC-MS/MS.

Ocular leprosy: from bench to bedside

PURPOSE OF REVIEW

Ocular manifestations of leprosy do occur despite advances in the areas of leprosy research. Understanding the nuances in the domain shall guide the clinician for effective patient-centered care.

RECENT FINDINGS

Despite the existence of microbiologic cure for leprosy, ocular manifestations of this disease do occur. Advances in genetic and genomic studies have better characterized the interaction that the bacteria has with the host. The ocular features vary with the spectrum of the disease. Its careful correlation can help to predict the bacillary load of the patient. Investigations are particularly relevant in multibacillary cases. The WHO suggests a treatment duration longer than the 2 years in ocular involvement.

SUMMARY

The isolation of lepra bacilli from the iris biopsy in negative skin smear patients and multidrug therapy completion highlights the potential role of bactericidal agents in the planned intraocular treatment. Lepra reactions need careful titration of oral steroids and appropriate antibacterial agents. Advances in phacoemulsification with in the bag implantation of intraocular lenses is a game changer in the management of the most common cause of blindness of leprosy. Advances in vaccine research in leprosy are promising.

Oral manifestation in leprosy: A cross-sectional study of 100 cases with literature review

BACKGROUND

Leprosy is a chronic granulomatous disease of the peripheral nerve and muscle of upper respiratory tract. Consequence to the neighboring primary site, oral lesions have been seen in 20--60% of patient with leprosy mainly lepromatous leprosy. The lepromatous nodules may be infective and may lead to the spread of disease and hence require proper diagnosis.

AIM

To assess oral lesion in leprosy patients. To assess the disease and the occurrence of oral lesion according to age and gender. To detect any primary lesion in oral cavity and compare these lesions in duration to study.

MATERIALS AND METHODS

A total of 100 patients with leprosy were examined and there oral manifestations were recorded.

RESULTS

It was found that 70 (70%) leprosy patients showed oral manifestations. And 18 (25%) had chronic generalized periodontitis, 9 (12.8%) cases of oral melanosis, 7 (10%) atrophy of papillae and loss of taste sensation each, 6 (8.5%) complained of aphthous and candidiasis each, 5 (7.14%) depigmentation, and 4 (5.71%) smokers palate, oral submucous fibrosis, and fissured tongue.

CONCLUSION

Our clinical findings are in conjugation with previous studies; however, as per the review of literature this is the first study worldwide where we have examined 100 cases of leprosy which has not been documented till date. We suggest that the lesser incidence of oral lesions observed recently compared to older reports because of more effective present treatment which is initiated earlier.

BCG vaccine and leprosy household contacts: Protective effect and probability to becoming sick during follow-up

BACKGROUND

Immunoprophylaxis with Bacillus Calmette-Guérin (BCG) vaccine is still the most effective intervention in the prevention of leprosy among household contacts (HHCs) of leprosy patients.

METHODS

A retrospective cohort study using data of 5.061 HHCs for a period of 16 years (follow-up of 7 years per leprosy HHCs), evaluating the occurrence of disease as the main outcome and the presence or absence of BCG scars verified at the first evaluation. Statistical analyzes were performed using the relative risk, hazard ratio and survival curves by Kaplan-Meier test.

RESULTS

A total of 92 contacts sickened, of which 41.3% (38/92) in the first year and 58.7% (54/92) in the course of the other years of follow-up. Of those who became sick, 62% (57/92) developed borderline tuberculoid (BT). The additional protective effect occurred for those who had 2 BCG scars at the first follow-up assessment (Relative Risk: 0.41; p = 0.007) when compared to those not previously exposed to the vaccine. The number of BCG scars examined at the first assessment (t₀ = time zero) affected the occurrence of the outcome evidenced by the difference in survival curves throughout the follow-up (Log Rank, p = 0.041; Breslow, p = 0.012; Tarone-Ware, p = 0.020). Leprosy HHCs with 0 BCG scar at time zero (t₀) have a shorter survival time (average time of 22 months between t₀ and outcome) when compared to those with 2 BCG scars (average time of 36 months between t₀ and outcome).

CONCLUSIONS

Vaccination of healthy individuals without signs and symptoms of leprosy is extremely important because BCG vaccine has an additional protective effect in those cases with 2 BCG scars throughout follow-up. Reducing the risk of leprosy HHCs becoming sick depends on preventive actions such as immunoprophylaxis and index cases treatment.

Diet and nutrition: An important risk factor in leprosy

Leprosy, once considered as poor man's disease may cause severe neurological complications and physical disabilities. Classification of leprosy depends upon the cell mediated and humoral immune responses of the host, from tuberculoid to lepromatous stage. Current therapy to prevent the disease is not only very lengthy but also consists of expensive multiple antibiotics in combination. Treatment and the duration depend on the bacillary loads, from six months in paucibacillary to a year in multibacillary leprosy. Although as per WHO recommendations, these antibiotics are freely available but still out of reach to patients of many rural areas of the world. In this review, we have focused on the nutritional aspect during the multi-drug therapy of leprosy along with the role of nutrition, particularly malnutrition, on susceptibility of Mycobacterium leprae and development of clinical symptoms. We further discussed the diet plan for the patients and how diet plans can affect the immune responses during the disease.

Invasion of human microvascular endothelial cells by Mycobacterium leprae through Mce1A protein

In patients with lepromatous leprosy, Mycobacterium leprae is often observed inside the human microvascular endothelial cells (HMVEC) surrounding Schwann cells (SC) at the site of lesions in the peripheral nerves. Based on this observation, it is considered that the nasal mucous may be the invasion pathway for M. leprae and HMVEC serve as an important reservoir for the bacteria before they invade SC. In light of previous research which revealed that Mce1A protein mediates bacterial invasion into nasal epithelial cells and HMVEC, we conducted a study to determine whether the invasion of M. leprae into HMVEC can be suppressed by blocking the Mce1A protein. In this study, we analyzed bacterial invasive activity by adding recombinant Escherichia coli, which express the active region (InvX:72 a.a.) of Mce1A protein on their external membrane, into cultured HMVEC, using the adhesin involved in the diffuse adherence mechanism. The number of bacteria that invaded into the cells was then measured by a colony counting method. The active region of Mce1A was divided into four sections, and hyperimmune antisera was prepared for each section for analyzing the inhibitory effect against invasion. The invasive activity was suppressed by antibodies against InvX regions 1-24 a.a., 25-46 a.a. and 58-72 a.a. This suggests that the InvX regions 1-24 a.a., 25-46 a.a. and 58-72 a.a. of Mce1A protein play an important role in the invasion of M. leprae into HMVEC and that it may be possible to suppress entry of M. leprae in HMVEC with antibodies against these regions.

Neurosurgical treatment of leprosy neuropathy in a low-incidence, European country

INTRODUCTION

Leprosy is nowaday increasingly encountered in non-endemic countries. Nerve involvement is common. Swelling of the nerves may lead to entrapment neuropathy causing pain and neurological deficits. Delay in diagnosis and treatment may lead to loss of chance of improvement. Surgical decompression in conjunction with medical therapy allows relief of symptoms.

METHODS

We present a retrospective series of 21 patients surgically treated in our center for leprosy entrapment neuropathy. We report presentation, treatment, and outcome at follow-up including a brief literature review.

RESULTS

Twenty-one patients were treated for nerve entrapments in four different anatomical districts. We reported good clinical outcomes mainly in motor deficits but also in improvement of sensitive deficits and pain symptoms. We did not experience surgical complications.

DISCUSSION

Although there is a lack of high-quality prospective studies comparing medical and surgical treatment of leprosy neuropathy, benefits of surgery are widely reported in series and case reports from endemic countries. There is scant literature from low-incidence countries even if leprosy incidence is nowaday increasing in these countries and will likelihood further increase in the future. Our results are in line with the literature presenting good outcomes after surgery.

CONCLUSION

We believe that a precise knowledge of the pathology and its management is crucial also for physicians who work in low-incidence countries to maximize healing chances with timely diagnosis and treatment.

Dependence on others for oral hygiene and its association with hand deformities and functional impairment in elders with a history of leprosy

OBJECTIVE

To analyse the frequency of dependence on others for oral hygiene and its association with hand deformities, frailty and dependence on others for basic activities of daily living (BADL) among elders with a history of leprosy.

BACKGROUND

Dependence on others for oral hygiene has not been considered in multifunctional geriatric assessments.

MATERIAL AND METHODS

Edentulous elders with a history of leprosy who used complete dentures and resided in a former leprosy colony were classified as independent or partially/completely dependent on others for brushing their dentures or rinsing and for BADL, and as frail or robust. The presence of hand deformities was assessed by an occupational therapist.

RESULTS

28.4% and 14.9% were completely/partially dependent on others for brushing and rinsing, respectively. The dependence for BADL was observed in 21.6% and hand deformities in 17.6%. A higher odds of dependence for brushing/rinsing was found among elders who were dependent on others for BADL. Brushing dependence (61.5%) was more frequent among participants with hand deformities than those without this condition (21.3%) (OR: 6.8; 95% IC: 1.2-37.9; P = .028). There was no association between frailty and brushing (P = .068) or rinsing (P = .202) dependence.

CONCLUSION

Approximately one-third of elders have a dependence on others for brushing; a smaller proportion is dependent on others for rinsing. Older people who are dependent on others for BADL and who present hand deformities are more likely to be dependent on others for denture brushing and rinsing. Elders may perform oral self-care even when they present frailty.

Cytokines as biomarkers to monitoring the impact of multidrug therapy in immune response of leprosy patients

Leprosy or Hansen's disease is a chronic infectious disease of the skin and nerves, caused by the intracellular bacilli Mycobacterium leprae. It is characterized by a spectrum of clinical forms depending on the host's immune response to M. leprae. Patients with tuberculoid (TT) leprosy have strong cell-mediated immunity (CMI) with elimination of the bacilli, whereas patients with lepromatous (LL) leprosy exhibit defective CMI to M. leprae. Despite advances in the understanding of the pathogenesis of leprosy and the development of new therapeutic strategies, there is a need for the identification of biomarkers which be used for early diagnosis and to discrimination between different forms of the disease, as prognostic markers. Here, we analyzed the serum levels of IL-1β, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-17A, IFN-γ and TNF in order to address the contribution of these cytokines in late phase of M. leprae infection, and the impact of multidrug therapy (MDT). Our results demonstrated that patients of LL group presented higher expression of serum levels of inflammatory cytokines before MDT, while TT patients presented a balance between inflammatory and regulatory cytokines. MDT changes the profile of serum cytokines in M. leprae infected patients, as evidenced by the cytokine network, especially in TT patients. LL patients displayed a multifaceted cytokine system characterized by strong connecting axes involving inflammatory/regulatory molecules, while TT patients showed low involvement of regulatory cytokines in network overall. Cytokines can be identified as good biomarkers of the impact of MDT on the immune system and the effectiveness of treatment.

In Vivo Confocal Microscopy of Corneal Nerves in Health and Disease

In vivo confocal microscopy (IVCM) is becoming an indispensable tool for studying corneal physiology and disease. Enabling the dissection of corneal architecture at a cellular level, this technique offers fast and noninvasive in vivo imaging of the cornea with images comparable to those of ex vivo histochemical techniques. Corneal nerves bear substantial relevance to clinicians and scientists alike, given their pivotal roles in regulation of corneal sensation, maintenance of epithelial integrity, as well as proliferation and promotion of wound healing. Thus, IVCM offers a unique method to study corneal nerve alterations in a myriad of conditions, such as ocular and systemic diseases and following corneal surgery, without altering the tissue microenvironment. Of particular interest has been the correlation of corneal subbasal nerves to their function, which has been studied in normal eyes, contact lens wearers, and patients with keratoconus, infectious keratitis, corneal dystrophies, and neurotrophic keratopathy. Longitudinal studies have applied IVCM to investigate the effects of corneal surgery on nerves, demonstrating their regenerative capacity. IVCM is increasingly important in the diagnosis and management of systemic conditions such as peripheral diabetic neuropathy and, more recently, in ocular diseases. In this review, we outline the principles and applications of IVCM in the study of corneal nerves in various ocular and systemic diseases.

Evaluation and Monitoring of Mycobacterium leprae Transmission in Household Contacts of Patients with Hansen's Disease in Colombia

Leprosy in Colombia is in a stage of post elimination-since 1997, prevalence of the disease is less than 1/10000. However, the incidence of leprosy has remained stable, with 400-500 new cases reported annually, with MB leprosy representing 70% of these case and 10% having grade 2 disability. Thus, leprosy transmission is still occurring, and household contacts (HHCs) of leprosy patients are a population at high risk of contracting and suffering from the effects of the disease during their lifetime. We performed a cross-sectional study with the aim of evaluating leprosy transmission within Family Groups (FGs) from four Colombian departments: Antioquia, Bolívar, Córdoba and Sucre. This study included 159 FGs formed by 543 HHCs; 45 FGs were monitored twice, first in 2003 and again in 2012. Migration, forced displacement by violence, loss of contact with the health center and the lack of an agreement to participate in the second monitoring were the primary reasons not all FGs were tested a second time. In each HHC, a clinical examination was performed, epidemiological data recorded, the bacillary index determined, DNA was isolated for M. leprae detection by nested PCR and IgM anti-phenolic glycolipid-I (PGL-I) titers were inspected. Further, DNA from M. leprae isolates were typed and compared among FGs. Twenty-two (4.1%) of the 543 HHCs had IgM anti-PGL-I positive antibody titers, indicating infection. Nasal swabs (NS) taken from 113 HHCs were tested by RLEP PCR; 18 (16%) were positive for M. leprae DNA and two new leprosy cases were detected among the HHCs. Of the confirmed HHCs with leprosy, it was possible to genotype the bacterial strains from both the index case and their HHCs. We found that the genotype of these two strains agreed at 9 markers, showing the individuals to be infected by the same strain, indicating familiar transmission. HHCs of leprosy patients not only are a high-risk population for M. leprae infection, they can act as M. leprae carriers and therefore serve as sources for transmission and infection. Our results confirm familiar leprosy transmission and suggest that follow-up of HHCs is a good strategy for early diagnosis of leprosy and to monitor its transmission.

Granulomatous & histiocytic dermatitides

Granulomas of the skin may be classified in several ways. They are either infectious or non-infectious in character, and they contain areas of necrobiosis or necrosis, or not. Responsible infectious agents may be mycobacterial, fungal, treponemal, or parasitic organisms, and each case of granulomatous dermatitis should be assessed histochemically for those microbes. In the non-infectious group, examples of necrobiotic or necrotizing granulomas include granuloma annulare; necrobiosis lipoidica; rheumatoid nodule; and lupus miliaris disseminates faciei. Non-necrobiotic/necrotizing and non-infectious lesions are exemplified by sarcoidosis; foreign-body reactions; Melkersson-Rosenthal syndrome; Blau syndrome; elastolytic granuloma; lichenoid and granulomatous dermatitis; interstitial granulomatous dermatitis; cutaneous involvement by Crohn disease; granulomatous rosacea; and granulomatous pigmented purpura. Histiocytic dermatitides that do not feature granuloma formation are peculiar reactions to infection, such as cutaneous malakoplakia; leishmaniasis; histoplasmosis; lepromatous leprosy; rhinoscleroma; lymphogranuloma venereum; and granuloma inguinale.

Leprous macrocheilia: A rare clinical presentation

Oral leprosy, a granulomatous disease is classified under the term oro-facial granulomatosis which comprises a group of diseases characterized by noncaseating granulomas affecting the soft tissues of the oral and maxillofacial region. The most common clinical presentation of oro-facial granulomatous conditions is persistent swelling of one or both lips. Due to its rare incidence and clinical findings overlapping with other granulomatous conditions such as sarcoidosis, Crohn's disease, and cheilitis granulomatosa; it is practically difficult for a dental surgeon to easily diagnose this condition. This study presents a case of leprosy causing macrocheilia as the only clinical presentation and diagnosed initially as Miescher's cheilitis based on exclusion criteria.

Systematic review: Whipple's disease (Tropheryma whipplei infection) and its unmasking by tumour necrosis factor inhibitors

BACKGROUND

The classical form of Whipple's disease (WD), clinically characterised by arthropathy, diarrhoea and weight loss, is rare. Recently, other more frequent forms of Tropheryma whipplei infection have been recognised. The clinical spectrum includes an acute, self-limiting disease in children, localised forms affecting cardiac valves or the central nervous system without intestinal symptoms, and asymptomatic carriage of T. whipplei which is found in around 4% of Europeans. Genomic analysis has shown that T. whipplei represents a host-dependent or opportunistic bacterium. It has been reported that the clinical course of T. whipplei infection may be influenced by medical immunosuppression.

AIM

To identify associations between immunomodulatory treatment and the clinical course of T. whipplei infection.

METHODS

A PubMed literature search was performed and 19 studies reporting on immunosuppression, particularly therapy with tumour necrosis factor inhibitors (TNFI) prior to the diagnosis in 41 patients with Whipple?s disease, were evaluated.

RESULTS

As arthritis may precede the diagnosis of WD by many years, a relevant percentage (up to 50% in some reports) of patients are treated with immunomodulatory drugs or with TNFI. Many publications report on a complicated Whipple?s disease course or T. whipplei endocarditis following medical immunosuppression, particularly after TNFI. Standard diagnostic tests such as periodic acid-Schiff stain used to diagnose Whipple?s disease often fail in patients who are pre-treated by TNFI.

CONCLUSIONS

In cases of doubt, Whipple?s disease should be excluded before therapy with TNFI. The fact that immunosuppressive therapy contributes to the progression of T. whipplei infection expands our pathogenetic view of this clinical entity.

Nerve conduction studies in early tuberculoid leprosy

CONTEXT

Hansen's disease is a chronic illness; besides involving skin and peripheral nerves, it affects multiple organs. Nerve involvement is always present in leprosy, and it may be present much before the patient manifests clinically.

AIMS

To assess nerve conduction parameters in thickened and contralateral non-thickened nerves in early tuberculoid leprosy.

MATERIALS AND METHODS

Fifty new untreated male patients with tuberculoid and borderline tuberculoid leprosy in the age group of 15-50 years with thickened peripheral nerves on one side were included in the study. Nerve conduction studies consisting of sensory and motor velocity (NCV), distal latencies, and amplitude were carried out on thickened ulnar, common peroneal, and posterior tibial nerves and contralateral normal nerves.

STATISTICAL ANALYSIS USED

Mean values along with coefficient of variation were obtained for various parameters. These were compared with normal values of the control population. P value was used to verify statistical significance.

RESULTS

Nerve conduction parameters were deranged in most of the thickened nerves. Sensory parameters were affected early in the disease process.

CONCLUSION

Additional parameters are required to assess nerve damage in early cases, where it is more in slow conducting fibers (average velocity fibers). Change in conduction velocity may not be marked; this calls for the measurement of fast fibers separately because potentials recorded are mainly from myelinated fibers.

Relationship between growth factors and its implication in the pathogenesis of leprosy

Leprosy is a chronic infectious disease caused by Mycobacterium leprae which affects the skin and peripheral nervous system. The immune response of the host determines the clinical course of the disease. The tuberculoid form is the result of high cell-mediated immunity characterized by a Th1 response, whereas the lepromatous form is characterized by low cell-mediated immunity and a Th2 humoral response. The neural damage established produces marked changes in the expression of growth factors such as nerve growth factor (NGF) and its receptors (NGF-R). The expression of NGF, associated with the expression of Th1 and Th2 cytokines, might be involved in the tissue damage caused by the bacillus. Therefore, the objective of this study was to correlate the immunoexpression patterns of NGF and NGF-R in the different clinical forms of leprosy, and to associate the findings with the in situ expression of TGF-β and clinical classification of the disease. TGF-β, NGF and NGF-R immunoexpression was analyzed by immunohistochemistry in paraffin-embedded material. Most patients were males with a mean age of 40.7 years. TGF-β levels were significantly higher in the lepromatous forms. No significant difference in the immunoexpression of NGF or NGF-R was observed between the clinical forms, but expression tended to be higher at the lepromatous pole. There was a significant positive correlation between NGF and NGF-R in the different clinical forms of leprosy. A significant positive correlation was observed between NGF, NGF-R and TGF-β. It can be concluded that, even existing evidence on the role of these molecules in the clinical spectrum of leprosy.

Assessment of serum level of interleukin-1b and interleukin-12 in leprosy: impact of previous Bacillus Calmitte Guerin vaccination

Macrophages play an important role in attempt to eliminate mycobacteria, via production of cytokines, including interleukin-1, and interleukin-12. Bacillus Calmitte Guerin (BCG) vaccination, known to induce interleukin-1β in tuberculosis, was originally aimed at tuberculosis control, but it showed efficacy against leprosy. Our aim was to estimate serum levels of interleukin-1β and interleukin-12, in leprosy, and to assess the impact of previous BCG vaccination on their levels. Serum interleukin-1β and interleukin-12 p70 were estimated in 43 leprotic patients and 43 controls by enzyme-linked immunosorbent assay. Patients were grouped according to presence or absence of reactions, as well as bacillary load. Serum interleukin-1β was significantly higher in patients as compared to controls (p = 0.047), and was significantly different in patients' groups (p = 0.036); with significantly higher level in multibacillary patients, both non reactional and with erythema nodosum leprosum, compared with paucibacillary/non reactional patients (p = 0.012 and 0.049 respectively). A statistically significant higher interleukin-1β was found in BCG vaccinated paucibacillary patients as compared to unvaccinated patients (p = 0.031). Significantly elevated interleukin-12 was present in patients as compared to controls (p < 0.001), with no statistically significant difference comparing patients' groups. BCG vaccination showed stimulatory effect on monocytes only in the immunocompetent paucibacillary leprosy patients, as evidenced by higher Interleukin-1β in this group. Interleukin-1β was shown to have a pro-inflammatory role in multibacillary patients with or without erythema nodosum leprosum. Targeting interleukin-1β may be promising to control episodic refractory erythema nodosum leprosum. Interleukin-12 may be a general marker of active Mycobacterium leprae infection.

An immunological marker of tolerance to infection in wild rodents

Hosts are likely to respond to parasitic infections by a combination of resistance (expulsion of pathogens) and tolerance (active mitigation of pathology). Of these strategies, the basis of tolerance in animal hosts is relatively poorly understood, with especially little known about how tolerance is manifested in natural populations. We monitored a natural population of field voles using longitudinal and cross-sectional sampling modes and taking measurements on body condition, infection, immune gene expression, and survival. Using analyses stratified by life history stage, we demonstrate a pattern of tolerance to macroparasites in mature compared to immature males. In comparison to immature males, mature males resisted infection less and instead increased investment in body condition in response to accumulating burdens, but at the expense of reduced reproductive effort. We identified expression of the transcription factor Gata3 (a mediator of Th2 immunity) as an immunological biomarker of this tolerance response. Time series data for individual animals suggested that macroparasite infections gave rise to increased expression of Gata3, which gave rise to improved body condition and enhanced survival as hosts aged. These findings provide a clear and unexpected insight into tolerance responses (and their life history sequelae) in a natural vertebrate population. The demonstration that such responses (potentially promoting parasite transmission) can move from resistance to tolerance through the course of an individual's lifetime emphasises the need to incorporate them into our understanding of the dynamics and risk of infection in the natural environment. Moreover, the identification of Gata3 as a marker of tolerance to macroparasites raises important new questions regarding the role of Th2 immunity and the mechanistic nature of the tolerance response itself. A more manipulative, experimental approach is likely to be valuable in elaborating this further.

Mycobacterial phylogenomics: an enhanced method for gene turnover analysis reveals uneven levels of gene gain and loss among species and gene families

Species of the genus Mycobacterium differ in several features, from geographic ranges, and degree of pathogenicity, to ecological and host preferences. The recent availability of several fully sequenced genomes for a number of these species enabled the comparative study of the genetic determinants of this wide lifestyle diversity. Here, we applied two complementary phylogenetic-based approaches using information from 19 Mycobacterium genomes to obtain a more comprehensive view of the evolution of this genus. First, we inferred the phylogenetic relationships using two new approaches, one based on a Mycobacterium-specific amino acid substitution matrix and the other on a gene content dissimilarity matrix. Then, we utilized our recently developed gain-and-death stochastic models to study gene turnover dynamics in this genus in a maximum-likelihood framework. We uncovered a scenario that differs markedly from traditional 16S rRNA data and improves upon recent phylogenomic approaches. We also found that the rates of gene gain and death are high and unevenly distributed both across species and across gene families, further supporting the utility of the new models of rate heterogeneity applied in a phylogenetic context. Finally, the functional annotation of the most expanded or contracted gene families revealed that the transposable elements and the fatty acid metabolism-related gene families are the most important drivers of gene content evolution in Mycobacterium.

Mechanobiological dysregulation of the epidermis and dermis in skin disorders and in degeneration

During growth and development, the skin expands to cover the growing skeleton and soft tissues by constantly responding to the intrinsic forces of underlying skeletal growth as well as to the extrinsic mechanical forces from body movements and external supports. Mechanical forces can be perceived by two types of skin receptors: (1) cellular mechanoreceptors/mechanosensors, such as the cytoskeleton, cell adhesion molecules and mechanosensitive (MS) ion channels, and (2) sensory nerve fibres that produce the somatic sensation of mechanical force. Skin disorders in which there is an abnormality of collagen [e.g. Ehlers–Danlos syndrome (EDS)] or elastic (e.g. cutis laxa) fibres or a malfunction of cutaneous nerve fibres (e.g. neurofibroma, leprosy and diabetes mellitus) are also characterized to some extent by deficiencies in mechanobiological processes. Recent studies have shown that mechanotransduction is crucial for skin development, especially hemidesmosome maturation, which implies that the pathogenesis of skin disorders such as bullous pemphigoid is related to skin mechanobiology. Similarly, autoimmune diseases, including scleroderma and mixed connective tissue disease, and pathological scarring in the form of keloids and hypertrophic scars would seem to be clearly associated with the mechanobiological dysfunction of the skin. Finally, skin ageing can also be considered as a degenerative process associated with mechanobiological dysfunction. Clinically, a therapeutic strategy involving mechanoreceptors or MS nociceptor inhibition or acceleration together with a reduction or augmentation in the relevant mechanical forces is likely to be successful. The development of novel approaches such as these will allow the treatment of a broad range of cutaneous diseases.

Essential role of hormone-sensitive lipase (HSL) in the maintenance of lipid storage in Mycobacterium leprae-infected macrophages

Mycobacterium leprae (M. leprae), the causative agent of leprosy, parasitizes within the foamy or enlarged phagosome of macrophages where rich lipids accumulate. Although the mechanisms for lipid accumulation in the phagosome have been clarified, it is still unclear how such large amounts of lipids escape degradation. To further explore underlying mechanisms involved in lipid catabolism in M. leprae-infected host cells, we examined the expression of hormone-sensitive lipase (HSL), a key enzyme in fatty acid mobilization and lipolysis, in human macrophage THP-1 cells. We found that infection by live M. leprae significantly suppressed HSL expression levels. This suppression was not observed with dead M. leprae or latex beads. Macrophage activation by peptidoglycan (PGN), the ligand for toll-like receptor 2 (TLR2), increased HSL expression; however, live M. leprae suppressed this increase. HSL expression was abolished in the slit-skin smear specimens from patients with lepromatous and borderline leprosy. In addition, the recovery of HSL expression was observed in patients who experienced a lepra reaction, which is a cell-mediated, delayed-type hypersensitivity immune response, or in patients who were successfully treated with multi-drug therapy. These results suggest that M. leprae suppresses lipid degradation through inhibition of HSL expression, and that the monitoring of HSL mRNA levels in slit-skin smear specimens may be a useful indicator of patient prognosis.

Alzheimer's Disease: APP, Gamma Secretase, APOE, CLU, CR1, PICALM, ABCA7, BIN1, CD2AP, CD33, EPHA1, and MS4A2, and Their Relationships with Herpes Simplex, C. Pneumoniae, Other Suspect Pathogens, and the Immune System

Alzheimer's disease susceptibility genes, APP and gamma-secretase, are involved in the herpes simplex life cycle, and that of other suspect pathogens (C. pneumoniae, H. pylori, C. neoformans, B. burgdorferri, P. gingivalis) or immune defence. Such pathogens promote beta-amyloid deposition and tau phosphorylation and may thus be causative agents, whose effects are conditioned by genes. The antimicrobial effects of beta-amyloid, the localisation of APP/gamma-secretase in immunocompetent dendritic cells, and gamma secretase cleavage of numerous pathogen receptors suggest that this network is concerned with pathogen disposal, effects which may be abrogated by the presence of beta-amyloid autoantibodies in the elderly. These autoantibodies, as well as those to nerve growth factor and tau, also observed in Alzheimer's disease, may well be antibodies to pathogens, due to homology between human autoantigens and pathogen proteins. NGF or tau antibodies promote beta-amyloid deposition, neurofibrillary tangles, or cholinergic neuronal loss, and, with other autoantibodies, such as anti-ATPase, are potential agents of destruction, whose formation is dictated by sequence homology between pathogen and human proteins, and thus by pathogen strain and human genes. Pathogen elimination in the ageing population and removal of culpable autoantibodies might reduce the incidence and offer hope for a cure in this affliction.

Evaluation of cellular phenotypes implicated in immunopathogenesis and monitoring immune reconstitution inflammatory syndrome in HIV/leprosy cases

BACKGROUND

It is now evident that HAART-associated immunological improvement often leads to a variety of new clinical manifestations, collectively termed immune reconstitution inflammatory syndrome, or IRIS. This phenomenon has already been described in cases of HIV coinfection with Mycobacterium leprae, most of them belonging to the tuberculoid spectrum of leprosy disease, as observed in leprosy reversal reaction (RR). However, the events related to the pathogenesis of this association need to be clarified. This study investigated the immunological profile of HIV/leprosy patients, with special attention to the cellular activation status, to better understand the mechanisms related to IRIS/RR immunopathogenesis, identifying any potential biomarkers for IRIS/RR intercurrence.

METHODS/PRINCIPAL FINDINGS

Eighty-five individuals were assessed in this study: HIV/leprosy and HIV-monoinfected patients, grouped according to HIV-viral load levels, leprosy patients without HIV coinfection, and healthy controls. Phenotypes were evaluated by flow cytometry for T cell subsets and immune differentiation/activation markers. As expected, absolute counts of the CD4+ and CD8+ T cells from the HIV-infected individuals changed in relation to those of the leprosy patients and controls. However, there were no significant differences among the groups, whether in the expression of cellular differentiation phenotypes or cellular activation, as reflected by the expression of CD38 and HLA-DR. Six HIV/leprosy patients identified as IRIS/RR were analyzed during IRIS/RR episodes and after prednisone treatment. These patients presented high cellular activation levels regarding the expression of CD38 in CD8+ cells T during IRIS/RR (median: 77,15%), dropping significantly (p<0,05) during post-IRIS/RR moments (median: 29,7%). Furthermore, an increase of cellular activation seems to occur prior to IRIS/RR.

CONCLUSION/SIGNIFICANCE

These data suggest CD38 expression in CD8+ T cells interesting tool identifying HIV/leprosy individuals at risk for IRIS/RR. So, a comparative investigation to leprosy patients at RR should be conducted.

Leprosy in the Philippines: a review

Leprosy is a skin disease that accounts for serious deformities and disabilities, leading to stigmatization and psychosocial suffering. It is included in "The Neglected Tropical Diseases". Not surprisingly, its management is increasingly reported as a function of Dermatology Departments, with a strong community-orientated bias. Prompt and accurate diagnosis of leprosy is crucial in the control of leprosy. Its management requires a multidisciplinary team of skilled physicians, laboratory staff, and nurses. All members of the health sectors should remain vigilant to combat this battle against leprosy.

Hepatitis C virus infection in a Japanese leprosy sanatorium for the past 67 years

Oku-Komyo-En is one of the national leprosy sanatoria, located on a small island in Setouchi city, Okayama prefecture of Japan since 1938. Since autopsies were carried out routinely on almost all patients who had died in the sanatorium up to 1980, approximately 1,000 formalin-fixed autopsy tissue samples were available for analysis. When these samples were reviewed, the pathological data indicated a sharp rise in the death rate caused by cirrhosis of the liver and hepatocellular carcinoma (HCC) since 1960 and 1970, respectively. Hepatitis C virus (HCV) infection is a common cause of HCC in Japan. The presence of HCV RNA was demonstrated in paraffin sections prepared from the autopsied liver tissue fixed in formalin for a prolonged period of time, by employing nested RT-PCR using type-specific primers. The data showed that HCV RNA was detectable in samples of the liver archived as early as 1940, representing the liver tissues kept in formalin for up to 67 years. HCV genotypes 1b and 2a were found by RT-PCR at 85.7% and 14.3%, respectively, in patients with leprosy.

Growth, cell division and sporulation in mycobacteria

Bacteria have the ability to adapt to different growth conditions and to survive in various environments. They have also the capacity to enter into dormant states and some bacteria form spores when exposed to stresses such as starvation and oxygen deprivation. Sporulation has been demonstrated in a number of different bacteria but Mycobacterium spp. have been considered to be non-sporulating bacteria. We recently provided evidence that Mycobacterium marinum and likely also Mycobacterium bovis bacillus Calmette–Guérin can form spores. Mycobacterial spores were detected in old cultures and our findings suggest that sporulation might be an adaptation of lifestyle for mycobacteria under stress. Here we will discuss our current understanding of growth, cell division, and sporulation in mycobacteria.

Role of ulnar nerve sonography in leprosy neuropathy with electrophysiologic correlation

OBJECTIVE

The purpose of this study was to evaluate the diagnostic usefulness of ulnar nerve sonography in leprosy neuropathy with electrophysiologic correlation.

METHODS

Twenty-one consecutive patients with leprosy (12 men and 9 women; mean age +/- SD, 47.7 +/- 17.2 years) and 20 control participants (14 men and 6 women; mean age, 46.5 +/- 16.2 years) were evaluated with sonography. Leprosy diagnosis was established on the basis of clinical, bacteriologic, and histopathologic criteria. The reference standard for ulnar neuropathy in this study was clinical symptoms in patients with proven leprosy. The sonographic cross-sectional areas (CSAs) of the ulnar nerve in 3 different regions were obtained. Statistical analyses included Student t tests and receiver operating characteristic curve analysis.

RESULTS

The CSAs of the ulnar nerve were significantly larger in the leprosy group than the control group for all regions (P < .01). Sonographic abnormalities in leprosy nerves included focal thickening (90.5%), hypoechoic areas (81%), loss of the fascicular pattern (33.3%), and focal hyperechoic areas (4.7%). Receiver operating characteristic curve analysis showed that a maximum CSA cutoff value of 9.8 mm(2) was the best discriminator (sensitivity, 0.91; specificity, 0.90). Three patients with normal electrophysiologic findings had abnormal sonographic findings. Two patients had normal sonographic findings, of which 1 had abnormal electrophysiologic findings, and the other refused electrophysiologic testing.

CONCLUSIONS

Sonography and electrophysiology were complementary for identifying ulnar nerve neuropathy in patients with leprosy, with clinical symptoms as the reference standard. This reinforces the role of sonography in the investigation of leprosy ulnar neuropathy.

Influence of TNF and IL10 gene polymorphisms in the immunopathogenesis of leprosy in the south of Brazil

OBJECTIVE

To determine whether cytokine polymorphisms are associated with leprosy and/or their subtypes in a Brazilian population.

METHODS

Genotyping using polymerase chain reaction with sequence-specific primers (PCR-SSP) was performed for: TNF(-308/-238), IL2(-330/+166), IL6(-174), IFNG(+874), TGFB1(+869/+915), and IL10(-592/-819/-1082) in 240 healthy controls and 167 patients with leprosy.

RESULTS

For TNF(-308), a higher frequency of GG genotype (85.5% vs. 74.1% in healthy controls, p = 0.009), along with a decreased frequency of GA/AA genotypes was observed among leprosy patients as compared to the control group (14.5% vs. 25.9%, p = 0.009). The GG genotype was particularly higher in patients with tuberculoid (TT) and borderline (BB) leprosy (90.5% and 89.8%, respectively). Analysis of IL10 genotypes revealed a lower frequency of GCC/GCC haplotype in lepromatous leprosy (LL) patients (6.2%) in comparison to controls (15.4%).

CONCLUSION

It is suggested that the G-->A substitution at position -308 in the TNF promoter region plays an important role in leprosy patients.

The imperatives of leprosy treatment in the pre- and post-global leprosy elimination era: appraisal of changing the scenario to current status

Leprosy was supposed to be eliminated by WHO at the global level by the end of the year 2000; however, it still remains a significant public health problem at a national level in six countries, where India alone accounts for 64% of prevalence and 78% of new case detection, worldwide. The global registered prevalence of leprosy at the beginning of 2006 was 219,826 cases. The number of new cases reported during 2005 was 296,499. The clinical diagnosis of leprosy continues to be based on patients having one or more of the three cardinal signs: hypopigmented or reddish anesthetic skin lesion(s); involvement of the peripheral nerves, as demonstrated by definite thickening with loss of sensation in the area of distribution; and a positive skin smear for acid-fast bacilli. Multidrug therapy (MDT) for leprosy has proved to be highly effective, with low relapse rates resulting in a dramatic decrease in the global prevalence rate to less than one case per 10 000 by the end of the year 2000. It was thought to be worthwhile to review the progress made in the treatment of this neglected tropical disease from the time diaminodiphenylsulfone (dapsone) monotherapy was introduced in its management, to the rapidly changing situation following the advent of WHO-recommended MDT and subsequently to short-course newer drug regimens with the prime objective to eliminate/eradicate leprosy from the world. Several permutations and combinations of drugs were utilized, the outline of which are succinctly depicted in the following account. Furthermore, a synopsis of the role of immunoprophylaxis therapy has briefly been reviewed to arrive at the possible current status. It is expected that this article is not only essential at this point in time but is also likely to make clear the intricacies surrounding its management.

Whipple's disease: new aspects of pathogenesis and treatment

100 years after its first description by George H Whipple, the diagnosis and treatment of Whipple's disease is still a subject of controversy. Whipple's disease is a chronic multisystemic disease. The infection is very rare, although the causative bacterium, Tropheryma whipplei, is ubiquitously present in the environment. We review the epidemiology of Whipple's disease and the recent progress made in the understanding of its pathogenesis and the biology of its agent. The clinical features of Whipple's disease are non-specific and sensitive diagnostic methods such as PCR with sequencing of the amplification products and immunohistochemistry to detect T whipplei are still not widely distributed. The best course of treatment is not completely defined, especially in relapsing disease, neurological manifestations, and in cases of immunoreconstitution after initiation of antibiotic treatment. Patients without the classic symptoms of gastrointestinal disease might be misdiagnosed or insufficiently treated, resulting in a potentially fatal outcome or irreversible neurological damage. Thus, we suggest procedures for the improvement of diagnosis and an optimum therapeutic strategy.

Avaliação da neurólise ulnar na neuropatia hansênica

Os autores avaliam os resultados de 35 procedimentos de descompressão cirúrgica do nervo ulnar realizados em 28 pacientes hansênicos. Os parâmetros utilizados incluíram a escala analógica visual, a escala comportamental, a avaliação da força muscular, a estesiometria e a avaliação do efeito do procedimento no que tange à diminuição da corticoterapia no pós-operatório. Observou-se resolução imediata da dor após a realização da cirurgia, melhora da força muscular em metade dos pacientes, melhora da sensibilidade em metade dos pacientes. A diminuição da dosagem da prednisona após a cirurgia foi constante e significativa após a operação.

Hansen disease in the United States in the 21st century: a review of the literature

In this article we review the recent literature on Hansen disease (leprosy). We searched published literature through PubMed (National Library of Medicine) and extracted data through direct review of the literature and pathologic slides. Hansen disease continues to occur in the United States, including among the native-born population. Inclusion of the disease in the differential diagnosis is key to confirmation. Current epidemiology, classification systems, prevention measures, and therapy are reviewed.