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Voltan G, Marques-Júnior W, Santana JM, Lincoln Silva CM, Leite MN, De Paula NA, Bernardes Filho F, Barreto JG, Da Silva MB, Conde G, Salgado CG, Frade MAC. Silent peripheral neuropathy determined by high-resolution ultrasound among contacts of patients with Hansen's disease. Front Med (Lausanne) 2023; 9:1059448. [PMID: 36733931 PMCID: PMC9887334 DOI: 10.3389/fmed.2022.1059448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/21/2022] [Indexed: 01/18/2023] Open
Abstract
Introduction Hansen's disease (HD) primarily infects peripheral nerves, with patients without HD being free of peripheral nerve damage. Household contacts (HHCs) of patients with HD are at a 5-10 times higher risk of HD than the general population. Neural thickening is one of the three cardinal signs that define a case of HD according to WHO guidelines, exclusively considering palpation examination that is subjective and may not detect the condition in the earliest cases even when performed by well-trained professionals. High-resolution ultrasound (HRUS) can evaluate most peripheral nerves, a validated technique with good reproducibility allowing detailed and accurate examination. Objective This study aimed to use the peripheral nerve HRUS test according to the HD protocol as a diagnostic method for neuropathy comparing HHCs with healthy volunteers (HVs) and patients with HD. Methods In municipalities from 14 different areas of Brazil we selected at random 83 HHC of MB-patients to be submitted to peripheral nerve ultrasound and compared to 49 HVs and 176 HD-patients. Results Household contacts assessed by HRUS showed higher median and mean absolute peripheral nerve cross-sectional area (CSA) values and greater asymmetries (ΔCSA) compared to HVs at the same points. Median and mean absolute peripheral nerve CSA values were higher in patients with HD compared to HCCs at almost all points, while ΔCSA values were equal at all points. Mean ± SD focality (ΔTpT) values for HHCs and patients with HD, respectively, were 2.7 ± 2.2/2.6 ± 2.2 for the median nerve, 2.9 ± 2.7/3.3 ± 2.9 for the common fibular nerve (p > 0.05), and 1.3 ± 1.3/2.2 ± 3.9 for the ulnar nerve (p < 0.0001). Discussion Considering HRUS findings for HHCs, asymmetric multiple mononeuropathy signs (thickening or asymmetry) in at least 20% of the nerves evaluated could already indicates evidence of HD neuropathy. Thus, if more nerve points are assessed in HHCs (14 instead of 10), the contacts become more like patients with HD according to nerve thickening determined by HRUS, which should be a cutting-edge tool for an early diagnosis of leprosy cases.
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Affiliation(s)
- Glauber Voltan
- Healing and Hansen's Disease Laboratory, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- National Referral Center for Sanitary Dermatology and Hansen's Disease, Dermatology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Wilson Marques-Júnior
- Division of Neuromuscular Disorders, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Jaci Maria Santana
- National Referral Center for Sanitary Dermatology and Hansen's Disease, Dermatology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Claudia Maria Lincoln Silva
- Healing and Hansen's Disease Laboratory, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- National Referral Center for Sanitary Dermatology and Hansen's Disease, Dermatology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Marcel Nani Leite
- Healing and Hansen's Disease Laboratory, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- National Referral Center for Sanitary Dermatology and Hansen's Disease, Dermatology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Natália Aparecida De Paula
- Healing and Hansen's Disease Laboratory, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- National Referral Center for Sanitary Dermatology and Hansen's Disease, Dermatology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Fred Bernardes Filho
- National Referral Center for Sanitary Dermatology and Hansen's Disease, Dermatology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Josafá Gonçalves Barreto
- Dermato-Immunology Laboratory, Institute of Biological Sciences, Federal University of Pará, Marituba, Brazil
| | - Moises Batista Da Silva
- Dermato-Immunology Laboratory, Institute of Biological Sciences, Federal University of Pará, Marituba, Brazil
| | - Guilherme Conde
- Decision Support Laboratory, Federal University of Pará West, Santarem, Brazil
| | - Claudio Guedes Salgado
- Dermato-Immunology Laboratory, Institute of Biological Sciences, Federal University of Pará, Marituba, Brazil
| | - Marco Andrey Cipriani Frade
- Healing and Hansen's Disease Laboratory, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- National Referral Center for Sanitary Dermatology and Hansen's Disease, Dermatology Division, Internal Medicine Department, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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Verma S, Garg RK, Rizvi I, Malhotra HS, Kumar N, Jain A, Suvirya S, Parihar A, Verma R, Sharma PK, Pandey S, Uniyal R, Prakash S. Central nervous system, spinal root ganglion and brachial plexus involvement in leprosy: A prospective study. J Cent Nerv Syst Dis 2022; 14:11795735221135477. [PMID: 36277272 PMCID: PMC9583215 DOI: 10.1177/11795735221135477] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 06/13/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022] Open
Abstract
Background Leprosy is primarily a disease of peripheral nerves. Some isolated case
reports and case series have communicated imaging changes in the central
nervous system (CNS) and brachial plexus in patients with leprosy. Objectives To study the neuroimaging abnormalities in patients with lepra
bacilli-positive neuropathy in the context of CNS, spinal root ganglion, and
brachial plexus. Design Prospective observational study Methods We screened newly-diagnosed patients with multibacillary leprosy presenting
with neuropathy. Patients with bacilli-positive sural nerve biopsies were
included in the study and subjected to magnetic resonance imaging (MRI) of
the brain and spinal cord. Results A total of 54 patients with bacteriologically confirmed multibacillary
leprosy were screened; Mycobacterium leprae was
demonstrated in the sural nerve biopsies of 29 patients. Five patients
(5/29; 17.24%) had MRI abnormalities in CNS, spinal root ganglion, and/or
brachial plexus. Three patients had MRI changes suggestive of either
myelitis or ganglionitis. One patient had T2/FLAIR hyperintensity in the
middle cerebellar peduncle while 1 had T2/FLAIR hyperintensity in the
brachial plexus. Conclusion CNS, spinal root ganglion, and brachial plexus are involved in patients with
leprous neuropathy. Immunological reaction against M leprae
antigen might be a plausible pathogenetic mechanism for brachial plexus and
CNS imaging abnormalities.
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Affiliation(s)
- Sumit Verma
- Department of Neurology, King George Medical
University, Uttar Pradesh, Lucknow, India
| | - Ravindra Kumar Garg
- Department of Neurology, King George Medical
University, Uttar Pradesh, Lucknow, India,Ravindra Kumar Garg, Department of
Neurology, King George Medical University, B-22, Sector-E, Aliganj, Uttar
Pradesh, Lucknow 226003, India.
| | - Imran Rizvi
- Department of Neurology, King George Medical
University, Uttar Pradesh, Lucknow, India
| | | | - Neeraj Kumar
- Department of Neurology, King George Medical
University, Uttar Pradesh, Lucknow, India
| | - Amita Jain
- Department of Microbiology, King George Medical
University, Uttar Pradesh, Lucknow, India
| | - Swastika Suvirya
- Department of Dermatology, King George Medical
University, Uttar Pradesh, Lucknow, India
| | - Anit Parihar
- Department of Radiodiagnosis, King George Medical
University, Uttar Pradesh, Lucknow, India
| | - Rajesh Verma
- Department of Neurology, King George Medical
University, Uttar Pradesh, Lucknow, India
| | - Praveen Kumar Sharma
- Department of Neurology, King George Medical
University, Uttar Pradesh, Lucknow, India
| | - Shweta Pandey
- Department of Neurology, King George Medical
University, Uttar Pradesh, Lucknow, India
| | - Ravi Uniyal
- Department of Neurology, King George Medical
University, Uttar Pradesh, Lucknow, India
| | - Shantanu Prakash
- Department of Microbiology, King George Medical
University, Uttar Pradesh, Lucknow, India
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Luciano CA, Caraballo-Cartagena S. Treatment and Management of Infectious, Granulomatous, and Toxic Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tomaselli PJ, Dos Santos DF, Dos Santos ACJ, Antunes DE, Marques VD, Foss NT, Moreira CL, Nogueira PTB, Nascimento OJM, Neder L, Barreira AA, Frade MA, Goulart IMB, Marques W. Primary neural leprosy: clinical, neurophysiological and pathological presentation and progression. Brain 2021; 145:1499-1506. [PMID: 34664630 DOI: 10.1093/brain/awab396] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/25/2021] [Accepted: 09/26/2021] [Indexed: 11/13/2022] Open
Abstract
Disability in leprosy is a direct consequence of damage to the peripheral nervous system which is usually worse in patients with no skin manifestations, an underdiagnosed subtype of leprosy known as primary neural leprosy. We evaluated clinical, neurophysiological and laboratory findings of 164 patients with definite and probable primary neural leprosy diagnoses. To better understand the disease progression and to improve primary neural leprosy clinical recognition we compared the characteristics of patients with short (≤ 12 months) and long (> 12 months) disease duration. Positive and negative symptoms mediated by small-fibre were frequent at presentation (∼95%), and symptoms tend to manifest first in the upper limbs (∼68%). There is a consistent phenotypic variability between the aforementioned groups. Deep sensory modalities were spared in patients evaluated within the first 12 months of the disease, and were only affected in patients with longer disease duration (∼12%). Deep tendon reflexes abnormalities were most frequent in patients with longer disease duration (p < 0,001), as well as motor deficits (p = 0,002). Damage to large fibres (sensory and motor) is a latter event in primary neural leprosy. Grade-2 disability and nerve thickening was also more frequent in cases with long disease duration (p < 0,001). Primary neural leprosy progress over time and there is a marked difference in clinical phenotype between patients with short and long disease duration. Patients assessed within the first 12 months of symptom onset had a non-length-dependent predominant small-fibre sensory neuropathy, whilst patients with chronic disease presented an asymmetrical all diameter sensory-motor neuropathy and patchily decreased/absent deep tendon reflexes.
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Affiliation(s)
- Pedro J Tomaselli
- Division of Neuromuscular Disorders, Department of Neurology, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, 14048-900, Brazil.,International Centre for Genomic Medicine in Neuromuscular Diseases, ICGNMD
| | - Diogo F Dos Santos
- National Reference Centre for Sanitary Dermatology and Leprosy, Clinical Hospital, Federal University of Uberlândia (CREDESH/HC/UFU), Uberlândia, 38400-902, Brazil
| | - André C J Dos Santos
- Division of Neuromuscular Disorders, Department of Neurology, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, 14048-900, Brazil
| | - Douglas E Antunes
- National Reference Centre for Sanitary Dermatology and Leprosy, Clinical Hospital, Federal University of Uberlândia (CREDESH/HC/UFU), Uberlândia, 38400-902, Brazil
| | - Vanessa D Marques
- Division of Neuromuscular Disorders, Department of Neurology, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, 14048-900, Brazil
| | - Norma T Foss
- Division of Dermatology, Department of Internal Medicine, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, 14048-900, Brazil
| | - Carolina L Moreira
- Division of Neuromuscular Disorders, Department of Neurology, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, 14048-900, Brazil
| | - Patrícia T B Nogueira
- Division of Neuromuscular Disorders, Department of Neurology, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, 14048-900, Brazil
| | - Osvaldo J M Nascimento
- Antonio Pedro University Hospital (HUAP), Fluminense Federal University, Niterói, 24033-900, Brazil
| | - Luciano Neder
- Department of Pathology, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, 14048-900, Brazil.,Molecular Oncology Research Center (CPOM), Barretos Cancer Hospital, Barretos, 14784-400, Brazil
| | - Amilton A Barreira
- Division of Neuromuscular Disorders, Department of Neurology, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, 14048-900, Brazil
| | - Marco A Frade
- Division of Dermatology, Department of Internal Medicine, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, 14048-900, Brazil
| | - Isabela M B Goulart
- National Reference Centre for Sanitary Dermatology and Leprosy, Clinical Hospital, Federal University of Uberlândia (CREDESH/HC/UFU), Uberlândia, 38400-902, Brazil
| | - Wilson Marques
- Division of Neuromuscular Disorders, Department of Neurology, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, 14048-900, Brazil.,International Centre for Genomic Medicine in Neuromuscular Diseases, ICGNMD.,National Institute for Science and Technology for Translational Medicine, INCT, Brazil
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Santos LOD, Fernandes TRMDO, Barbosa TRDS, Batista JADS, Souza CDFD. Pure neural leprosy or amyloid neuropathy? Systematic review and clinical case report. ACTA ACUST UNITED AC 2021; 67:140-149. [PMID: 34161469 DOI: 10.1590/1806-9282.67.01.20200422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 10/22/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review the literature and to report a clinical case with initial suspicion of pure neural leprosy and final diagnosis of amyloid neuropathy. METHODS The study was conducted in two stages. In stage one, a systematic literature review was carried out, with searches performed in the PubMed, Medline, and Lilacs databases, as well as in the leprosy sectoral library of the Virtual Health Library, using the following descriptors: neuritic leprosy, pure neural leprosy, primary neural leprosy, pure neuritic leprosy, amyloid polyneuropathy, amyloid neuropathies, and amyloid polyneuropathy. The search was carried out on May 28, 2020. Clinical trials, cohort studies, cross-sectional studies, clinical cases, and case studies published in Portuguese, English or Spanish between 2010 and 2020 were included. Stage two reports a case with initial suspicion of pure neural leprosy. Laboratory tests, electroneuromyography, ultrasound, and biopsy of the sural nerve were requested. RESULTS Twenty-three scientific texts were included. No publications were found that contained both topics together. The challenging diagnosis of pure neural leprosy and the possibility of using auxiliary resources in diagnosis were the most emphasized themes in the studies. In the clinical case, the patient's electroneuromyography showed sensitive and motor polyneuropathy of the lower limbs, which was predominantly sensory and axonal, symmetrical, of moderate intensity, and the mixed type (axonal-demyelinating). Ultrasonography of the sural nerve revealed changes in the contour of the deep fibular nerves; biopsy of the sural nerve showed an accumulation of amorphous eosinophilic material in the nerve path, and Congo red stain showed apple-green birefringence of the deposit under polarized light. The final diagnosis was amyloid neuropathy. CONCLUSIONS The final clinical diagnosis was amyloid neuropathy. The diagnosis of pure neural leprosy in endemic areas in Brasil is still a challenge for the health system.
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Khadilkar SV, Patil SB, Shetty VP. Neuropathies of leprosy. J Neurol Sci 2020; 420:117288. [PMID: 33360424 DOI: 10.1016/j.jns.2020.117288] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 09/02/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
Neuropathies form an integral part of the symptomatology of leprosy. Neuropathies of leprosy take various forms and shapes. At one end is the cutaneous nerve involvement adjacent to the anaesthetic skin patch and the other is of symmetrical pansensory neuropathy and the devastating sensory ataxia of leprous ganglionits. Lepra reactions add to the spectrum. Hosts immunological status largely decides the clinical manifestations seen in nerves and skin. A wide array of diagnostic techniques like ultrasonography, magnetic resonance neurography, serological markers, molecular tests, skin biopsy and in selected cases, the nerve biopsy with special stains and electron microscopy are obtainable to help the clinical diagnosis. The unsuspecting clinician, lack of community awareness and limited availability of diagnostic tests are important adverse factors in the total outcome. Multi drug therapy is efficacious and corticosteroids reduce the impact of nerve damage in leprosy. The efficacy, dose and duration of corticosteroid therapy are presently inexact and other immune suppressants like azathioprine are being evaluated. Chronic disabilities and residual deficits require attention of multiple specialties. In the coming time, focus on prevention could lead to favourable results. This review will discuss the classification systems, common and uncommon clinical features, diagnostic armamentarium and therapeutic and preventive aspects of neuropathies of leprosy.
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Shukla B, Verma R, Kumar V, Kumar M, Malhotra KP, Garg RK, Malhotra HS, Sharma PK, Kumar N, Uniyal R, Pandey S, Rizvi I. Pathological, ultrasonographic, and electrophysiological characterization of clinically diagnosed cases of pure neuritic leprosy. J Peripher Nerv Syst 2020; 25:191-203. [PMID: 32250546 DOI: 10.1111/jns.12372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/18/2020] [Accepted: 03/30/2020] [Indexed: 11/29/2022]
Abstract
A subset of neuritic form of leprosy, called pure neuritic leprosy (PNL), seen in a minority of leprosy patients, is characterized by peripheral neuropathy without skin lesions and an absence of acid-fast bacilli on skin smears. Patients with PNL are often started on drug therapy without confirmation of diagnosis. We, therefore, did a prospective study of clinically diagnosed PNL patients with correlation of ultrasonographic and biopsy findings. A total of 100 consecutive patients with PNL, diagnosed according to the consensus case definition, were included in the study. All patients underwent nerve conduction study, peripheral nerve ultrasonography, and sural nerve biopsy. Multiple mononeuropathies were present in 75% of cases, mononeuropathy in 18%, and polyneuropathy in the remaining 7%. Compared to clinical examination, ultrasonographic assessment of the peripheral nerves was not only better at the detection of thickening but also helped in characterization of their fascicular architecture, echogenicity, and vascularity. A total of 32 cases were confirmed on nerve biopsy, out of which 75% had demonstrable lepra bacilli. Cranial nerve involvement, presence of trophic ulcers, and bilateral thickening of the great auricular nerve were significantly associated with the positivity of lepra bacilli. A significant improvement in the disability score happened after multidrug therapy. A comprehensive electrophysiologic, ultrasonographic, and histological evaluation may be helpful in establishing a diagnosis of PNL with greater confidence, while ruling out other non-leprosy diagnoses.
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Affiliation(s)
| | | | - Vijay Kumar
- Department of Plastic Surgery, KGMU, Lucknow, India
| | - Manoj Kumar
- Department of Radiology, KGMU, Lucknow, India
| | | | | | | | | | | | - Ravi Uniyal
- Department of Neurology, KGMU, Lucknow, India
| | | | - Imran Rizvi
- Department of Neurology, KGMU, Lucknow, India
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