This summarizes a variety of impairments found in healed leprosy patients. Visible impairments and some secondary complications are presented from the viewpoint of dermatology. Neural damage may bring neuralgia, paraesthesia and progressive neuropathy after healing of leprosy itself.
1) No more deformities which are the cause of social stigma by early detection and chemotherapy ! 2) Let patients learn how to avoid getting deformed to keep normal ADL & QOL. 3) Fight against the nerve damage and stop the progressive deformities by organizing the team approach. 4) In stead of intense effors of taking care by well organized team work, deformities are resulted inevitablly in some cases. Let their deformities be out of the way of their keeping normal community lives without any prejudice, respecting their human rights and dignity.
The proportion of glomerulonephritis, often a sequence of arteriolitis, among the sequelae of Hansen's disease after the introduction of chemotherapy increased markedly in Japan and nullified that of once prevalent tuberculosis after 1960s. However, most significant aftermath of the disease for numbers of years in the past have been peripheral nerve injuries worldwide for which effective countermeasures are yet to be developed. In this brief autopsy cases study from 1960s to 1990s, we confirmed the presence of cases in which arteriolitis and resulted infarction of peripheral nerves and not M. leprae itself were shown to be the major cause of axonal damages. There were also cases in which the accumulation of the bacilli without vascular changes did not damage the axons. The cases as these could not be solitary but should be rather common in this time of chemotherapy. If so, the methods to reconstruct nerves and blood vessels by promoting those regeneration should be developed to cope with the situation for surgeon, assisted by pathologists.
A 26-year-old Indonesian male living in Japan consulted our hospital with complaint of fever, general malaise and infiltrative erythematous plaques associated with lymph node swelling. Physical examination revealed a sensation disorder in the distal portion of the extremities and hypertrophy of peripheral nerves. Histopathology of the skin lesion showed the multifocal granulomatous inflammation containing many acid-fast baclli associated with infiltration of foam cells and neutrophils. Under the diagnosis of leprosy (LL type) accompanied by erythema nodosum leprosum, the combined chemotherapy (clofazimine, rifampicin, and diphenyl sulfone) was started. For the leprosy reaction, short-term administration of the systemic steroid was added. The general condition was carried out soon, and the sensation disorder has also been gradually improved. The patient came back to Indonesia after 6 months treatment because of the time limit of visa. We traced the patient's condition through personal networks, and knew that the patient could not have continual treatment for the disease, and that he is suffering from disability of hands and feet. In this case, several medical facilities were consulted before the final diagnosis of leprosy. The Japanese medical doctors should also remember this disease when they examine persons with infiltrative skin eruptions and sensation disorders.
We report a case of leprosy. A31-old-filippine female present with 5 month history of an erythematous plaqe on her right neck. Examination showed 4 erythematous plaqes with her. A histological examination of the skin lesion of hir thigh revealed granulomas around nerve and skin appendages which consist of lymphocytes, epidermoid cells and giant cells. Although no acid fast bacilli were not demonstrated by skin biopsy with Ziehl-Neelsen staining, the Mycobacterium leprae-specific DNA was detected by polymerase chain reaction method. A diagnosis ofpaucibacillary leprosy had made. We started treatment with ofloxacin but she return to filippine soon.
A 68 year-old male presented with painful swelling in the extremities and disseminated small brownish nodules over his entire body. A histological examination of the skin nodules showed multiple granuloma and a thickened peripheral nerve bundle surrounded with foamy macrophages and a few lymphocytes. Fite stain revealed numerous acid fast bacilli within the cytoplasm of the foamy cells. A diagnosis of lepromatous leprosy was thus made and multi-drug therapy following the Japanese guideline with DDS, rifampicin and clofazimine was started. The clinical features improved, and the morphological index decreased after undergoing chemotherapy. Although a severe type 1 reaction developed after four months of treatment, he was treated with oral prednisolone at a dose of 40 mg/day.
We report two cases of Hansen's disease. Case 1 was 71-year old Japanese man who developed left ulnar nerve palsy since 7 years ago, multiple erythema on his body since 2-3 years ago, and erythematous nodules on his face since 3 months ago. He had no history of living outside Ibaraki prefecture. The clinical feature, the skin biopsy, laboratory data showed that he had borderline lepromatous leprosy. He was treated with multi-drug therapy which was effective and was stopped 3 years after the bacterial index showed negative. Ten months later, erythema on his body and face appeared and the therapy was restarted. Case 2 was 68-year old Japanese man who developed 5 cm of nummular erythema with slight numbness on his right forearm since 3 months ago. He had lived in Brazil since he was 24 to 64 years old. The skin biopsy showed epithelioid cell granuloma in the dermis involving vessels and nerves. Polymerase chain reaction test showed the M.leprae DNA, and he was diagnosed as indeterminate leprosy. He was treated with dapson and rifampicin and 2 months later, erythema and numbness disappeared.
With the abolition of Leprosy Prevention Act of 1996, that opportunities examining the Hansen's disease patient with a general medical institution increase is expected. Because we experienced Hansen's disease of a staying in Japan foreigner then in such time, we present it. A case is a man of 50 years old, who is a Filipino of 3 years living in Japan. It recognized infiltrating deep erythema in a face and trunk. Furthermore, in dysesthesia, nerve hyperplasia, and BI is positive in skin smear. Histopathology is a typical finding. Than the above, we diagnosed it as Hansen's disease of BL-LL type.
We report a 74-year-old Japanese man who occurred leprosy at the age of 68. He moved to Bolivia at the age of 33 as an immigrant. He complained erythematous plaques on his trunk and extremeties and dysuria. Skin biopsy specimen revealed granulomatous lesions and acid fast staining showed numerous number of positively stained bacilli. He was diagnosed as multibacillary leprosy and MDT containing DDS, RFP, and CLF was started. During the treatment, he developed borderline reaction twice presenting severe pain and marked swelling on his hand and foot. The reaction was successfully treated with daily dose of 50mg prednisolone combined with anti-leprosy drugs. SPFX, MINO, and CAM were not able to be used due to the side effects. One year has been passed after the stop of treatment without relapse.
Out of the cases we experienced in our 11-year service in sanatorium, 6 cases were selected to review the medical care and social environment that each patient was involved. Two cases were the residents in a sanatorium and 4 cases were in the community, including 2 cases having foreign nationality. The review of these cases drew the following conclusions. 1. We must be aware of our responsibility for early diagnosis and treatment of leprosy to prevent tragic disability. 2. The fixed duration of MDT/MB may not be enough for LL cases having high bacterial load before treatment. Enough duration of chemotherapy and follow-up is desired to prevent avoidable disability. 3. Basically, the treatment of leprosy should be carried on in outpatient clinic. The duration of hospitalization, if necessary, should be shortest to enhance patient's motive for treatment. 4. Intermittent administration of RFP must be done under direct observation. 5. For foreign patients not accustomed to the life in Japan or elderly patient living by oneself, various supports from community are greatly helpful to achieve the long course of leprosy treatment. Through these supports, we can expect community enlightening that may promote rehabilitation of the people once suffered from leprosy.
The presence of acid-fast bacilli in the lesion and its positive culture usually provide the diagnosis in cutaneous mycobacteriosis. But in diagnosis of leprosy, characteristic clinico-histopathological findings are so important as the demonstration of the organism, because of the failure to grow Mycobacterium leprae in vitro. It is classified in various forms along a spectrum of infectious and immunological symptoms supported by the pathogen-host relationship. The patient was a Japanese woman 69 years of age. She had been diagnosed as multibacillary leprosy with the positive results of slit-smear tests and the confirmation of the genomic sequence by PCR. Multidrug therapy had been started, but it was discontinued afterwards because an exact diagnosis of leprosy could not be determined by clinical, histological, and immunological assessment. As its diminishing prevalence in Japan, where ordinary physicians cannot have opportunities to see leprosy patients and they are unfamiliar with protean manifestations of the disease, it can be very difficult to make accurate diagnosis in those cases with atypical findings.