Diagnosing multibacillary leprosy: a comparative evaluation of diagnostic accuracy of slit-skin smear, bacterial index of granuloma and WHO operational classification.

BACKGROUND: In view of the relatively poor performance of skin smears WHO adopted a purely clinical operational classification, however the poor specificity of operational classification leads to overdiagnosis and unwarranted overtreatment while the poor sensitivity leads to underdiagnosis of multibacillary (MB) cases with inadequate treatment. Bacilli are more frequently and abundantly demonstrated in tissue sections. AIMS AND METHODS: We compared WHO classification, slit-skin smears (SSS) and demonstration of bacilli in biopsies (bacterial index of granuloma or BIG) with regards to their efficacy in correctly identifying multibacillary cases. The tests were done on 141 patients and were evaluated for their ability to diagnose true MB leprosy using detailed statistical analysis. RESULTS: A total of 76 patients were truly MB with either positive smears, BIG positivity or with a typical histology of BB, BL or LL. Amongst these 76 true-MB patients, WHO operational classification correctly identified multibacillary status in 56 (73.68%), and SSS in 43 (56.58%), while BIG correctly identified 65 (85.53%) true-MB cases. CONCLUSION: BIG was most sensitive and effective of the three methods especially in paucilesional patients. We suggest adding estimation of bacterial index of granuloma in the diagnostic workup of paucilesional patients.

Cutaneous manifestation of diabetes mellitus.

One hundred consecutive diabetes mellitus patients attending the diabetic clinic of the hospital constituted the study group. One hundred age and sex matched non-diabetics were taken as controls. The majority, 63%, belonged to the 41-60 years age group and 98% had non-insulin dependent diabetes. Among the study group, 64% had one or more cutaneous manifestations as compared to 22% in the controls. This was statistically highly significant (p < 0.001). Infections comprised the largest group affecting 35 of the 64 cases. Among the bacterial infections, pyodermas were observed in 11 and erythrasma in one. Fungal infections were seen in 21, dermatophytoses in 11, and candidiasis in 10. Herpes zoster was seen in 2 cases. Pruritus was observed in 10, neurological abnormalities in the form of paresthesias was seen in 6, mal perforans in one, and meralgia paresthetica in one. Diabetic dermopathy was seen in 6 and rubeosis in 4. Six dermatoses strongly associated with DM were seen, namely one each of waxy skin syndrome, granuloma annulare, eruptive xanthoma, scleredema adultorum, and 2 cases of diabetic bulla. Ten patients exhibited other dermotoses less associated with diabetics: xanthelasmo palpebrarum in 5 patients, acrochordi in 4, and pigmented purpuric dermatoses in one. Likewise syndromes of insulin resistance were seen in 4 patients of whom 3 had aconthosis nigricans and one had congenital lipodystrophy. Furthermore, 9 patients had dermatoses known to be associated with an increased incidence of diabetes; vitiligo in 4, acquired perforating dermatoses in 3, and lichen planus in 2. Four patients had dermatoses known to be associated with diabetes: psoriasis in 3 and diffuse alopecia in one. Three had adverse drug reactions to anti-diabetic therapy.

Screening for Chlamydial infection in women attending STD clinic by polymerase chain reaction, ELISA and cell cytology.

Thirty five female patients with endocervicitis attending STD clinic were studied for the presence of Chlamydial infection by Polymerase Chain Reaction (PCR), Enzyme Immunoassay (EIA) and Cell Cytology. PCR was found to be positive in 54.2% of patients, Enzyme-Linked Immunosorbent Assay (ELISA) in 25.7% of patients, but cell cytology revealed the presence of inclusion bodies only in 3% of the cases, thereby showing that polymerase chain reaction is a better method for detection of Chlamydia trachomatis than EIA and cell cytology.

Primary drug resistance to both rifampicin and dapsone in a paucibacillary leprosy patient.

A thirty-one year old male patient was diagnosed and treated for a pure or better primary neuritic case of leprosy with dapsone (100 mg daily for 2 years) and rifampicin (600 mg daily for 6 months). From the very outset, the patient did not show any improvement; on the top of it, he subsequently, developed a cutaneous patch, which on histopathological examination, revealed classical features of BT leprosy. Acid-fast bacilli were absent both in skin slit smear and histologic section. A primary resistance to both dapsone and rifampicin, even in paucibacillary patient, is speculated.

The histopathology of type I (lepra) and type II (ENL) reactions in leprosy.

The histopathological features in type I (lepra) reaction comprised a loose and disorganised granuloma in the upper and mid-dermis, dermal edema and variable cellular contents, namely, epithelioid cells, lymphocytes, giant cells, and macrophages. While ENL reactions, were characterised by predominant involvement of subcutaneous vessels, vasculitis, and polymorphonuclear infiltration in and around the blood vessels.

Erythema nodosum leprosum (ENL) in histoid leprosy.

The morphological features of ENL, occurring in histoid leprosy are described. Its infrequent occurrence has been emphasised. The possible immunopathogenesis of its occurrence in histoid leprosy is briefly outlined.