Effectiveness of the retreatment of patients with multibacillary leprosy and episodes of erythema nodosum leprosum and/or persistent neuritis: a single-center experience

Abstract: Background: Erythema nodosum leprosum may appear before, during or after treatment of leprosy and is one of the main factors for nerve damage in patients. When it occurs or continues to occur after treatment, it may indicate disease recurrence and a new treatment may be instituted again. Objective: To evaluate the retreatment of patients with multibacillary leprosy who underwent standard treatment with multidrug therapy, but developed or continued to present reactions of erythema nodosum leprosum and/or neuritis 3-5 years after its end. Method: For this objective, a new treatment was performed in 29 patients with multibacillary leprosy who maintained episodes of erythema nodosum and/or neuritis 3-5 years after conventional treatment. Results: In general, we observed that 27 (93.10%) had no more new episodes after a follow up period of eight months to five years. In five of these patients the reason for the retreatment was the occurrence of difficult-to-control neuritis, and that has ceased to occur in all of them. Study limitations: Small number of patients.. Conclusion: In the cases observed, retreatment was an effective measure to prevent the occurrence of erythema nodosum leprosum and/or persistent neuritis.

O uso da sorologia como ferramenta adicional no apoio ao diagnóstico de casos difíceis de hanseníase multibacilar: lições de uma unidade de referência / The use of serology as an additional tool to support diagnosis of difficult multibacillary leprosy cases: lessons from clinical care

Sete casos de hanseníase multibacilar (MB) e dois casos com suspeição de hanseníase atendidos em situações distintas do atendimento clínico-dermatológico na Universidade Federal do Rio de Janeiro são descritos. Todos apresentaram dificuldades no diagnóstico visto que não tinham sinais e sintomas cardinais da hanseníase. Um teste sorológico utilizado como ferramenta auxiliar foi útil no processo de diagnóstico ou exclusão de cada caso e facilitou as discussões acadêmicas na hora do exame clínico. A sorologia e baciloscopia de linfa são consideradas como os únicos instrumentos rápidos e de baixo custo para a confirmação de casos MB atípicos, e as vantagens e desvantagens de cada exame são discutidas. Ambos os testes complementam o processo diagnóstico e classificação dos casos para fins terapêuticos. A vantagem da baciloscopia está na sua capacidade de confirmação do diagnóstico. As vantagens da sorologia são: (a) sua aplicabilidade para uso direto por profissionais de saúde no momento da consulta, visto que os resultados são imediatos, (b) a possibilidade da participação dos pacientes no processo, e (c) oferece uma oportunidade para melhor ensino da patogênese da hanseníase.

Seven multibacillary leprosy and two suspected cases assisted in different situations during clinical care activities at the university in Rio de Janeiro city are described. All cases presented some difficulties for diagnosis, since they evolved with few or no cardinal signs or symptoms of leprosy. A serological test used as an auxiliary tool was helpful in the diagnosis or exclusion procedure of each case, facilitating academic discussions at the time of case examination. Considering serology and bacilloscopy (skin smear) as the only rapid and relatively cheap available tests for confirmation of atypical MB leprosy, the advantages and disadvantages of their use were discussed. Both tests support the diagnostic procedure and the classification of cases for treatment purposes. The advantage of bacilloscopy is its capacity for diagnosis confirmation. The advantages of serology are: (a) its applicability for direct use by health workers, providing immediate results; (b) the potential for patient participation in the process; and (c) it provides a learning opportunity, allowing for improved teaching of leprosy pathogenesis.

Indices baciloscópicos e morfológico na hanseníase após doze doses do esquema poliquimioterápico (PQT/OMS) / Bacilloscopic and morphologic indexes in leprosy after twelve doses of multidrug therapy (WHO/MDT)

A hanseníase é uma doença infecciosa crônica causada pelo Mycobacterium leprae e que ainda apresenta altas taxas de prevalência nas regiões norte, nordeste e centro-oeste do Brasil. Atualmente, o esquema poliquimioterápico (PQT) preconizado para os pacientes multibacilares tem duração de 12 meses; após o término da última dose esses pacientes recebem alta, sem a necessidade de qualquer avaliação bacteriológica. No presente estudo avaliou-se os índices baciloscópico (IB) e morfológico (IM) de 73 pacientes multibacilares, no momento do diagnóstico e ao final de 12 doses da PQT. Após o término das 12 doses, o IM foi positivo em 20,54% deles, sendo todos virchovianos; esses pacientes continuaram a receber a medicação até 24 meses, persistindo a positividade em 4,11% deles; estes continuaram com a medicação até a negativação do IM. Neste sentido, os autores sugerem que os IB e IM deveriam ser realizados ao final do tratamento e, nos casos de positividade do IM, os pacientes poderiam continuar recebendo a medicação por 24 meses ou mais, evitando, assim, possíveis recidivas e transmissão. A mesma recomendação é feita para pacientes portadores de alguma imunodeficiência.

Fnac study of histoid nodule: an early tool for diagnosis.

Histoid lesion, a variety of lepromatous leprosy, is due to alteration in the growth pattern of Mycobacterium leprae, possibly due to loss of immunity in localized areas. The distinction is based on cellular morphology by demonstrating pallisading arrangement of multi-layered spindle-shaped histocytes. Cytodiagnosis by fine needle aspiration cytology is therefore an early tool to recognize the histoid variety, differentiating it from a conventional LL module, as it is a simple and less traumatic procedure.

Use of reverse transcription polymerase chain reaction for the detection of Mycobacterium leprae in the slit-skin smears of leprosy patients.

The relevance of bacterial index (BI) for understanding the prognosis of leprosy patients on treatment has been extensively debated, as it does not give a very clear idea of the viability of the bacteria in patients under treatment. Here we used slit-skin smear samples of leprosy patients to test the suitability for studying viability of Mycobacterium leprae using reverse transcription polymerase chain reaction (RT-PCR). For this purpose, we recruited 13 multibacillary (MB) leprosy patients (8 lepromatous and 5 borderline lepromatous). Of these, 7 were relapse cases, 3 were under treatment (MB-MDT), 2 were new cases and 1 had completed treatment. We carried out extraction of RNA using Trizol reagent (Life Technologies, UK) from the slit-skin smear samples from these patients. The RNA preparation was then used for the RT-PCR using Mycobacterium leprae-specific primers for the fragment of 16s ribosomal RNA gene. Samples from both the new cases, 4 suspected relapse cases and 1 patient under treatment showed positive RT-PCR results. Other 6 patients whose smear samples did not show any amplification by RT-PCR were on MB-MDT from 8 to 30 months. The usefulness of the technique needs to be validated using mouse footpad technique and also should be more extensively explored for studying the viability of M. leprae, the efficacy of treatment and the presence of other mycobacteria in the slit-skin smear samples.

Alteracoes palpebrais na hanseniase virchowiana de longa evolucao / ?

Foram examinados 128 pacientes hansenianos que compareceram ao ambulatorio de oftalmologia do Hospital "Dr. Francisco Ribeiro Arantes", e Itu, Sao Paulo, Brasil, no periodo entre 01 de junho de 1994 e 10 de julho de 1995. Destes, 110 (101 (91,82 por cento) de forma virchowiana (V) e 9 (8,18 por cento) da forma tuberculoide (T) foram incluidos no estudo. Colheram-se dados retrospectivos (a) identificacao: 1) Numero de registro; 2) Nome; 3) Data de nascimento; 4) Sexo; 5) Forma clinica da doenca; 6) Data de registro; 7) Tempo de evolucao da doenca; b) incapacidades: caracterizacao das incapacidades em maos, pes, nariz e presenca de paralisia facial periferica) e propectivos (altercaoes qualitativas (presenca ou ausencia de patologias, tais como

Presence of M. leprae in the conjunctiva, vitreous body and retina of a patient having lepromatous leprosy.

Histopathological study of the ocular globe of a lepromatous leprosy patient revealed the presence of lepra bacilli in the conjunctiva, sclera, episclera, cornea, iris, ciliary body, vitreous body and retina.

Bilateral iridocyclitis caused by Mycobacterium leprae diagnosed through paracentesis.

The authors conducted an anterior chamber paracentesis in a patient with lepromatous leprosy showing bilateral iridocyclitis. The paracentesis was performed in the outpatients department. The aqueous humor was studied by Ziehl-Nielsen staining method and the result was the isolation of the M. leprae in the anterior chamber. This study shows that M. leprae can promote uveitis in leprosy patients. Therefore, it should be looked for in patients having this type of disease.

A semi quantitative analysis of bacterial load in different cell types in leprous nerves using transmission electron microscope.

Thirty lepromatous (BL-LL) and 25 tuberculoid (TT-BT) nerve lesions obtained from untreated cases of leprosy were scanned using transmission electron microscope for assessing the bacterial load in different cell types. Major bulk of infection was seen in the Schwann cells of nonmyelinated fibres, in both early lepromatous and tuberculoid nerve lesions, suggesting that M. leprae spread mainly via the Schwann cells within the nerve.

Culture of nocardioform bacilli from leprosy patients & clinical evaluation of nocardioform bacilli derived antigen.

An antigen derived from cultured nocardioform bacilli was compared with Mitsuda lepromin in intradermal skin test reactions. Nocardioform bacilli were cultured in gelatin minimal medium from the tissue fluid of 85 lepromatous patients (56 M, 29 F). Of these, 65 samples showed uncontaminated growth of the organism, which were pooled for the manufacture of the test antigen. This antigen was intradermally tested in 50 untreated leprosy patients irrespective of the type, together with Mitsuda lepromin and sterile gelatin minimal media, which served as a control. No early reaction was observed at 72 h, while the late reaction at 28 days was positive in all patients in the Tuberculoid (TT) group with both antigens. Eighteen patients (81.8%) in the Borderline tuberculoid (BT) group reacted strongly to Mitsuda lepromin at 28 days, while 21 patients (95.5%) in this group showed a strong late reaction with the test antigen. The lepromatous (LL) group did not show any reaction with the two antigens. It is inferred that nocardioform bacilli are easy to cultivate, and that the test antigen compares well with Mitsuda lepromin.

Water soluble palmitic acid in media for cultivation of leprosy derived psychrophilic mycobacteria from Mycobacterium leprae infected tissues

Cultivation trials for Mycobacterium leprae resulted in growth of Mycobacterium psychrophilum (L). Media were inoculated with host grown Mycobacterium leprae cells from armadillo tissues, Nu mice foot pads or human lepromata. Cultures were obtained in liquid and on semisolid multifactoria 1 media containing water soluble palmitic acid or its salts. Ammonium thioglycolate and Napalmitate served as carbon and energy sources. The water soluble palmitic acid remained in perfect solution following sterilization in the autoclave, thus easily accessible to the cells. The cyclodextrin-Fe complex served as a siderophore to grow the obtained leprosy derived psychrophilic cells. The leprosy derived cultures and subcultures grew opimally at+10 degrees Celssius but deteriorated rapidly at + 32 degrees Celsius, in the multifactorial media. No growth occurred in 7H9 media. Cultures were not identified for classification.

Estudo do índice baciloscópico em pacientes de hanseníase multibacilares durante tratamento com esquema MDT/OMS e no período de dois anos após interrupçäo da terapêutica / Study of bacteriological index in patients with multibacillary leprosy during treatment with MDT/WHO regimens in a period of two years after therapeutical interruption

Os autores acompanham o comportamento dos índices baciloscópicos (IB), em três grupos de pacientes hansenianos, multibacilares, que haviam recebido como terapêutica o esquema padräo PQT/OMS, com duraçäo de 24, 36 e 48 meses. A queda do IB foi mais acentuada nos primeiros dois anos de tratamento, e este declínio continuou mesmo naquels grupos onde a medicaçäo foi interrompida

Antigenic similarity of a cultivable acid fast bacterium to Mycobacterium leprae.

A cultivable acid fast stainable bacterium obtained from leprosy nodule showed similarity to M. leprae in antigenicity to serum antibodies of lepromatous leprosy patients. The antigenic similarity has been seen more clearly in the delipidified cell components of both these bacteria. An antigen of 35-38 kDa has been seen as a common antigen between M. leprae and the cultivable bacilli with binding ability to sera from leprosy patients. This cultivable bacterial component could be used for serodiagnosis of lepromatous leprosy.

Mycobacterium leprae en conjuntiva: búsqueda de BAAR en 30 biopsias de conjuntiva de enfermos de lepra / Mycobacterium leprae in conjunctiva: search of BAAR in 30 conjuntival biopsy of diseases of leprosy

En 30 enfermos de lepra se obtuvieron los datos de daño ocular mediante biomicroscopias y se practicaron biopsias del fondo de saco conjuntival. El objetivo fue establecer una correlación clínico-bacteriológica entre la biopsia conjuntival con la baciloscopia, la clasificación y la evolución de la enfermedad. Las lesiones oculares predominantes fueron la madarosis y el engrosamiento de los nervios corneanos. No se encontró ningún caso de ceguera. La concordancia fue del 46.6 por ciento en un total de 6 biopsias conjuntivales positivas.

Adenosine triphosphate content of Mycobacterium leprae by percoll buoyant density centrifugation.

Thirty nine untreated patients of bacilliferous leprosy with a mean bacteriological index of 4.8 and morphological index of 1.3% formed the study group. Adenosine triphosphate assay was carried out by (i) enzyme treatment method in 18 patients and (ii) percoll buoyant density gradient method in 21 patients. ATP content obtained by percoll buoyant density gradient method was significantly higher than that obtained by enzyme treatment method. Percoll buoyant density centrifugation for purification and isolation of bacilli from human leproma is simplier, quicker and can serve as an alternate method of enzyme treatment.

Mouse footpad pathogenicity of leprosy derived nocardioform bacteria cultivated in vitro.

In vitro cultures of the nocardioform bacteria from leprosy-infected tissues consisted of granules and bacilli. Inoculation of these granules into mouse footpads (MFP) produced a mild, localised, inflammation for 4-6 weeks. The granules evoked typical granulomatous response in the subcutaneous tissue and showed gradual disintegration. Infiltration of muscles, connective tissue and epithelial cells by bacillary/mycelial masses was seen very frequently, and that of nerve bundles occasionally. Plenty of mycelial tufts emanated from many 'macrophage globi'. By 6-8 months, the granules disintegrated nearly completely releasing a large number of acid-fast bacilli (AFB), single layered rings of AFB, small globi and some residual mycelia. These AFB, harvested from the MFP, were similar to or indistinguishable from the bacillary preparations from the in vitro cultures and from the leprosy bacillus obtained directly from humans or as passaged into the MFP, on the basis of many criteria studied, including the 36k gene positivity.