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.

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.

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.

Isolation of a DOPA positive rapid growing mycobacterium from blood of a leprosy patient.

A rapid growing acid-fast organism was isolated from the blood of a borderline leprosy patient. The isolate appeared to be close to Mycobacterium cheloni group of organisms but showed globi, cigar shaped bundles and was positive for DOPA-oxidase. Catalase, iron uptake, sodium chloride tolerance, tellurite reduction, Tween 80 hydrolysis and pyridine extraction tests were also positive. The 3-days arylsulphatase test and nitrate reduction test were negative.

Involvement of palate and cheek in leprosy.

22 Cases of bacillary positive leprosy with no apparent lesion in the oral cavity, soft or hard palate were studied for any evidence of pathological involvement. Granulomata were present in 11 (65%) out of 17 cheek biopsies studied. M. leprae were identified in four specimens only. 9 specimens (64%) out of 14 palate biopsies showed definite granulomata. M. leprae were seen in six specimens.