Disease and survival on the Thai-Burma railway: lessons for modern tropical medicine?

During the 2nd World War, large numbers of allied military personnel in south-east Asia became prisoners-of-war (POWs) of the Japanese. During their internment of three and a half years, they suffered undernutrition, exposure to tropical diseases and frequently overwork. Perhaps the harshest POW experience was the construction of the railway between Thailand and Burma. This paper explores the medical conditions during Far East imprisonment, and in particular on the Thai-Burma Railway, as well as the long-term health effects in post-war decades.

Flight Lieutenant Peach's observations on Burning Feet Syndrome in Far Eastern Prisoners of War 1942-45.

INTRODUCTION: 'Burning Feet Syndrome' affected up to one third of Far Eastern Prisoners of War in World War 2. Recently discovered medical records, produced by RAF Medical Officer Nowell Peach whilst in captivity, are the first to detail neurological examinations of patients with this condition. METHODS: The 54 sets of case notes produced at the time were analysed using modern diagnostic criteria to determine if the syndrome can be retrospectively classed as neuropathic pain. RESULTS: With a history of severe malnutrition raising the possibility of a peripheral polyneuropathy, and a neuroanatomically plausible pain distribution, this analysis showed that Burning Feet Syndrome can now be described as a 'possible' neuropathic pain syndrome. CONCLUSION: After 70 years, the data painstakingly gathered under the worst of circumstances have proved to be of interest and value in modern diagnostics of neuropathic pain.

Long-term glycaemic outcome of structured nurse-led diabetes care in rural Africa.

BACKGROUND: Diabetes care delivery in rural Africa is difficult. Problems include lack of dedicated personnel, monitoring systems, laboratory support and drugs. Few structured intervention projects have been undertaken, none with long-term follow-up. AIM: To determine the long-term (4 years) glycaemic outcome of a structured nurse-led intervention programme for type 2 diabetic patients in rural Africa. DESIGN: Single-centre, observational cohort study. METHODS: The programme was delivered in the scattered primary health clinics of Hlabisa District, in northern Kwazulu Natal, South Africa. Monthly diabetic clinics were held at which empowerment-based education was delivered and regularly reinforced. Oral hypoglycaemic agents (OHAs) were titrated according to a previously validated clinical algorithm. Outcome was measured by glycated haemoglobin (HbA(1)c), as well as body mass index (BMI). Data were collected at baseline, and then 6, 18, 24 and 48 month's post-intervention. RESULTS: Eighty patients had data available at all time collection points. They were of mean ± SD, age 56 ± 11 years, 70% were female, BMI 31.5 ± 7.2 kg/m(2) and HbA(1)c 10.8 ± 4.2%. HbA(1)c fell significantly to 8.1 ± 2.2% at 6 months and 7.5 ± 2.0% at 18 months. By 24 months, it had risen (8.4 ± 2.3%), and at 4 years post-intervention it was 9.7 ± 4.0% (still significantly lower than baseline, P = 0.015). BMI rose significantly at 6 and 18 months, but by 48 months was not significantly different from baseline. CONCLUSION: We conclude that the intervention led to marked HbA(1)c improvements up to 18 months follow-up, but thereafter there was 'glycaemic slippage'. This may be not only due to educational 'wear-off', noted in other education-intervention programmes, but also to the expected glycaemic deterioration with time known to occur in type 2 diabetes. Nevertheless, 4-year HbA(1)c levels were still significantly lower than at baseline. The programme was also well received by staff and patients, and we believe is an appropriate and effective diabetes intervention system in rural Africa.

The outcome of brittle type 1 diabetes--a 20 year study.

AIMS: To determine the long-term (20 years from presentation) outcome of brittle type 1 diabetes characterized by recurrent episodes of ketoacidosis (DKA). METHODS: The cohort studied was a group of brittle diabetic patients from various parts of UK originally identified between 1979 and 1985. Patients were traced, where possible, via their diabetic clinics and/or general practitioners. Data on survival or otherwise were obtained from hospital case notes and information from diabetes care team members. For survivors, clinical and demographic information obtained included complication status and whether they still had brittle characteristics. They were also compared with a matched case-control group of type 1 patients with no history of brittle behaviour. RESULTS: The original cohort comprised 33 patients- all female and mean ± SD, aged 18 ± 5 years and diabetes duration 8 ± 4 years. Thirteen were not traceable and 10 of the remaining 20 (50%) had died during the mean 22 years of follow-up. Deaths occurred evenly throughout the period, and causes were chronic renal failure (3), DKA (3), hypoglycaemia (2), subarachnoid haemorrhage (1) and uncertain (1). Age at death ranged from 27 to 45 years. Of the 10 survivors, none remained brittle, but they had a substantial burden of complications. Compared with the non-brittle control group, there was a significant excess of nephropathy and autonomic neuropathy. CONCLUSION: We conclude that brittle diabetes characterized by recurrent DKA has high long-term outcome mortality. These deaths were premature and almost all diabetes related. Those who survived had resolution of brittleness, but suffered a significant complication burden.

Nurse-led cardiovascular risk factor intervention leads to improvements in cardiovascular risk targets and glycaemic control in people with Type 1 diabetes when compared with routine diabetes clinic attendance.

AIM: To compare the effects of a dedicated cardiovascular risk factor clinic run by a nurse consultant with routine diabetes clinic attendance in achieving glycaemic and cardiovascular risk targets in patients with Type 1 diabetes. METHODS: Eighty-one patients (45 male, mean age 34.6 years, mean duration of diabetes 15 years) with an HbA(1c) ≥ 8% (64 mmol/mol) and at least one other risk factor for the development of cardiovascular disease were randomized to receive either routine care or intensive nurse-led cardiovascular risk factor intervention. HbA(1c) , non-fasting lipid profile, blood pressure, weight, BMI and insulin dose were recorded at baseline, 6, 12 and 24 months. RESULTS: At baseline there were no differences between the groups. At 12 months, there were significant improvements in the nurse-led cardiovascular risk factor group: HbA(1c) [10.1% (87 mmol/mol) vs. 9.3% (78 mmol/mol), P < 0.001], total cholesterol (5.8 vs. 4.3 mmol/l, P < 0.001), systolic blood pressure (127 vs. 115 mmHg, P < 0.001) and diastolic blood pressure (71 vs. 65 mmHg, P < 0.05). Improvements were maintained in all variables at 24 months except diastolic blood pressure. In the routine group, only total cholesterol improved significantly (5.8 vs. 5.2 mmol/l, P < 0.01) after 12 months and this was maintained at 24 months. CONCLUSION: A nurse consultant cardiovascular risk factor clinic has a beneficial effect on cardiovascular risk targets in Type 1 diabetes, probably attributable to the increased use of lipid-lowering and anti-hypertensive agents and this was maintained at 24 months. Glycaemic control also improved.

Immunological and C-peptide studies of patients with diabetes in northern Ethiopia: existence of an unusual subgroup possibly related to malnutrition.

AIMS/HYPOTHESIS: Surveys in northern Ethiopia have demonstrated that apparent type 1 diabetes occurs more frequently than elsewhere in Africa and, indeed, in other parts of the world. We therefore investigated in detail a cohort of diabetic patients from this region to clarify the nature of this type of diabetes. METHODS: All patients attending the diabetic clinic at Mekelle Hospital in the Tigray region of northern Ethiopia were investigated over a 6 week period. Clinical, demographic and anthropometric data were collected, as well as measurements of HbA(1c), fasting lipid profile, fasting serum C-peptide and serum markers of beta cell autoimmunity, i.e. islet antigen-2 and GAD antibodies (GADA). RESULTS: Of 105 patients seen, 69 (66%) were on insulin treatment and had been from or close to diagnosis. Their median age and diabetes duration were 30 and 5 years, respectively, with a male excess of 2:1. Median BMI was 20.6 kg/m². Despite these clinical characteristics suggestive of type 1 diabetes, only 42 of 69 (61%) patients were C-peptide-negative and 35% GADA-positive. Overall, 38 (36%) of the total group (n = 105) had immunological or C-peptide characteristics inconsistent with typical type 1 or type 2 diabetes. The clinical characteristics, local prevalence of undernutrition, and GADA and C-peptide heterogeneity suggest a malnutrition-related form of diabetes. CONCLUSIONS/INTERPRETATION: Not all patients in northern Ethiopia with apparent type 1 diabetes appear to have the form of disease seen in Europids; their disease may, in fact, be related to malnutrition.

The insulin dilemma in resource-limited countries. A way forward?

The International Insulin Foundation (IIF) has developed and validated a needs-assessment instrument called the Rapid Assessment Protocol for Insulin Access (RAPIA) which has been used in seven countries in four continents to analyse the constraints to delivering effective continuing care for people with diabetes. One major contributor to the difficulties in availability of insulin is a failure to use the least costly sources and types of insulin and other effective drugs for diabetes. The purchase of insulins can consume as much as 10% of government expenditure on drugs, this being highly sensitive to the selection of newer analogue insulins as first-choice options, which cost between three and 13 times more than biosynthetic human insulin. Insulin cartridges for use with injection pens further add to costs. Similar considerations apply to most of the newer treatments for people with type 2 diabetes, which may cost up to 40 times more than metformin and sulfonylureas, still considered first-line drugs by European and US guidelines. Both biosynthetic human insulin and the first-line oral hypoglycaemic drugs are available from generic manufacturers. With the present price differentials, there is thus a growing need for countries involved in tendering for sourcing insulin to be provided with the guarantees of Good Manufacturing Practice, quality and bioequivalence, which would come from a WHO Pre-Qualification Scheme as currently exists for a variety of drugs for chronic diseases, both communicable and non-communicable. The IIF has developed a position statement on the provision and choice of diabetes treatments in resource-limited settings which should be applicable wherever consideration of resources is a component of therapeutic decision making.

Nurse-led clinics for strict hypertension control are effective long term: a 7 year follow-up study.

AIMS: The primary aim was to assess long-term blood pressure in 110 patients with Type 2 diabetes who had achieved optimal blood pressure control during attendance at a protocol-based nurse-led hypertension intensive intervention clinic 7 years previously. The secondary aim was to assess modifiable cardiovascular risk factor status. METHODS: One hundred and ten patients who attended the clinic during 2000-2002 were selected to reattend to have their blood pressure measured to the same standard as it was during the intensive intervention clinic, by the same specialist nurse. Treatment details were recorded. RESULTS: Of the 110 patients, 36 (33%) had died; 69 (63%) of the remaining 74 patients were eligible to be contacted by letter; and 35 (51%) agreed to reattend. Age was 70 +/- 9 years; 21 (60%) were male; and the duration of diabetes was 17 +/- 7 years. Compared with 7 years previously, there was no difference in blood pressure control (systolic 130 +/- 17 vs. 131 +/- 16 mmHg, P = 0.62; diastolic 68 +/- 9 vs. 65 +/- 9 mmHg, P = 0.11). The number of patients with blood pressure <130/80 mmHg remained the same: 17 (49%) vs. 17 (49%; P > 0.99). During the 7 year period, 14 (40%) vs. 20 (57%) had macrovascular disease (P = 0.23), and 14 (40%) vs. 19 (54%) microvascular disease (P = 0.33). Thirteen (37%) vs. 18 (51%) were taking three or more antihypertensive drugs (P = 0.33), and 26 (74%) vs. 28 (80%) angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (P = 0.77). CONCLUSIONS: Optimal blood pressure control was sustained with no significant changes to antihypertensive medication, demonstrating the effectiveness of a protocol-based nurse-led clinic in achieving strict BP control.

Leukocytosis as a predictor for non-infective mortality and morbidity.

Leukocytosis (raised concentration of white cells in the blood) is commonly associated with infection or inflammation, but can occur in a wide variety of other conditions. Leukocytosis has also been linked with increased mortality and morbidity in a number of studies. We have systematically reviewed the relevant literature, which clearly demonstrates an association between leukocytosis and mortality-particularly due to cardiovascular or cerebrovascular causes. The mechanisms of this effect are uncertain but, when combined with other markers predictive of death, leukocytosis may contribute to modelling systems to predict in-patient mortality risk.

Nocturnal hypoglycaemia in type 1 diabetes--frequency and predictive factors.

BACKGROUND: Nocturnal hypoglycaemia (NH) remains a problem in type 1 diabetes and spontaneous asymptomatic NH may be a risk factor for sudden death ('Dead in Bed' syndrome). AIMS: To explore whether any predictive relationship exists between the average or time-specific glycaemia and the occurrence of NH. METHODS: Twenty-five healthy patients with type 1 diabetes underwent two separate overnight periods of continuous glucose monitoring (CGM) using a MMT-7002 Medtronic MiniMed System. There was a 6-week interval before the second monitoring period. CGM glucose levels recorded between 23:00 and 08:00 h defined the nocturnal period and recorded glucose monitoring levels <3.5 mmol/l for at least 10 min during this time-defined NH. A CGM recording at 23:00 h and 08:00 h were taken as the bedtime and fasting glucose levels, respectively. RESULTS: The mean +/- SD age was 37 +/- 7 years and duration of diabetes 13 +/- 7 years; 16 (64%) were on long-acting analogue insulin. Forty-nine CGM data sets were recorded. Fourteen episodes of NH occurred in 12 patients (Group 1), 13 patients (Group 2) had no NH. Group 1 (NH) had a lower mean bedtime glucose recorded compared with Group 2 (7.7 +/- 4.3 vs. 11.4 +/- 4.0 mmol/l, P = 0.0035). Fasting glucose level was also lower in Group 1 following the occurrence of NH (P = 0.014). There was no difference in the type of insulin used between the two groups. CONCLUSION: Our data show that in normal day to day settings, NH is common and that the bedtime glucose level is a significant predictive factor.

'Microalbuminuric anaemia'--the relationship between haemoglobin levels and albuminuria in diabetes.

BACKGROUND: There is an increasing incidence of anaemia in diabetes despite the absence of significant renal impairment. AIMS: This study set out to determine the prevalence of anaemia in a diabetic population and to explore the relationship between anaemia and urinary albumin excretion in diabetes mellitus. Also, to determine the difference between those with overt nephropathy, microalbuminuria and those without evidence of renal disease. METHODS: Five hundred and two consecutive diabetes patients were screened for anaemia. Anaemia was defined by World Health Organization criteria (<13 g/dl for men and <12 g/dl for women). Urinary albumin excretion was determined by urinary albumin creatinine ratio (ACR) from a single urine sample. RESULTS: Anaemia was present in 118 (23.5%) patients. There was a rise in the prevalence of anaemia from 19% in patients with a normal ACR to 29% in those with microalbuminuria and to 41% in macroalbuminuria. This increase in the prevalence of anaemia in microalbuminuria compared to normoalbuminuria was not explained by declining renal function as there was no significant difference in eGFR between the two groups. CONCLUSION: Anaemia was common in the study population. Early detection and correction of anaemia in diabetes is important for patients at risk of impaired quality of life and increased cardiovascular risk.

Strongyloides hyperinfection syndrome in British veterans.

Strongyloides hyperinfection syndrome is a rare but serious and often fatal complication of strongyloidiasis, usually precipitated by immune suppression (frequently caused by corticosteroidal drugs). Infections with Strongyloides stercoralis are known to occur in British veterans who served in South-east Asia during the Second World War, particularly in those held as prisoners of war by the Japanese. No information on the frequency of disseminated strongyloidiasis in these men is, however, available. A multi-source enquiry designed to detect the cases of Strongyloides hyperinfection syndrome that occurred, in the U.K., in the 60 years following the end of the Second World War was therefore initiated. The relevant data were collected from death certificates, searches of the medical literature, enquiries with veterans' organizations, and questionnaires sent to all the units of infectious and tropical disease in the U.K.. Overall, 25 cases of hyperinfection in the U.K. were detected but only two involved veterans of the Second World War (one British ex-Far East prisoner of war and a British former soldier who had been involved with the evacuation of Singapore in 1945). Although the risk of hyperinfection in veterans appears small, information from the literature and veterans' organizations indicates that there are still probably 300-400 such veterans who remain alive in Britain and have Strongyloides infections. Attempts at the detection and eradication of the infections in the surviving veterans are recommended.

Chronic kidney disease in long duration type 1 diabetes lasting more than 50 years.

OBJECTIVE: There is evidence that microalbuminuria and overt nephropathy may progress more slowly in long duration (> 20 years) type 1 diabetes (T1DM). To explore this further, we examined the characteristics of chronic kidney disease (CKD) in a large cohort of long duration T1DM in the United Kingdom (UK). RESEARCH DESIGN AND METHODS: We studied the UK 'Golden Years' cohort--a group of 400 patients from various parts of the UK with T1DM > 50 years duration. Demographic and clinical information were obtained. HbA(1c), lipids, creatinine and urinary albumin-creatinine ratio (ACR) were measured. Microalbuminuria was defined as 2.5-25.0 mg/mmol for males and 3.5-25.0 mg/mmol for females; macroalbuminuria was defined as an ACR > 25.0 mg/mmol for both sexes. RESULTS: Mean age was 69 years and duration of diabetes 55 years. Nine percent had macroalbuminuria and 27% microalbuminuria. No patient had stage 5 CKD. Microalbuminuria was associated significantly with increased diabetes duration (p = 0.02), male sex (p = 0.02), smoking (p = 0.002), higher HbA(1c) (p < 0.0001), raised triglycerides (p = 0.04), and peripheral vascular disease (PVD) (p < 0.0001). Macroalbuminuria had significant associations with smoking (p = 0.02), raised triglycerides (p = 0.01), raised creatinine (p = 0.02), PVD (p = 0.01) and hypertension (p = 0.01). CONCLUSIONS: We conclude that microalbuminuria and CKD are common, even at long duration (> 50 years) of T1DM, and have similar characteristics and associations as they do with shorter disease duration. There is a striking absence, however, of stage 5 CKD, but selection bias may be an important confounder since patients with advanced disease may have not survived.

Cardiac arrhythmia and nocturnal hypoglycaemia in type 1 diabetes--the 'dead in bed' syndrome revisited.

AIMS/HYPOTHESIS: Sudden nocturnal death in type 1 diabetes ('dead in bed' syndrome) is thought to be due to ECG QT prolongation with subsequent ventricular tachyarrhythmia in response to nocturnal hypoglycaemia. We investigated this theoretical mechanism using continuous ECG and continuous glucose monitoring in a group of patients with type 1 diabetes. METHODS: Twenty-five patients with type 1 diabetes (age 20-50 years) underwent two separate 24 h ECG and continuous glucose monitoring periods. Patients were fully ambulant and carried out normal daily activities. RESULTS: There were 13 episodes (26% of recordings) of nocturnal hypoglycaemia, eight of <2.2 mmol/l and five of 2.2-3.4 mmol/l. Corrected QT interval (QTc) was longer during nocturnal hypoglycaemia compared with normoglycaemic control periods (445 +/- 40 vs 415 +/- 23 ms; p = 0.037). Cardiac rate and rhythm disturbances (excluding sinus tachycardia) were seen in eight of the 13 nocturnal hypoglycaemia episodes (62%). These were sinus bradycardia (<40 beats/min; three episodes), ventricular ectopics (three episodes), atrial ectopics (one) and P wave abnormalities (one). CONCLUSIONS/INTERPRETATION: This study demonstrates QTc prolongation and cardiac rate/rhythm disturbances in response to episodes of nocturnal hypoglycaemia in ambulant patients with type 1 diabetes. This may support an arrhythmic basis for the 'dead in bed' syndrome.

A sub-Saharan African perspective of diabetes.

Diabetes mellitus is an important and increasing cause of morbidity and mortality in sub-Saharan Africa. Accurate epidemiological studies are often logistically and financially difficult, but processes of rural-urban migration and epidemiological transition are certainly increasing the prevalence of type 2 diabetes. Type 1 disease is relatively rare, although this may be related to high mortality. This diabetic subgroup appears to present at a later age (by about a decade) than in Western countries. Variant forms of diabetes are also described in the continent; notably 'atypical, ketosis-prone' diabetes, and malnutrition-related diabetes mellitus. These types sometimes make the distinction between type 1 and type 2 diabetes difficult. Interestingly, this is also a current experience in the developed world. As more detailed and reliable complication studies emerge, it is increasingly apparent that African diabetes is associated with a high complication burden, which is both difficult to treat and prevent. More optimistically, a number of intervention studies and twinning projects are showing real benefits in varying locations. Future improvements depend on practical and sustainable support, coupled with local acceptance of diabetes as a major threat to the future health and quality of life of sub-Saharan Africans.

Consequences of captivity: health effects of far East imprisonment in World War II.

Though medical consequences of war attract attention, the health consequences of the prisoner-of-war (POW) experience are poorly researched and appreciated. The imprisonment of Allied military personnel by the Japanese during the World War II provides an especially dramatic POW scenario in terms of deprivation, malnutrition and exposure to tropical diseases. Though predominantly British, these POWs also included troops from Australia, Holland and North America. Imprisonment took place in various locations in Southeast Asia and the Far East for a 3.5-year period between 1942 and 1945. Nutritional deficiency syndromes, dysentery, malaria, tropical ulcers and cholera were major health problems; and supplies of drugs and medical equipment were scarce. There have been limited mortality studies on ex-Far East prisoners (FEPOWs) since repatriation, but these suggest an early (up to 10 years post-release) excess mortality due to tuberculosis, suicides and cirrhosis (probably related to hepatitis B exposure during imprisonment). In terms of morbidity, the commonest has been a psychiatric syndrome which would now be recognized as post-traumatic stress disorder--present in at least one-third of FEPOWs and frequently presenting decades later. Peptic ulceration, osteoarthritis and hearing impairment also appear to occur more frequently. In addition, certain tropical diseases have persisted in these survivors--notably infections with the nematode worm Strongyloides stercoralis. Studies 30 years or more after release have shown overall infection rates of 15%. Chronic strongyloidiasis of this type frequently causes a linear urticarial 'larva currens' rash, but can potentially lead to fatal hyperinfection if immunity is suppressed. Finally, about 5% of FEPOW survivors have chronic nutritional neuropathic syndromes--usually optic atrophy or sensory peripheral neuropathy (often painful). The World War II FEPOW experience was a unique, though often tragic, accidental experiment into the longer term effects of under nutrition and untreated exotic disease. Investigation of the survivors has provided unique insights into the medical outcome of deprivation in tropical environments.

Hypertriglyceridaemia is associated with an increased likelihood of albuminuria in extreme duration (> 50 years) Type 1 diabetes.

AIMS: To explore the association between dyslipidaemia and albuminuria at the extreme of diabetes duration. METHODS: Data and samples were collected from 400 patients with extreme duration (> 50 years) of Type 1 diabetes in the UK (Golden Years Cohort). Urinary albumin-creatinine ratio (ACR), glycated haemoglobin (HbA(1c)), creatinine, non-fasting triglycerides, total cholesterol, high-density lipoprotein- and low-density lipoprotein-cholesterol were analysed in all patients. RESULTS: Thirty-six percent of patients had albuminuria (micro- or macroalbuminuria). After adjusting for age, gender, HbA(1c), disease duration and presence of macrovascular disease, hypertriglyceridaemia was more likely to be associated with the presence of albuminuria. CONCLUSIONS: High triglycerides may be a potential risk factor for progression of diabetic nephropathy at the extreme of diabetes duration, but the benefit of targeting this aggressively remains to be evaluated further.

An effective system of nurse-led diabetes care in rural Africa.

AIMS: Delivering adequate diabetes care is difficult in rural Africa because of drug and equipment shortages; as well as lack of trained medical expertise. We aimed to set up and evaluate a nurse-led protocol and education-based system in rural Kwazulu Natal in South Africa. METHODS: A treatment algorithm and education system adapted from previously validated methods was used; care was devolved to primary health clinics and was delivered by two nurses. Glycaemic control was assessed by glycated haemoglobin (HbA1c), assayed off site and not available for clinical use during the study. Results A total of 284 patients were enrolled, with 197 followed for 18 months (13 died and 26% lapsed during the period). HbA1c was 11.6 +/- 4.5% (sd) at baseline, 8.7 +/- 2.3% at 6 months and 7.7 +/- 2.0% at 18 months. There was a small associated increase in weight but no increase in hypoglycaemia. Subgroup analysis showed that education alone, without drug type or dose changes, also improved control (HbA1c 10.6 +/- 4.2% baseline and 7.6 +/- 2.3% at 18 months). The service was very popular with patients, families and other health workers. CONCLUSIONS: We conclude that a simple protocol and education-based diabetes care system can be successfully introduced and run by nurses in rural Africa. Medium-term glycaemic improvements are excellent and the service has been very well received.

Familial transmission of leprosy in post-war Britain--discrimination and dissent.

A Polish immigrant, who was resident in the United Kingdom (UK), presented with lepromatous leprosy and was detained in two hospitals against his wishes in the late 1940s. The public reaction to his diagnosis was remarkable, with street riots and questions in the Houses of Parliament about 'this leper'. His wife was persecuted and had to change her name. The index patient died of tuberculosis during enforced isolation in hospital, and several years later his daughter (who had never left the UK) presented with a left median nerve palsy and probable lepromatous dactylitis of the left third finger, eventually requiring amputation and prolonged dapsone treatment. Her disease resolved slowly but completely. We believe these two familial cases represent the first documented episode of autochthonous leprosy transmission in the UK since the early 1920s. They also demonstrate the ability of this disease to engender fear, dissent and discrimination amongst the public. Parallels are drawn with reactions to the cholera epidemics in nineteenth century Britain, and to HIV/AIDS, SARS and multi-drug resistant tuberculosis in more recent times.