A study of standardized regimens of steroid treatment in reactions in leprosy at a referral centre.

It is a well known fact that reactions and nerve function impairment (NFI) account for majority of disabilities and morbidities in leprosy. Steroids are the principal agents administered for treatment of reactions and NFI. In this study, we compared the efficacy of two regimens namely high dose (60 mg) regimen tapered over 28 weeks and low dose (40 mg) regimen tapered over 22 weeks in treatment of reactions and early NFI as regards to incidence of recurrence of reactions in 209 patients. Concerns about the side-effects of steroids were also addressed byfollowing a strict pre-steroid investigation protocol. We observed that the low dose regimen was associated with a higher incidence of recurrence (48.3%) as compared to high dose regimen (16%) signifying the efficacy of longer duration of therapy with a higher starting dose. No patient developed side-effects which necessitated withdrawal of steroids. Early detection with prompt and adequate therapy with proper dose and duration is the key to reduce recurrence of reactions and to minimize deformities due to reactions and NFI in leprosy.

A retrospective cohort study of dermatological problems observed in paediatric intensive care unit.

BACKGROUND: Dermatological manifestations are often encountered in paediatric intensive care units (PICU). Spectrum of dermatological problems that may arise in critically ill children in intensive care unit remains unknown. OBJECTIVES: The aim of this study was to find out the burden of dermatological problems and to describe the proportional distribution of paediatric dermatoses in ICU set-up. METHODS: In a retrospective cohort study, we analysed all types of paediatric dermatological conditions manifesting in children admitted to a tertiary level ICU in South India. RESULTS: During the study period of 25 months, 1180 new cases were admitted to PICU. A total of 318 children with 361 skin manifestations were observed. Majority of the skin lesions were minor and were secondary to systemic disease. Infection was the leading cause of dermatoses in ICU. Dengue infection was detected in 64% of total cases included in the study. Stevens-Johnson syndrome was the only primary dermatological condition leading to PICU admission in the present cohort. CONCLUSIONS: The spectrum and proportional distribution of skin conditions in children differ from adult ICU-data. Further large-scale investigations are needed to define the characteristics and distribution of infections along with other disease conditions leading to ICU-admissions and mortality among critically ill paediatric patients.

Posterior fossa dermoid cysts in association with Klippel-Feil syndrome: report of three cases.

Although the association of spinal lumbosacral dysraphism and congenital spinal dermoid tumors is well known, the association of craniocervical spinal anomalies and posterior fossa dermoids has only been recognized recently. Advances in imaging technology and awareness of the association likely contribute to an increase in recently reported cases.

Clinical, histopathological and bacteriological study of 52 referral MB cases relapsing after MDT.

Fifty-two BB-LL relapse cases referred to our centre during 1997-2003 were investigated in detail. Twenty-four cases had been treated with extended MB-MDT [until smear negativity (NON-FDT)]. The remaining 28 cases (54%) had received one of the fixed duration regimens (FDT), of whom 11 had 24 months and 6 had 12 months of WHO MB-MDT. Eleven cases had received rifampicin/ofloxacin (RO) treatment. Follow-up slit skin smear reports were available for 41 cases, all but three cases had been smear negative at some point after release from treatment. None of the cases showed any clinical or bacteriological evidence of upgrading, i.e. LL to BT where as downgrading BB to BL occurred in five cases. The duration between cessation of treatment and reappearance of lesions (DCTR) varied from 2 to 15 years. The mean DCTR was longest (9.4 years) for the NON-FDT and 24 months MB-MDT cases. The mean DCTR was significantly lower in the 12 months MB-MDT and RO treated cases (6.8 and 6.2 years, respectively). Four of RO treated cases and four cases with multiple episodes of reaction had DCTR less than 5 years. Inadequate treatment/poor killing of Mycobacterium leprae results in early onset relapse, whereas 'persisting' or 'drug resistant mutants' contribute to late onset relapse.

Reactions and their management.

The uneventful response to chemotherapy in leprosy is marked by clinically disturbing episodes encountered in 20-30% of patients and these phenomena are called "reactions". Generally they are classified as reversal reaction (type-1) and erythema nodosum leprosum (type-2). The cutaneous menifestations are: (1) Type-2 reactions in LL, BL types constituting erythema nodosum leprosum, erythema multiforme, erythema necroticans, subcutaneous nodules, lepromatous exacerbation. (2) Type-1 reactions in borderline and tuberculoid leprosy. The other manifestations include: Acute neuritis, lymphadenitis, arthritis, oedema of the hands and feet, ocular lesions, etc. Sequelae of reactions are: Paralytic deformities, non-paralytic deformities, extensive scarring and renal damage. A simple guideline to identify the risk-prone cases has been narrated. Prednisolone in standard dosage schedule as recommended by WHO is now being widely used in control programmes.

Viability and drug susceptibility testing of M. leprae using mouse footpad in 37 relapse cases of leprosy.

Mycobacteria leprae isolates obtained from 37 referral relapse cases of leprosy (37 skin and 10 nerve biopsy samples) received during the years 1994-2001, were tested for viability and drug sensitivity in the mouse footpad. A significant M. leprae yield in the footpads of control mice was obtained, with 32/47 (68%) isolates (from 26 cases) thus confirming viability. Of the 28 isolates successfully drug tested, 6 (21%) were resistant to one or more drugs. All except one, were multidrug treated cases (5/24 = 21%). One of the isolates was resistant to all three drugs, i.e., dapsone (di-aminodiphenyl sulphone, DDS), rifampin (RFP), and clofazimine (CLF). Two were resistant to two drugs, i.e., DDS and RFP, and each of the others were mono resistant to DDS, RFP, or CLF. Notably, one of the isolates that showed combined resistance to DDS and RFP was derived from a borderline tuberculoid case. Also, in one case skin and nerve showed that discordance viz: M. leprae derived from skin were resistant to RFP, while those derived from nerve tested sensitive to all three drugs, indicating tissue related difference.

Disability prevention and management in leprosy: a field experience.

Bombay Leprosy Project has conducted operational research into cost effective ways of using therapeutic management for prevention of disabilities (POD). The goal of achieving this are broadly divided as 1) prevention of impairments and disabilities [POID] and 2) prevention of worsening of disabilities [POWD]. About 33-56% of newly registered leprosy patients already have clinically detectable nerve function impairment [NFI], often no longer amenable to MDT. An analysis of 892 leprosy cases treated with WHO-MDT stresses the need to focus attention on leprosy patients having > 5 skin lesions and multiple nerve thickening. Assessment of 454 disabled leprosy patients after 4 years indicated that the compliance for the services offered was good and it helped to improve the disability status in more than 50% of patients. In terms of effectiveness of the services, it was found to be effective in preventing worsening of deformities in hands and healing of trophic ulcers in feet. The methodology adopted has also helped us to develop an operational research model about the necessity to systematize the assistance and support to be given if the services can be routed through a public health facility. Because of the large numbers of leprosy patients with disability living in this region and the limited resources available, the services have to be targeted towards those who are most in need. The major advantage of such community based program is an attempt to eliminate the social stigma in the patients' families and the education of the community.