Clinically unsuspected neuritic leprosy with caseation necrosis.

Leprosy is a devastating disease caused by Mycobacterium leprae. It includes a spectrum of clinicopathological lesions. Neuritic leprosy with caseation necrosis (abscess) manifesting as a soft tissue mass is a relatively rare presentation of leprosy. Here, the authors report their experience with three patients with neuritic leprosy. The patients presented with swellings in the right ulnar nerve, the right great auricular nerve, and the temporal branch of the right sixth cranial nerve. The clinical impression was that of tumorous masses. Gross examination of the biopsy specimens revealed caseous necrotic materials. Further histological evaluation disclosed tuberculoid granulomas with extensive caseation necrosis. Stains for acid-fast bacilli were positive in the third case. A comparison between the caseation encountered in the tuberculoid neurotic leprosy and the neurolysis of lepromatous neurotic leprosy has been also discussed. The findings here emphasize "mass lesion with necrosis" as a possible clinical presentation of the neuritic leprosies. The clinicopathologic features were addressed and the relevant literature was reviewed.

Detection of neuropathy due to Mycobacterium leprae using noninvasive neurosensory testing of susceptible peripheral nerves.

The prevalence of disability in patients with Hansen disease is related to peripheral nerve dysfunction. This dysfunction, which is due to chronic nerve compression, is the result of invasion of the peripheral nerve by Mycobacteria leprae. This suggests that early identification of M. leprae would be aided by detection of early stages of peripheral nerve compression. Traditional evaluation of peripheral nerve function with monofilaments, electrodiagnostic testing, or by observing motor palsy or digital ulcers unfortunately identifies only late sequelae of peripheral nerve dysfunction. The cutaneous pressure threshold required to identify 1 from 2 static-touch stimuli was obtained with the Pressure-Specified Sensory Device in upper and lower extremities of 51 patients who completed multidrug therapy for Hansen disease. Abnormal peripheral nerve function was identified in each patient and in each of the 120 bilateral nerves that were evaluated. The degree of nerve dysfunction included the range from early to late stages of nerve compression, suggesting that this method of neurosensory testing offers the possibility for early detection of peripheral nerve problems in Hansen disease.

Ulnar nerve abscess and relapse in a patient with indeterminate leprosy 1 year after completion of multidrug therapy.

The introduction of multidrug therapy has efficiently controlled leprosy in developing countries. However, Mycobacterium laprae may survive and cause relapse despite adequate treatment with antileprosy drugs. Relapse may be characterized by a combination of new signs or symptoms and presence of acid-fast bacilli on skin or nerve biopsy samples. We report a case of a child in whom ulnar abscess developed 12 months after successful completion of multidrug therapy with clinical and histopathological evidence of relapse.

Nerve abscess in children and adults leprosy patients: analysis of 145 cases and review of the literature.

The authors report on their experience of nerve abscess in leprosy. They have found that in the last 5 years there is a significant increase in this type of pathology, at a time when the total number of patients has decreased in adults. Nerve abscesses are, recently, noticed in a large number of children and teenagers. This was not the case 7-9 years ago. Abscesses were excised from one hundred forty-five nerves in one hundred and sixteen patients between May 1985 and May 1994, out of which, 14 patients (12.6%) were operated during the period May 1985 to December 1989 and 102 (87.93%) in the period January 1990 to May 1994. Children and teenagers account for 47% of all cases of nerve abscess in this series. The incidence of abscess in multiple nerves is high too in these groups. Abscess of cutaneous nerves is very common too (35% of cases) though rarely reported in the literature. There is a higher incidence of nerve abscess in male adults as compared to females. The authors believe that this sudden increase in neural pathology can be attributed, in part, to the extension of multidrug therapy (MDT) programmes without adequate infrastructure to detect and treat early neuritis.

Calcification of peripheral nerves in leprosy.

A study conducted in 74 TT/TB patients, with gross thickening of nerves together with nerve abscess, showed calcification in 8 patients. Calcification was most common in the ulnar nerve followed by the lateral popliteal nerve. All eight patients were males with significantly longer duration of illness before start of treatment. Patients with late onset of nerve abscess were found to be more prone to calcium deposition in the nerves. Caseous pus of the abscess had high lipid content with raised cholesterol and cholesterol ester ratio to total lipids suggesting a dystrophic nature of calcification.