Leprosy case series in the emergency room: A warning sign for a challenging diagnosis

Filho, Fred Bernardes; Lima, Filipe Rocha; Voltan, Glauber; Paula, Natália Aparecida de; Frade, Marco Andrey Cipriani

doi:10.1016/j.bjid.2021.101634

Cited by 7 publications

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“…There is thickening with increased CSA in all nerves of HD contacts compared to healthy individuals although this thickening is lower compared to patients with HD. Our results support the findings of other studies by objectively demonstrating that the contact factor increases the risk of developing HD ( 6 , 11 , 13 , 19 , 22 – 24 ); furthermore, peripheral nerve US with an HD protocol demonstrated that the neuropathy secondary to HD is a multiple peripheral mononeuropathy, confirming the results of other authors ( 22 , 40 , 43 , 44 , 58 – 64 ).…”

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confidence: 92%

Silent peripheral neuropathy determined by high-resolution ultrasound among contacts of patients with Hansen's disease

et al. 2023

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IntroductionHansen's disease (HD) primarily infects peripheral nerves, with patients without HD being free of peripheral nerve damage. Household contacts (HHCs) of patients with HD are at a 5–10 times higher risk of HD than the general population. Neural thickening is one of the three cardinal signs that define a case of HD according to WHO guidelines, exclusively considering palpation examination that is subjective and may not detect the condition in the earliest cases even when performed by well-trained professionals. High-resolution ultrasound (HRUS) can evaluate most peripheral nerves, a validated technique with good reproducibility allowing detailed and accurate examination.ObjectiveThis study aimed to use the peripheral nerve HRUS test according to the HD protocol as a diagnostic method for neuropathy comparing HHCs with healthy volunteers (HVs) and patients with HD.MethodsIn municipalities from 14 different areas of Brazil we selected at random 83 HHC of MB-patients to be submitted to peripheral nerve ultrasound and compared to 49 HVs and 176 HD-patients.ResultsHousehold contacts assessed by HRUS showed higher median and mean absolute peripheral nerve cross-sectional area (CSA) values and greater asymmetries (ΔCSA) compared to HVs at the same points. Median and mean absolute peripheral nerve CSA values were higher in patients with HD compared to HCCs at almost all points, while ΔCSA values were equal at all points. Mean ± SD focality (ΔTpT) values for HHCs and patients with HD, respectively, were 2.7 ± 2.2/2.6 ± 2.2 for the median nerve, 2.9 ± 2.7/3.3 ± 2.9 for the common fibular nerve (p > 0.05), and 1.3 ± 1.3/2.2 ± 3.9 for the ulnar nerve (p < 0.0001).DiscussionConsidering HRUS findings for HHCs, asymmetric multiple mononeuropathy signs (thickening or asymmetry) in at least 20% of the nerves evaluated could already indicates evidence of HD neuropathy. Thus, if more nerve points are assessed in HHCs (14 instead of 10), the contacts become more like patients with HD according to nerve thickening determined by HRUS, which should be a cutting-edge tool for an early diagnosis of leprosy cases.

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Section: Discussionsupporting

confidence: 92%

Silent peripheral neuropathy determined by high-resolution ultrasound among contacts of patients with Hansen's disease

et al. 2023

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“…In the diagnosis of patients presenting only hypochromatic macular lesions investigations focusing almost exclusively on cutaneous signs, the inability of widely used tests to detect the different clinical forms and reaction states, and the identification of subclinical infection are challenges in controlling the magnitude of the disease and result in a non-timely diagnosis ( 14 , 21 , 22 ). The PCR technique consists of extracting, amplifying, and identifying M. leprae DNA in clinical samples, such as intradermal scrapings, with higher laboratory accuracy, and it mitigates the main gaps with the use of the SSS alone in laboratory diagnosis across the clinical spectrum of HD.…”

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confidence: 99%

Bacilloscopy and polymerase chain reaction of slit-skin smears and anti-phenolic glycolipid-I serology for Hansen’s disease diagnosis

et al. 2022

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The bacilloscopy of the slit-skin smear (SSS) is the exclusive laboratory test associated with dermato-neurological evaluation for Hansen’s disease (HD) diagnosis; however, it is negative in the majority of PB or primary neural forms. Thus, a PCR technique involving different sequences and target genes has been performed with an aim to increase the sensitivity and specificity of M. leprae identification, especially in patients with low bacillary loads. Additionally, serological assays based on antibody response reflect infection levels and indicate that this could be a simpler, less invasive technique for estimating M. leprae exposure. Serological tests and PCR have been shown to be more sensitive and accurate than the SSS. Our study aimed to measure accuracy and performance among the SSS and PCR of dermal scrapings stored on filter paper and APGL-I serology for diagnosis in HD. A cross-sectional study analyzing the medical records (n = 345) of an HD outpatient-dermatology clinic from 2014 to 2021 was conducted. Accuracy performance parameters, correlation, and concordance were used to assess the value among the SSS, PCR, and APGL-I exams in HD. The SSS presented 24.5% sensitivity, 100% specificity, 37.4% accuracy, and the lowest negative predictive value (21.5%). The PCR assay had 41, 100, and 51% sensitivity, specificity, and accuracy, respectively. PCR and APGL-I serology increased the detection of HD cases by 16 and 20.6%, respectively. PCR was positive in 51.3% of patients when the SSS was negative. The SSS obtained moderate concordance with PCR [k-value: 0.43 (CI: 0.33–0.55)] and APGL-I [k-value: 0.41 (CI: 0.31–0.53)]. A moderate positive correlation was found between the APGL-I index and the bacillary index (r = 0.53; P < 0.0001). Thus, the use of the SSS is a low sensitivity and accuracy method due to its low performance in HD detection. The use of PCR and serological tests allows for a more sensitive and accurate diagnosis of patients.

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“…pacientes (figuras 3 e 4 -(FRADE et al, 2022)). Figura 3: Dermatomos dos nervos radial, ulnar e mediano e os pontos avaliados na mão com o teste dos monofilamentos de Semmes-Weinstein.Figura 4: Dermatomos dos ramos dos nervos fibular e tibial e os pontos avaliados no pé através do teste dos monofilamentos de Semmes-Weinstein.baseada nesse fato que tem seu emprego na hanseníase(BERNARDES FILHO, 2021;CRIADO et al, 2010). O teste da histamina exógena é o processo mais simples para realizar a prova da histamina e consiste em picar com uma agulha de injeção fina através de uma gota de fosfato ou cloridrato de histamina 1 por 1000 colocada previamente sobre a área suspeita e numa região normal mais distante(COOPER, 1950).…”

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“…Na sequência, observamos uma série de alterações cutâneas conhecidas como tríplice reação deLewis (LEWIS, 1924), são elas: 1º) No local da picada, 20 a 40 segundos após, aparece um eritema circunscrito resultante da vasodilatação das vênulas cutâneas; 2°) Depois de 1 a 3 minutos, observa-se um eritema reflexo secundário, de 3 a 5 cm de diâmetro, cujos limites periféricos são irregulares. Essa reação, característica da pele normal, estará ausente na pele que apresente alterações no reflexo ou este está em menor intensidade na mácula ou área suspeita, o este estará incompleto e deve-se descrever como arreflexia ou hiporreflexia à histamina(BERNARDES FILHO, 2021;LEWIS, 1924) Uma outra forma simples e prática de se avaliar a capacidade reativa dos vasos dérmicos à histamina endógena, sem o inconveniente do desconforto por múltiplas puncturas por agulha é pela aplicação de uma pressão como na indução do dermografismo, na mácula suspeita e na área que a circunda. Traça-se uma reta com um objeto rombo, com pressão contínua, passando da área proximal supostamente normal à área suspeita e, por fim, sobre área distal também supostamente normal.Observam-se após alguns segundos as mesmas reações propostas por Lewis à histamina, porém de menor intensidade (BERNARDES FILHO, 2021)2.6.7 Teste termorregulador do suorO teste termorregulador do suor é usado para avaliar a integridade das vias sudomotoras simpáticas centrais e periféricas do sistema nervoso central para as glândulas sudoríparas cutâneas.…”

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“…Com a perspiração do paciente, de forma semelhante ao teste do iodo-amido, o resultado se firma pela ausência e/ou diminuição de coloração azulada/vinhosa na área suspeita, como se apresenta na periferia com sudorese normal. Pode-se observar ilhas ou ilhotas de anidrose e/ou hipoidrose após exercícios(BERNARDES FILHO, 2021). sural: lateralmente no tornozelo atrás do maléolo lateral.…”

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Ultrassom point-of-care dos nervos periféricos para o diagnóstico da hanseníase e avaliação de contatos

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Ao meu orientador Prof. Dr. Marco Andrey Cipriani Frade, pela luta incansável, pelos ensinamentos ímpares, pela transformação que promove em cada qual que está ao seu lado. O seu brilho é contagiante.Aos meus pais, Guilherme Voltan e Sueli Elisabete Fittipaldi Voltan, pelo amor, apoio e admiração em cada fase da minha vida.Ao "mão", Guilherme Voltan Júnior, pelo amor eterno e por sempre acreditar em mim.Às minhas sobrinhas, Maria Eduarda e Rafaela.À minha mulher, grande amor da minha vida, Tatiana Venâncio Nakamura, por cada olhar, cada ensinamento, por estar ao meu lado nessa trajetória chamada de vida.Ao meu padrinho, Luis Fittipaldi Neto, por sempre abençoar meu caminho.

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Leprosy case series in the emergency room: A warning sign for a challenging diagnosis

Cited by 7 publications

References 9 publications

Silent peripheral neuropathy determined by high-resolution ultrasound among contacts of patients with Hansen's disease

Silent peripheral neuropathy determined by high-resolution ultrasound among contacts of patients with Hansen's disease

Bacilloscopy and polymerase chain reaction of slit-skin smears and anti-phenolic glycolipid-I serology for Hansen’s disease diagnosis

Ultrassom point-of-care dos nervos periféricos para o diagnóstico da hanseníase e avaliação de contatos

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