Download MBBS Dermatology PPT 15 Leprosy Lecture Notes

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? 1. Anaesthetic/hypoaeshetic skin lesion or lesions
? 2. Enlarged peripheral nerve\s with impairment of sensations in the

area supplied

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? 3. Acid-fast bacilli in the slit skin smear

? Any one of these signs is sufficient for diagnosis of leprosy. Two of

them are clinical. Therefore clinical skill of the health care worker is

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important for diagnosis of leprosy.
Exclusion criteria for diagnosis of leprosy

? White (de-pigmented), dark red or black in colour

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? Scaly lesion (regressed type 1 lepra reaction lesion may show scaling)
? Present since birth
? Seasonal or appears and disappears suddenly
? Hurts (discomfort may be felt in leprosy reaction )/ itches
? Presence of sweating

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Current WHO classification.

MB; Multi bacil ary. PB; Pauci bacil ary.

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Criteria

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MB

> 6 skin lesions, or

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Positive bacterial

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index

PB

5 skin lesions

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and

Negative bacterial

index

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Leprosy Spectrum

CMI+Ab-ve

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CMI?ve, Ab+


? Il -defined patch of

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indeterminate leprosy

RIDLEY-JOPLING

CLASSIFICATION

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RIDLEY JOPLING CLASSIFICATION

Tuberculoid leprosy (plaque type)

-Single or 2 or 3

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-Erythematous or coppery
-Dry surface, hairless
-Raised well defined edge with sharp outer

margin and sloping inside & tendency of

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central flattening

-Sensation(touch, temp. pain) : absent
-Feeding nerve to the patch or solitary

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peripheral nerve may be thickened

-AFB: negative
Lepromin: +++

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TT

? WELL DEFINED RAISED OUTER

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BORDER OF A TT LESION .

? ENLARGED GREATER AURICULAR

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NERVE

? INVOLVEMENT OF EAR

BT

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? Large patches of BT leprosy

? SATELLITE LESIONS
BB Leprosy (macular, plaque, inverted saucer

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shaped)

? Several number, bilateral but

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asymmetrical distribution

? Variable size, sloping outer edge &

central punched out area

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? Sensation: slightly diminished
? Slightly shiny
? Asymmetrical many nerve thickening
? AFB: moderate 2+to3+

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? Lepromin: negative

Inverted saucer-shaped lesion of BB

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LL (Fine to course infiltration)


? BILATERAL LOSS OF EYEBROWS ,

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MOUSTACHE & BEARD

? glove & stocking distribution of

neuropathy.

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Pure neuritic leprosy

HISTORY TAKING

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?

Primary goal of history taking is to establish the diagnosis by excluding

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other conditions simulating leprosy. History should be taken

according to the fol owing steps, mostly like any other medical history;

? ? Personal identification and demographic data.

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? ? Presenting complaints.

? ? History of present il ness.

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? ? Past history.

? ? Family history.

? ? Personal history.

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Various presenting features of leprosy



IN ABSENCE OF REACTION

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1.Skin lesions:; hypopigmented / erythematous, hypoaesthetic patches, skin-coloured / erythematous

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papules,plaques nodules, which may be waxy ? umbilication.



2. Hypoaesthesia along distribution of peripheral nerves / gloves and stockings hypoaesthesia

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3. Spontaneous blisters and ulcers on the hands and/ or
feet

4.

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Trophic changes ; dryness, ichthyosis, fissuring / trophic ulcer

5.

Diffuse swelling of hands and feet ( early sign of lepromatous leprosy / leprosy reactions)

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6.

Nasal stuffiness, epistaxis (early sign of lepromatous leprosy)

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7.

Irregular thickening of ear and nodules on face (lepromatous leprosy)

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WH I LE IN REACTION

1. Tingling and numbness of hands and/ or feet

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2. Sudden w eakness of hands and/ or feet / inability to close eyelids

3. Sudden redness, swelling and pain of existing lesions and / or appearance of new lesions with or without

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constitutional symptoms (type 1 reaction)

4. Sudden appearance of crops of evanescent, erythematous, painful nodules on apparently normal looking skin

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with or without constitutional symptoms (erythema nodosum leprosum / type 2 reaction) / type 2 reaction)

5. Painful swelling on the dorsal aspect of wrists (tenosynovitis)

6. Acute scrotal pain (epididymo-orchitis)

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7. Pain in and around eyes, redness, photophobia or diminished vision (iridocyclitis)

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IN PRESENCE OF DEFORMITY

1.

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Inability to use hands for precision works; e.g., button a shirt, eating rice with hands, typing, etc;



2.

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Inability to make a power-grip; e.g., holding a rod, carrying utensils.

3.

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Inability to wear slipper.

(al these are indicative of peripheral anaesthesia and poor functioning of smal muscles of hands and feet).

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Looking for other organ involvement in leprosy

Table 10.2: Looking for other organ involvement in l

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ORGAN

SPECIFIC QUESTIONS TO BE ASKED

Eye

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Difficulty in eye closure? (Lagophthalmos)

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Red eye with pain, watering and sticky discharge? (Corneal ulceration)

Red eye with pain, photophobia and diminished vision? (Iridocyclitis)

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Localized redness, severe radiating pain to temporal region, normal/ slightly reduced vision? (Scleritis)

Localized redness, mild pain, normal vision? (Episcleritis)

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Upper respiratory tract

Unable to perceive smel of food and scented materials? (Anosmia)

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Nose is blocked with occasional bleeding?

Change of voice, chronic cough, and occasional breathlessness? (Laryngeal involvement)

Any episode of acute respiratory distress? (Laryngeal oedema)

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Cardiovascular system*

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Palpitation?

Dyspnoea on exertion?

Swelling of feet?

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Adrenal glands**

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Features of adrenal insufficiency? e.g., hypotension, asthenia, prostration

Male reproductive system

Normal / diminished libido? (Testicular atrophy)

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Enlarging male breasts? ( Testicular atrophy)

If married, whether having children? (Sterility)

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*Cardiovascular involvement in leprosy is very rare and rarely gives rise to symptoms. Involvement of peripheral blood vessels, though frequent, is rarely symptomatic.

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** Adrenal suppression is very rare in leprosy. However, it may occur rarely during an episode of T2R..

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? RR in a case of BT leprosy,

(left), RR in a case of BB leprosy

(Right), note the shiny erythematous

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and oedematous plaques.

? BT lesion with type 1 reaction

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? ENL in a case of LL. Note the

shiny erythematous papules

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and nodules (usual y tender)

over face and thighs. The

lesions are evanescent and

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usual y associated with systemic

features like fever, malaise,

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joint pain etc.

? NODULES OF ENL

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? Spontaneous blister on finger

? Cal osity over lateral mal eolus

(pressure point)

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? Trophic ulcer

? partial or ulnar clawhand

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? Bilateral complete claw hands

with guttering of dorsal

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? interosseous spaces and

cal osities on interphalangeal

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joints.

? A case of Bell's palsy (right side).

The facial paralysis in leprosy

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involves upper part of face (due to

selective involvement of

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zygomatic branch of facial nerve

by a leprosy lesion in the vicinity).

In Bell's palsy the involvement of

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facial nerve is higher up, due to

oedematous compression in facial

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canal, affecting al branches,

leading to paralysis of both upper

& lower parts of face.

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? Secondary ichthyosis in

lepromatous leprosy with

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brownish discoloration of the

scales due to clofazimine.

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? LAGOPHTHALMOS
Lagophthalmos- inability to close the eyes , is in direct

proportion to the extent of damage to facial nerve
If the eyes cannot be closed regularly by normal blinking, or if

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the eyes are not closed while sleeping , then the eyes are at risk

of exposure keratitis

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CLINICAL EXAMINATION

? Clinical examination involves the following steps:
? 1. General physical examination
? 2. Cutaneous and mucosal examination

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? 3. Ocular examination
? 4 Palpation of peripheral nerves and testing for sensory impairment.
? 5. Examination of musculoskeletal system
? 6. Examination of external genitalia
? 7. Other systemic examination, wherever indicated.

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Precautions for examination of skin lesion

?

Examine patient under good light (preferably natural light)

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?

Provide privacy to the patient

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?

Examine the whole skin from head to toe as much as possible.

?

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Always use the same order of examination, so that you do not forget to

examine any part of the body.

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?

Ensure presence of an assistant of the same sex as that of the patient to assist

you. Especially, if the patient is of the opposite sex.

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? A quick general cutaneous survey should be done followed by

examination of individual skin lesions.

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? Prior explanation to the patient along with gaining his / her

confidence is of immense importance in achieving patient

cooperation.

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? DIFFUSE COARSE INFILTRATION OF THE SKIN- LL

? MORE SEVERE INFILTRATION

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WITH NODULAR LESIONS

(LEONINE FACIES)

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LL (Leonine face)

Lepromatous nodule on tongue and palate

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(same pt.)


? Oedema of hands and feet in a

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patient with

untreated LL

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? Recommended sensory testing

sites (WHO) on palms and soles

OCULAR EXAMINATION

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? Tested by-

- fine wisp of cotton

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- lightly blowing a puff of air into each cornea (Hutchison's 21 ed)
- aesthesiometer (fine filament ?calibrated)
- observing infrequent blinking (because the stimulus for eye closure

is decreased)

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? TESTING CORNEAL SENSATION

PALPATION OF PERIPHERAL NERVES

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? Clinician should be well aware of the specific sites / bony land-marks

along which the peripheral nerves commonly involved in leprosy are

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to be palpated, as well as the area of distribution of sensory nerves.

? Nerve palpation should be gentle (using pulps of fingers rather than

tips) to avoid causing pain to an inflamed nerve (neuritis).

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Nerve

Site / bony landmark

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Patient position

Method

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Head & Neck
Supraorbital

Supraorbital notch at the junction of medial 1/3rd and

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Sitting / standing with

Palpate with both thumbs on both sides (Fig 38)

lateral 2/3rd of supraorbital ridge

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head kept straight.

Supratrochlear

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Medial to the supraorbital nerve

Same as above

Same as above

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Infra orbital foramen, just below the medial part of inferior Same as above

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Same as above

orbital margin

Infraorbital

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Branches of facial nerve:

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Zygomaic & temporal.

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Zygomatic arch

Same as above

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Same as above

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Great auricular

Lateral side of neck, crosses sternomastoid muscle, from

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Sitting / standing with head turned completely to

Easily visible, crossing sternomastoid obliquely. May be palpated with 2 fingers

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lateral side to infra-auricular area.

opposite side

Clavicular

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Shaft of clavicle

Sitting / standing straight

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Fingers rol ed along the shafts of both clavicles

(3 sets)

Upper extremity

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Sitting / standing with elbow flexed at 90?.

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Spiral groove on humerus, posterior to the deltoid

Examiner's right hand holds patient's right hand in Examiner's left fingers rol the nerve in the radial groove.

insertion.

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shaking-hand manner (& vice versa).

Radial

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Examiner's left little finger locate the nerve in the groove; other fingers palpate

the nerve upwards along medial aspect of arm (Fig 39).

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Ulnar groove on medial epicondyle of humerus, medial to

Same as above.

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the point of elbow.

Ulnar

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(Both the nerves may be palpated simultaneously
for better comparison)

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Lateral border of radius, just proximal to the wrist;

Same as above.

Examiner's left fingers rol the nerve against radius (Fig 40). It can be further

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thereafter along the proximal part of extensor pollicis

traced and rol ed from side to side on extensor pol icis longus tendon &dorsum

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longus tendon, which stands out prominently on ulnar side Patient is asked to extend the thumb to visualize of hand.

of the anatomical snuff box

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the anatomical snuff box.

Radial cutaneous

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Proximal to the flexor aspect of wrist joint (proximal to

Sitting / standing with elbow flexed at 90?, &

Examiner's right fingers palpate the nerve deep between the tendons.

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flexor retinaculum), between the tendons of palmaris

wrist in supination. Examiner's left hand

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Median

longus and flexor carpi radialis

stabilizes patient's right hand and vice versa

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? Palpation of supraorbital nerve

with; fingers are used to

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stabilize the head.


? Palpation of radial cutaneous

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nerve.

? Palpation of ulnar nerve

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? Palpation of lateral popliteal

nerve.

? Palpation of sural nerve.

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? Palpation of posterior tibial

nerve.

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? Sensory distribution of feet by

various nerves

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? Sensory distribution of HANDS

by various nerves

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? Terminal branches of facial

nerve

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MUSKULOSKELETAL

SYSTEM EXAMINATION

? Z THUMB DEFORMITY

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? Ochsner's clasping test with

pointing index.

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? Pen test.


? Book test with positive

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Froment's sign (right side

? Positive Wartberg's sign:

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earliest evidence of

ulnar nerve palsy
Examination of External Genitalia

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? genitalia of both male and female patients should be inspected for presence of skin

lesions

? in male patients, testicles should be palpated gently to see for:

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? ? Size and consistency:

? Whether the testicles are firm, resilient and of appropriate size or smal and soft (sequel

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of advanced disease and / or repeated type 2 reaction).

? ? Testicular sensation:

? If absent, indicates fibrosis resulting from repeated episodes of epididymo-orchitis

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(type2 reaction).

? ? Tenderness:

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? Acute testicular pain indicates epididymo-orchitis, a part of type2 reaction and this may

be the presenting feature of type2 reaction.

OTHER SYSTEM EXAMINATION

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? Upper respiratory tract is the most common site of involvement.

Though several other organs are involved in lepromatous leprosy and

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also during type 2 reaction, clinical manifestations of such

involvement are unusual

? A hoarse voice, dry, hacking cough and occasional breathlessness are

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indicative of laryngeal involvement and or uvular dysfunction


LEPROSY (QUICK FACTS)

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Pole Tuberculoid Lepromatous
Skin

Localized lesion,

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Symmetric diffuse lesions,

hypopigmented, raised

papules/macules/nodules,

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erythematous margins

massive tissue destruction

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Nerves

Epitheloid granulomas

Poorly organised

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granulomas, vacuolated

M, few T cells

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M.Leprae

Rare

Abundant

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Classification
WHO

Paucibacillary Multibacillary

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RIDLEY-JOPLING
Immunology

TT

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BT

Borderline

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BL

LL

Adaptive

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Th1, cell mediated, IL-2, IFN- TH2, Humoral mediated,
IL-4, IL-10

Innate

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? ?
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