Wednesday, May 02, 2007

Leprosy Pearls-- lecture by Dr Swift at AAN 1007

1.  Most people (95 %) have immunity to leprosy and cannot get it.
2.  Leprosy is only infection that invades the peripheral nerve. Palpation of nerves is important.
3.  Invasion can take form of nodular or diffuse infiltration.
4.  Erythema nodosum leprosum is an immune reaction that occurs with treatment than can result in severe damage of skin, anterior eye, testes, and nerves and cause infarction/ulcers especially of skin. 
5.  The three types are tuberculous ( immune reaction present), lepromatous (immune reaction absent) and intermediate or borderline.  Borderline is unstable and tends towards lepromatous or tuberculous (reversal reaction).
6.  Signs include affected cool areas with involvement of upper lip (cooler than lower lip), tip of nose, ears, extensor surfaces of extremities, scrotum and testes, anterior third of eye.  May have sparing between toes (warmer).  Failure to close eyes results in corneal drying and lower lid hangs away (lagopthalmos).  Buccinator wrinkles since buccinator is deep.  Ulnar clawing, acute angle glaucoma, or corneal abrasions due to eyelids turning in.  Knee and ankle jerks are normal.  Scalp is only affected in bald patients. 
7.  Treatment of paucibacillary (tuberculoid)  leprosy is with a combination of rifamycin, ofloxacin, and minocycline (check standards which always change).   In paucibacillary intermediate disease use rifamycine 600 mg monthly and dapsone 100 mg daily for 6 months.  In multibacillary (lepromatous) use triple therapy with dapsone 100 mg/day, rifamycine 600 mg/mo, and clofazimine 50 mg per day for 12-14 months.  Also treat reactions with prednisone 60 mg/day or equivalent.  Rehab procedures of affected skin are helpful.  Patients are at high risk of osteomyelitis due to neuropathy.  Casting has been tried.   

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