Examination in Hansen’s Disease-Ajay v Menon

8/14/2019 Examination in Hansens Disease-Ajay v Menon

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EXAMINATIONEXAMINATIONIN HANSENSIN HANSENS

DISESEDISESEAJAY V MENONAJAY V MENON

2424THTH BATCHBATCH

Govt.Medical College,ThrissurGovt.Medical College,ThrissurIndiaIndia


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Eye involvementEye involvement

The hypoesthesia of the cornea,The hypoesthesia of the cornea,

paralysis of the eyelid muscle,paralysis of the eyelid muscle,

inflammation of the tear duct willinflammation of the tear duct will

contribute to the development ofcontribute to the development of

lesions due to exposure of the eye.lesions due to exposure of the eye.

Lagophthalmos-incomplete closure ofLagophthalmos-incomplete closure of

palpebral tissue when lids are shut.palpebral tissue when lids are shut.


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In lepromatous leprosy, beading ofIn lepromatous leprosy, beading of

corneal nerves may be a very earlycorneal nerves may be a very early

sign.sign.

The ciliary body, iris, and cornea areThe ciliary body, iris, and cornea are

directly involved.directly involved.

As the disease progresses, it willAs the disease progresses, it will

lead to loss of visual acuity, cataractlead to loss of visual acuity, cataract

development, glaucoma anddevelopment, glaucoma and

eventually blindness.eventually blindness.


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Nose involvementNose involvement

Rhinitis and nose bleeds are commonRhinitis and nose bleeds are common

in early lepromatous leprosy.in early lepromatous leprosy.

The thick mucous fluid contains largeThe thick mucous fluid contains large

numbers of bacilli and is probably anumbers of bacilli and is probably a

major source of infection.major source of infection.


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Peripheral nervePeripheral nerve

involvementinvolvement Sensory and motor impairment of theSensory and motor impairment of theperipheral nerve will lead to theperipheral nerve will lead to thefollowing deformities:following deformities:

Ulnar -Clawing of fingers IV and V nerve

Adductor weakness of thumb-Pinch impairment

Median - Clawing of fingers I and II alwaysassociated-Opposition and adduction thumbimpairment-Abnormal grasp mechanism


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Lateral Popliteal - Loss of dorsiflexion-Loss of eversion

Posterior Tibial - Clawing of toes


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UlcerationUlcerationUlcers are the result of repeatedUlcers are the result of repeated

trauma on the anaesthetic areas ontrauma on the anaesthetic areas on

the skin.the skin.

The feet may be injured by poorlyThe feet may be injured by poorly

fitting shoes. The patient walkingfitting shoes. The patient walkingbarefooted will often injure his feetbarefooted will often injure his feet

and be unaware of the injury.and be unaware of the injury.

The anaesthetic hands are alsoThe anaesthetic hands are alsoexposed to injury such as burns.exposed to injury such as burns.

Secondary infection of the ulcers isSecondary infection of the ulcers is

common.common.


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DiagnosisDiagnosis

A complete history, physicalA complete history, physical

examination and laboratory tests areexamination and laboratory tests are

the keys to the diagnosis of leprosy.the keys to the diagnosis of leprosy.

Sensory Changes, chieflySensory Changes, chiefly

anesthesia, are the most commonanesthesia, are the most common

symptoms reported by the patients.symptoms reported by the patients.


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NERVES:NERVES:1. There may be area of anaesthesia1. There may be area of anaesthesia

(pins and needles, ants crawling).(pins and needles, ants crawling).

2.Hands or feet-weakening of the small2.Hands or feet-weakening of the small

muscles.muscles.

3. Thickening/tenderness of the3. Thickening/tenderness of the

peripheral and cutaneous nervesperipheral and cutaneous nerves

4. Weakening or loss of function of the4. Weakening or loss of function of the

sweating mechanism in those areassweating mechanism in those areas


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SKIN:SKIN:

1.Erythematous or Hypo-pigmented1.Erythematous or Hypo-pigmented

patch of skin with loss of sensationpatch of skin with loss of sensation

to either/or/and touch, pain,to either/or/and touch, pain,

temperature.temperature.

2. Smooth, oily, shiny and oedematous2. Smooth, oily, shiny and oedematous

appearance of the skinappearance of the skin

3. Diffuse erythema of the skin3. Diffuse erythema of the skin


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4. On a shiny, erythematous and4. On a shiny, erythematous andoedematous skin, there may be nodulesoedematous skin, there may be nodules

or papulesor papules

5. There may be a sudden onset of5. There may be a sudden onset of

painful erythematous nodules as above.painful erythematous nodules as above.

6. There may be a thickening of the6. There may be a thickening of the

earlobesearlobes

7. The eyebrows may become thin or7. The eyebrows may become thin or

even disappear, beginning from theeven disappear, beginning from the


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Clinical examinationClinical examination

The total skin area should beThe total skin area should be

examined carefully.examined carefully.

Use the brightest available naturalUse the brightest available natural

light, side lighting may be useful.light, side lighting may be useful.

Examine from close and far distance.Examine from close and far distance.


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Light touch can be tested byLight touch can be tested by

touching the skin with a wisp oftouching the skin with a wisp of

cotton, while the patient's eyes arecotton, while the patient's eyes are

closed. Some surface areas withclosed. Some surface areas withthick callous skin are normally lessthick callous skin are normally less

sensitive: elbows, knees, soles,sensitive: elbows, knees, soles,

fingers of manual workers.fingers of manual workers.Test tubes with hot and cold waterTest tubes with hot and cold water

may be used to test temperaturemay be used to test temperature

perception.perception.


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Lateral Popliteal Nerve - Patient isLateral Popliteal Nerve - Patient is

asked to dorsiflex the great toeasked to dorsiflex the great toe

against resistance.against resistance.

Posterior Tibial Nerve- The patient isPosterior Tibial Nerve- The patient is

asked to spread the toesasked to spread the toes


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Other sitesOther sites

A detailed examination of the eye isA detailed examination of the eye is

necessary. Check the eyebrows,necessary. Check the eyebrows,

eyelashes, cornea, conjunctiva andeyelashes, cornea, conjunctiva and

iris.iris. Inspect the mouth and throat.Inspect the mouth and throat.

Examine the earlobes.Examine the earlobes.


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Skin SmearSkin Smear

A skin smear may demonstrate theA skin smear may demonstrate the

presence of acid fast bacilli in thepresence of acid fast bacilli in the

skin.skin.

If bacilli are located in the deepIf bacilli are located in the deep

layers of the skin or in the nerveslayers of the skin or in the nerves

they will not be found on the smear.they will not be found on the smear.


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Quantified with the BacteriologicalQuantified with the Bacteriological

Index (BI)-number of bacilli per oilIndex (BI)-number of bacilli per oil

immersion field at microscopicimmersion field at microscopicexamination.examination.

0 No bacilli0 No bacilli

1+ 1 to 10 bacilli per 100 OIF1+ 1 to 10 bacilli per 100 OIF





6+ Over 1000 bacilli per 1 OIF6+ Over 1000 bacilli per 1 OIF


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The Morphological Index (MI) is theThe Morphological Index (MI) is the

percentage of solidly stained bacillipercentage of solidly stained bacilli

of normal size and shape.of normal size and shape.

These bacilli are thought to be theThese bacilli are thought to be the

viable ones, that is the ones that areviable ones, that is the ones that are

alive and may infect someone.alive and may infect someone.

There are problems inThere are problems in

standardization and reproducibilitystandardization and reproducibility

that cause the index not to bethat cause the index not to be

routinely used in practice.routinely used in practice.


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Interpretation of BI andInterpretation of BI and

MIMI Indeterminate and Tuberculoid leprosyIndeterminate and Tuberculoid leprosy

may have ive or 1+ BI.may have ive or 1+ BI.

A nontreated advanced lepromatousA nontreated advanced lepromatous

may have a 4 to 6+BI with MI from 10may have a 4 to 6+BI with MI from 10to 50 %.to 50 %.

A Borderline may show lower BI and MI.A Borderline may show lower BI and MI.

With efficient treatment the MI will goWith efficient treatment the MI will goto 0% rapidly and the BI will generallyto 0% rapidly and the BI will generally

fall by 1+ every 1 or 2 years.fall by 1+ every 1 or 2 years.


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Technique of the skinTechnique of the skin

smearsmear A skin smear may be useful forA skin smear may be useful for

diagnosis: when positive it indicatesdiagnosis: when positive it indicates

leprosy but skin smears are usedleprosy but skin smears are used

primarily for the surveillance of theprimarily for the surveillance of thepatient's bacteriological status.patient's bacteriological status.

A skin smear may be taken on anyA skin smear may be taken on any

suspect lesion, or on the earlobe orsuspect lesion, or on the earlobe or

eyebrow, the elbow or the knee.eyebrow, the elbow or the knee.

This procedure is easy and totallyThis procedure is easy and totally

harmless.harmless.


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Pinch the skin to reduce blood flow.Pinch the skin to reduce blood flow.

Wipe the area with an alcohol sponge.Wipe the area with an alcohol sponge.

Make a small slit with a sterile scalpelMake a small slit with a sterile scalpel

blade or razor blade approximatelyblade or razor blade approximately

5mm long and 2mm deep.5mm long and 2mm deep.

Wipe away any blood which exudes.Wipe away any blood which exudes.

Scrape the edges of the wound with theScrape the edges of the wound with the

blade .blade .

Spread the materials obtained on aSpread the materials obtained on amicroscopic slide. Obtain as little bloodmicroscopic slide. Obtain as little blood

as possible.as possible.


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Skin BiopsySkin Biopsy Examination of a skin biopsy-Examination of a skin biopsy-

definitive diagnosis and classificationdefinitive diagnosis and classificationof the type of leprosy.of the type of leprosy.

Edge of skin lesions or the nodules-Edge of skin lesions or the nodules-

best sites for obtaining a biopsy.best sites for obtaining a biopsy.The biopsy is made-punch or byThe biopsy is made-punch or by

surgical incision-deep enough tosurgical incision-deep enough to

include subcutaneous fat.include subcutaneous fat.The specimens are best preserved inThe specimens are best preserved in

neutral buffered formaldehydeneutral buffered formaldehyde

solutionsolution


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Other skin testsOther skin tests

Histamine Test.Histamine Test.Rarely needed-Histamine Phosphate inRarely needed-Histamine Phosphate in

one drop (1:1000)-placed on an area ofone drop (1:1000)-placed on an area of

normal skin-pricked with a needle-If thenormal skin-pricked with a needle-If the

nerve is intact-weal and annerve is intact-weal and an

erythematous flare-There will be a wealerythematous flare-There will be a weal

as in the first test but no erythematousas in the first test but no erythematous

flare if the nerve is damaged, indicatingflare if the nerve is damaged, indicatinga case of H.D. This test is rarely neededa case of H.D. This test is rarely needed

and is performed only as a last resort.and is performed only as a last resort.


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1.Sweat Test:1.Sweat Test:

Feeling with the back of the fingers forFeeling with the back of the fingers for

coolness of the normal, moist skin, incoolness of the normal, moist skin, incomparison with the warmness of drycomparison with the warmness of dry

skin affected by M.leprae-rarely-skin affected by M.leprae-rarely-

Pilocarpine Nitrate (1:1000)Pilocarpine Nitrate (1:1000)

intradermally in both-sweating isintradermally in both-sweating isabsent-determined-applying Tr. Iodineabsent-determined-applying Tr. Iodine

on the skin, allowing to dry-covering theon the skin, allowing to dry-covering the

area with starch before injecting . Aarea with starch before injecting . Apositive sweat response will turn thepositive sweat response will turn the

starch blue, indicating that thestarch blue, indicating that the

sweating is intact.sweating is intact.


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Cultivation & AnimalCultivation & Animal

ModelsModels It has not yet been possible toIt has not yet been possible to

culture the M.leprae in vitro.culture the M.leprae in vitro.

Multiplies and produces disease-Multiplies and produces disease-

limited number of animal species:limited number of animal species:

The nine banded armadillo is the onlyThe nine banded armadillo is the only

source of large amounts for researchsource of large amounts for research

and production of vaccine.and production of vaccine.


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Inoculation of the normal mouse footInoculation of the normal mouse foot

pad is the basic tool used to studypad is the basic tool used to study

M.leprae drug resistance and theM.leprae drug resistance and the

protective effect of candidate vaccines.protective effect of candidate vaccines.

Immunodeficient mice (thymectomized,Immunodeficient mice (thymectomized,irradiated, bone marrow reconstituted,irradiated, bone marrow reconstituted,

nude) or neonatally thymectomized ratsnude) or neonatally thymectomized rats

are also used.are also used.

Several primates can also beSeveral primates can also be

experimentally infected.experimentally infected.


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Guideline For ScreeningGuideline For Screening

ContactsContacts Select a suitable area where theSelect a suitable area where the

patient will not be embarrassed bypatient will not be embarrassed by

onlookers for performing theonlookers for performing the

examination.examination.


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1.Skin examination:1.Skin examination:

Begin the examination at the headBegin the examination at the head

and proceed down to the extremities.and proceed down to the extremities.

Examine the entire skin surface forExamine the entire skin surface for

any lesions (patches, nodules,any lesions (patches, nodules,

ulcers...)ulcers...)

Check for thinning or absence ofCheck for thinning or absence of

eyebrows.eyebrows.

Examine earlobes for nodules andExamine earlobes for nodules and

enlargement.enlargement.


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2.Neurological2.Neurological

Examination:Examination: Examine the skin lesions, the medialExamine the skin lesions, the medial

parts of the hands and the feet forparts of the hands and the feet for

decreased sensation. Use a wisp ofdecreased sensation. Use a wisp of

cotton and have the patient point tocotton and have the patient point tothe area that was touched.the area that was touched.

Check the ulnar groove for enlargedCheck the ulnar groove for enlarged

ulnar nerveulnar nerve -Check the popliteal area for-Check the popliteal area for

enlarged peroneal nerveenlarged peroneal nerve


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Check for decreased motor functionCheck for decreased motor function

ability in the hand: ability to opposeability in the hand: ability to oppose

thumb to each finger (medialnerve),thumb to each finger (medialnerve),

ability to spread fingers apart andability to spread fingers apart andresist any oppositionresist any opposition


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THANK YOUTHANK YOU

Examination in Hansen’s Disease-Ajay v Menon

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