HANSENS DISEASELEPROSY2 Reactions in Leprosy Differential Diagnosis Examination

HANSEN’S DISEASE(LEPROSY)-2 • Reactions in Leprosy • Differential Diagnosis • Examination of nerves Dr. Rajeev Agarwal M. B. B. S. , M. D. (Dermatology) Associate Professor

Lepra Reactions �Acute episodes or bouts of exacerbations occurring in course of chronic disease �Sudden increase in activity of existing lesions, appearance of fresh lesions with or without constitutional symptoms �Type I reaction - all borderline cases (BT, BB, BL) �Type II reaction - BL & LL cases

Precipitating factors �Physiological conditions like pregnancy �Drugs: anti-leprosy drugs, iodides �Severe physical or mental stress �Infections

Type I Reaction �Sub-types - Upgrading (Reversal) - Downgrading �Type IV hypersensitivity reaction. �Existing lesions worsen/New lesions may appear �Neuritis / Nerve abscesses �Systemic disturbances: Unusual

Type 1 Reaction

Type 1 reaction

Type I reaction - complications �Neuritis �Dactylitis, edema of hands & feet, inflammation of small joints of fingers �Corneal anesthesia, Conjunctivitis �Sudden occurrence of claw hand, foot-drop, facial palsy

Type II Reaction �Occurs in BL and LL cases �Type III hypersensitivity reaction �Erythema Nodosum Leprosum-crops of painful, recurrent, erythematous, papulonodular lesions. �Fever and malaise �Iridocyclitis, episcleritis, epididymo-orchitis, arthritis, neuritis, lymphadenitis

Type 2 reaction

Type 2 reaction-ENL

Necrotic ENL

Type II Reaction - complications �Frozen hand �Laryngitis �Non-paralytic deformity �Polyarthritis/ RA-like syndrome �Multiple dactylitis �Leucocytosis, Anaemia, raised ESR �Albuminuria/ nephrotic syndrome �Liver/spleen enlargement �Epididimytis/ orchitis, Testicular atrophy/sterility �Gynaecomastia �Adrenal gland hypofunction �Eye involvement

Differential diagnosis of leprosy Macular lesions �Vitiligo � Occupational leucoderma � Tinea versicolor � Pityriasis alba � Post kala azar dermal leishmaniasis � Naevus depigmentosus � Scars

Nevus depigmentosus

Pityriasis alba

Pityriasis versicolor

Morphea

Vitiligo

Post steroid injection hypopigmentation

Post inflamatory hypopigmentation

Post Kala azar Dermal Leishmaniasis (PKDL)

Differential diagnosis of leprosy Papulo-plaque lesions with or without annular cofiguration �Lupus vulgaris �Lupus erythematosus �Granuloma annulare �Annular syphilides �Post kala azar dermal leismaniasis (infiltrated lesions) �Sarcoidosis �Psoriasis �Mycosis fungoidosis �Pityriasis rosea �Tinea corporis

Lupus Vulgaris

psoriasis

Granuloma Annulare

Pityriasis rosea

Sarcoidosis

Cutaneous Leishmaniasis

Mycosis Fungoidesannular lesions

Secondary Syphilisnoduloplaque lesions

Differential diagnosis of leprosy Nodular lesions �Post kala azar dermal leismaniasis � Cutaneous leismaniasis �Syphilis �Onchocerciasis �Sarcoidosis �Leukaemia cutis �Mycosis Fungoides �Nodules of neruofibromatosis

NEUROFIBROMAT OSIS

Nodular syphilis

Sarcoidosis- papulo nodular

Differential diagnosis of neurological conditions Sensory impairment with or without muscle wasting �Peripheral neuropathy � Diabetic neuropathy �Primary amyloidosis of peripheral nerves � Congential sensory neuropathy � Syringomyelia � Tabes dorsalis � Thoracic outlet syndrome �Alcoholic neuropathy

Clinical examination �Type and number of skin lesions �Sensory impairment �Motor examination �Nerve examination �Sweating �Loss of hair

Clinical examination: Sensory �Touch Tested with wisp of cotton, nylon thread or feather. �Temperature Tested with two test tubes – one containing hot water and other cold �Pain Tested by pin prick

Test for corneal sensation

Clinical examination : Motor �Testing of motor power- Done clinically �Electro-diagnosis - Employed in very early cases. Electrical stimulator using faradic and galvanic current used to test muscle power.

Oschner’s clasping test showing pointing index - median nerve above elbow

Pen test-median nerve

Book test showing positive Froment’s sign(flexion of DIP of thumb)-deep branch of ulnar nerve involvment

Card test-weakness of palmar interossei

Beak test-test radial, ulnar and median nerve

Nerves �Supra/ infraorbital �Greater auricular �Clavicular �Radial �Sup. Radial cut �Ulnar � Median � Lateral popliteal � Posterior tibial � Anterior tibial � Sural

Supra orbital nerve

Great auricular nerve

Ulnar nerve examination

Median nerve examination

Radial nerve examination at wrist

Lateral popliteal nerve

Sural nerve

Anterior tibial nerve

Posterior tibial nerve

Thank you