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A forgotten old disease
EJINME-03482; No of Pages 2 European Journal of Internal Medicine xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
A forgotten old disease Juan Carlos Cataño a,⁎, Sara Isabel Gomez b a b
Infectious Diseases Section, Internal Medicine Department, University of Antioquia School of Medicine, Medellín, Colombia University of Antioquia School of Medicine, Medellín, Colombia
a r t i c l e
i n f o
Article history: Received 2 February 2017 Accepted 19 February 2017 Available online xxxx Keywords: Leprosy Diabetes Infectious disease Hansen disease Mycobacterial infections
© 2017 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine.
1. Indication
2. What is the diagnosis?
An 81-year-old diabetic woman, presented to the out-patient clinic with a 10-year history of glove-like anesthesia in both hands. This neurologic deficit was reported to be accompanied by the spontaneous appearance of blisters on both palms that soon turned into ulcers and then healed only to appear again weeks later. She also disclosed incomplete anesthesia of the face, earlobes, and retroauricular region along with xerodermia, hypohidrosis, and difficulty on closing the eyelids. She reported no other skin lesions on any other part of her body. On physical examination both hands showed claw deformity with palm flattening due to severe thenar and hypothenar atrophy, together with finger shortening and distal phalangeal reabsorption on several of them (Fig. 1, Panel A and B). The sensory deficit compromised the palmar side of both hands but respected the territory of the radial nerve. Cubital nerve thickening was evident on palpation of the left wrist, and, Froment and bottle signs were positive on both hands. On facial examination, gleaming skin, ptosis, lagophthalmos, ectropion, partial madarosis of the lower eyelashes, diffuse skin thickening, and deep facial expression lines were noted (Panel C). Previously, the neurologic deficit on upper extremities and the skin thickening were adjudged to diabetic neuropathy, but glicosilated hemoglobin was normal.
2.1. Diagnosis Skin and lymph smears were obtained from hands, elbows, knees, and earlobes, where Ziehl-Nielsen stains showed abundant Hansen bacilli grouped on globi (Panel D), with a bacillary index of +5,5. The patient was treated with a 1-year course of Dapsone, Rifampin and Clofazimine, following the WHO recommendations for multibacillary leprosy, presenting clinical improvement of the skin lesions but not of the neurologic deficit. Leprosy is a chronic, infectious disease caused by Mycobacterium leprae. It mainly affects the peripheral nervous system, skin, and certain other tissues such as the reticulo-endothelial system, bones and joints, mucous membranes, eyes, testes, muscles, and adrenals [1]. Leprosy clinical presentation varies from few to widespread lesions. Cutaneous and peripheral nerve trunks are frequently invaded by M. leprae, the consequences of this invasion will depend on the affected nerves, individual immunological response, type of leprosy and reactions [2]. Nerve damage is usually characterized by impairment or complete sensory loss in the areas related to the peripheral nerves [3].
Authorship ⁎ Corresponding author at: Calle 15 Sur # 48-130, Medellín, Colombia. E-mail address: [email protected] (J.C. Cataño).
All authors participated equally in patient management, literature review and manuscript writing.
http://dx.doi.org/10.1016/j.ejim.2017.02.018 0953-6205/© 2017 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine.
Please cite this article as: Cataño JC, Gomez SI, A forgotten old disease, Eur J Intern Med (2017), http://dx.doi.org/10.1016/j.ejim.2017.02.018
2
J.C. Cataño, S.I. Gomez European Journal of Internal Medicine xxx (2017) xxx–xxx
Fig. 1. Panel A: Palm flattening due to severe thenar and hypothenar atrophy, associated with blisters and ulcers on both palms. Panel B: Claw deformity, together with finger shortening and distal phalangeal reabsorption on several of them. Panel C: Gleaming skin, lagophthalmos, ectropion, partial madarosis of the lower eyelashes, diffuse skin thickening, and deep facial expression lines. Panel D: Ziehl-Nielsen stain 1000×, showing abundant Hansen bacilli grouped on globi.
Funding Nothing to declare. Conflict of interest statement
References [1] Talhari C, Talhari S, Penna GO. Clinical aspects of leprosy. Clin Dermatol 2015;33(1): 26–37. [2] Scollard DM, Dacso MM, Abad-Venida ML. Tuberculosis and leprosy: classical granulomatous diseases in the twenty-first century. Dermatol Clin 2015;33(3):541–62. [3] de Freitas MR, Said G. Leprous neuropathy. Handb Clin Neurol 2013;115:499–514.
All authors declare no conflicts of interest.
Please cite this article as: Cataño JC, Gomez SI, A forgotten old disease, Eur J Intern Med (2017), http://dx.doi.org/10.1016/j.ejim.2017.02.018
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
A forgotten old disease Juan Carlos Cataño a,⁎, Sara Isabel Gomez b a b
Infectious Diseases Section, Internal Medicine Department, University of Antioquia School of Medicine, Medellín, Colombia University of Antioquia School of Medicine, Medellín, Colombia
a r t i c l e
i n f o
Article history: Received 2 February 2017 Accepted 19 February 2017 Available online xxxx Keywords: Leprosy Diabetes Infectious disease Hansen disease Mycobacterial infections
© 2017 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine.
1. Indication
2. What is the diagnosis?
An 81-year-old diabetic woman, presented to the out-patient clinic with a 10-year history of glove-like anesthesia in both hands. This neurologic deficit was reported to be accompanied by the spontaneous appearance of blisters on both palms that soon turned into ulcers and then healed only to appear again weeks later. She also disclosed incomplete anesthesia of the face, earlobes, and retroauricular region along with xerodermia, hypohidrosis, and difficulty on closing the eyelids. She reported no other skin lesions on any other part of her body. On physical examination both hands showed claw deformity with palm flattening due to severe thenar and hypothenar atrophy, together with finger shortening and distal phalangeal reabsorption on several of them (Fig. 1, Panel A and B). The sensory deficit compromised the palmar side of both hands but respected the territory of the radial nerve. Cubital nerve thickening was evident on palpation of the left wrist, and, Froment and bottle signs were positive on both hands. On facial examination, gleaming skin, ptosis, lagophthalmos, ectropion, partial madarosis of the lower eyelashes, diffuse skin thickening, and deep facial expression lines were noted (Panel C). Previously, the neurologic deficit on upper extremities and the skin thickening were adjudged to diabetic neuropathy, but glicosilated hemoglobin was normal.
2.1. Diagnosis Skin and lymph smears were obtained from hands, elbows, knees, and earlobes, where Ziehl-Nielsen stains showed abundant Hansen bacilli grouped on globi (Panel D), with a bacillary index of +5,5. The patient was treated with a 1-year course of Dapsone, Rifampin and Clofazimine, following the WHO recommendations for multibacillary leprosy, presenting clinical improvement of the skin lesions but not of the neurologic deficit. Leprosy is a chronic, infectious disease caused by Mycobacterium leprae. It mainly affects the peripheral nervous system, skin, and certain other tissues such as the reticulo-endothelial system, bones and joints, mucous membranes, eyes, testes, muscles, and adrenals [1]. Leprosy clinical presentation varies from few to widespread lesions. Cutaneous and peripheral nerve trunks are frequently invaded by M. leprae, the consequences of this invasion will depend on the affected nerves, individual immunological response, type of leprosy and reactions [2]. Nerve damage is usually characterized by impairment or complete sensory loss in the areas related to the peripheral nerves [3].
Authorship ⁎ Corresponding author at: Calle 15 Sur # 48-130, Medellín, Colombia. E-mail address: [email protected] (J.C. Cataño).
All authors participated equally in patient management, literature review and manuscript writing.
http://dx.doi.org/10.1016/j.ejim.2017.02.018 0953-6205/© 2017 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine.
Please cite this article as: Cataño JC, Gomez SI, A forgotten old disease, Eur J Intern Med (2017), http://dx.doi.org/10.1016/j.ejim.2017.02.018
2
J.C. Cataño, S.I. Gomez European Journal of Internal Medicine xxx (2017) xxx–xxx
Fig. 1. Panel A: Palm flattening due to severe thenar and hypothenar atrophy, associated with blisters and ulcers on both palms. Panel B: Claw deformity, together with finger shortening and distal phalangeal reabsorption on several of them. Panel C: Gleaming skin, lagophthalmos, ectropion, partial madarosis of the lower eyelashes, diffuse skin thickening, and deep facial expression lines. Panel D: Ziehl-Nielsen stain 1000×, showing abundant Hansen bacilli grouped on globi.
Funding Nothing to declare. Conflict of interest statement
References [1] Talhari C, Talhari S, Penna GO. Clinical aspects of leprosy. Clin Dermatol 2015;33(1): 26–37. [2] Scollard DM, Dacso MM, Abad-Venida ML. Tuberculosis and leprosy: classical granulomatous diseases in the twenty-first century. Dermatol Clin 2015;33(3):541–62. [3] de Freitas MR, Said G. Leprous neuropathy. Handb Clin Neurol 2013;115:499–514.
All authors declare no conflicts of interest.
Please cite this article as: Cataño JC, Gomez SI, A forgotten old disease, Eur J Intern Med (2017), http://dx.doi.org/10.1016/j.ejim.2017.02.018