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INTERNATIONAL JOURNAL OF LEPROSY^ Volume 64, Number 2

Printed in the U.S.A.

CORRESPONDENCE

This department is . for the publication of informal communications that are ofinterest because they are informative and stimulating, and for the discussion ofcontroversial matters-. The mandate of this JOURNAL is to disseminate informationrelating to leprosy in particular and also other nircobacterial diseases. Dissidentcomment or interpretation on published research is of course valid, but personalityattacks on individuals would seem unnecessary. Political comments, valid or not,also are unwelcome. They might result in interference with the distribution of theJOURNAL and thus interfere with its prime purpose.

Changes of Autonomic Nerve Function in the FirstTwo Weeks of Acute Neuritis in a Patient

with Borderline Leprosy

TO THE EDITOR:

Little is known of the time course of au-tonomic nerve dysfunction in the early stagesof acute leprous neuritis, and it is not knownhow steroid treatment affects autonomicnerve dysfunction. In comparison with mo-tor and sensory functions, we followed forover 2 weeks the autonomic nerve functionparameters of sympathetic skin response(SSR) and vasomotor response (VMR) in apatient with newly diagnosed leprosy andacute, severe, reversal reaction.

A 49-year-old Nepali woman with newlydiagnosed borderline lepromatous leprosydeveloped acute, severe, reversal reaction(type 1) 1 week after the first dose of mul-tidrug therapy (600 mg rifampin, 100 mg/day clofazimine, 100 mg/day dapsone). Shehad noticed several skin patches with hy-pesthesia on her hands and face as well asparesthesia in both hands over the past 3months. She had previously been in goodhealth with no malnutrition, and did notdrink any alcohol. On examination, skin le-sions were present in nine body areas andeight nerves were enlarged and tender. Bothhands and feet appeared warm and dry withno cracks or skin atrophy.

Treatment with 60 mg/day prednisonewas started. Over 14 days, autonomic nervefunction parameters of SSR and VMR weretested as described by Soliven, et al.( 9 ) andLow, et al.( 7 ) on days 1 (on admission beforesteroid treatment), 3, 5, 7, 10 and 14. In

parallel motor (modified MRC scale as de-scribed by Brandsma 2 ) and sensory function(standard set of five Semmes-Weinsteinmonofilaments) as described by Bell-Kro-toskin was semi-quantitatively measured.VMRs were measured over the skin of thepulp of the distal phalanges of 10 fingersand the two big toes. SSRs were measuredin each foot and hand.

VMRs are listed as the proportionate per-cent reduction for one digit by taking thesum of all and dividing by 12. In addition,the total number of digits with pathologicalreflexes is listed. Using the Low, et al. cri-terion, a reflex was considered pathologicalif <45% reduction (hand) and <40% (foot)occurred.

The SSR response is considered absentand pathological if no consistent skin volt-age change is observed using a sensitivityof 50 V/cm after at least 10 trials separatedby long intervals (1-3 min) to avoid thenatural habituation of the response.

To quantify sensory and motor testing wedeveloped a scoring system. The sensoryscore per site varies from 0-5. A score of 5is given when the thinnest monofilament inthe test series is felt (on the hand, 50 mg:on the feet, 200 mg). A score of zero is givenif the thickest filament is not felt. Three pre-determined bilateral ulnar nerve and me-dian nerve sites were tested. A maximumscore is 60. The motor score consists of thesum of individual scores (0-5: 0 = para-lyzed, 5 = normal strength) for muscles in-

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170^ International .Journal of Leprosy^ 1996

nervated by the ulnar, median and radialnerves with a maximum score of 60. (Fur-ther details on all technical procedures maybe requested from the author.)

Pain, sensation and weakness improvedmoderately (The Table) with prednisonetreatment which was reduced to 50 mg/dayon day 10. The results of the 2-week periodare given in The Table.

DISCUSSIONThere are no data available on the effects

of treatment on the autonomic nervous sys-tem involvement in acute neuritis of lep-rosy. Burte, et al.( 4) studied the effect of 1year of clofazimine therapy on the auto-nomic function in patients with longstand-ing lepromatous leprosy and found no sig-nificant improvement of function. How-ever, all patients had longstanding nervedamage with frequent type 2 (erythema no-dosum leprosum) reactions.

We have followed the course of autonom-ic dysfunction in newly diagnosed leprosywith acute neuritis (type 1, reversal reac-tion) over the first 2 weeks of treatment withhigh-dose prednisone. On the day of ad-mission, three pathological VMRs wereelicited. Over the following 2 weeks thenumber of pathological reflexes steadily in-creased to involve all 12 digits. In parallelthe average percent reduction of the re-sponse steadily decreased to very low levels.Interestingly, the SSR showed an oppositecourse. Absent until day 7, the SSR waspresent from day 10 onward. The course ofsensory and motor modalities was similarto the SSR with moderate improvement.How can SSR, sensory and motor functionimprove and vasomotor function deterio-rate in parallel?

One would expect that the broad im-munosuppression induced by prednisonewould have a positive effect at all levels ofneural function. Possibly the concepts of"selective early autonomic nerve damage"and "innocent bystander damage" to au-tonomic nerves may help to explain. "Se-lective early autonomic nerve damage" hasbeen suggested by immunocytochemical andvasomotor studies ('• 5 ). The longer leprosyinfection persists, the wider the spectrum ofnerve fiber involvement. Karanth, et al.'simmunocytochemical study( 5 ) specifically

looked at the differing extent of autonomicnerve damage innervating various skin or-gans. They found that autonomic nerve fi-bers supplying blood vessels were more fre-quently damaged than those innervatingsweat glands in patients with tuberculoidleprosy.

"Innocent bystander damage" to auto-nomic nerves may occur in acute reactionswhich incorporate a host of systemic cel-lular and humoral immune responses( 8 ).These concentrate in and around vessels,possibly damaging "innocent bystanders"such as the nerve endings innervatingsmooth muscle in the vessels. Here, damageto nerves may be for longer periods thandamage to the nerves innervating sweatglands. It is also conceivable that sweat glandinnervation has better plasticity than va-somotor innervation, although this has noclinical or experimental support.

Lastly, differing sensitivity of the two testsneeds to be considered as a possible con-flicting factor. The VMR is known to bemore sensitive than the SSR( 6 ). If this wereto be a conflicting problem in our case, onewould expect the SSR to be affected later onwhen the more sensitive VMR showedmaximal dysfunction.

This case report suggests that in predni-sone-treated, acute, early, leprous neuritisthere may be ongoing, selective, autonomicnerve damage while sensory and motornerve fibers are improving.

—Einar Wilder-Smith, M.D.Department of NeurologvInselspitalUniversity of BerneCII-3010 Berne, Switzerland

—Frauke Worpel, M.D.Annelies Wilder-Smith, M.D.

Green Pastures HospitalPokhara, Nepal

Acknowledgment. Our thanks go to the Physio-therapy Department of Green Pastures Hospital, Pok-hara, Nepal, in particular Mr. Khadka, Mr. Krishnaand Mr. Agdi for performing the TST and VMT tests.A special thanks to Mr. Khawas for help in performingneurophysiological tests. The research project was fi-nancially sponsored by the Swiss Academy for Medi-cine and the Swiss Sandoz Fund for Medico-BiologicalProjects.

64, 2^ Correspondence^ 171

REFERENCES1. BECK, J. S., ABBOT, N. C., SAMSON, P. D., BUTLIN,

C. R., GRANGE, J. M., CREE, I. A., FORSTER, A. andKHAN, F. Impairment of vasomotor reflexes in thefingertips of leprosy patients. J. Neurol. Neurosurg.Psych. 54 (1991) 965-971.

2. BELL-KROTOSKI, J. A. "Pocket" filaments andspecifications for the Semmes-Weinstein monofi-laments. J. Hand Ther. 3 (1990) 26-31.

3. BRANDSMA, W. Basic nerve function assessment inleprosy patients. Lepr. Rev. 52 (1981) 161-170.

4. BURTE, N. P., CHANDORKAR, A. G., MULEY, M. P.,BAL-SARA, J. J. and BULAKH, P. M. Effect of oneyear treatment on autonomic functions in lepro-matous leprosy with lepra (ENL) reaction. Lepr.India 55 (1983) 278-285.

5. KARANTH, S. S., SPRINGALL, D. R., LUCAS, S., LEVY,D., ASHBY, P., LEVENE, M. M. and POLAK, J. M.

Changes in nerves and neuropeptides in skin from100 leprosy patients investigated by immunocyto-chemistry. J. Pathol. 157 (1989) 15.26.

6. Low, P. A. Autonomic nervous system function.J. Clin. Neurophysiol. 10 (1993) 14-27.

7. Low, P. A., NEUMANN, C., DYCK, P. J. and FEALEY,

R. D. Evaluation of skin vasomotor reflexes byusing laser doppler velocimetry. Mayo Clin. Proc.58(1983) 583-592.

8. MEYERS, W. M. and MARTY, A. M. Current con-cepts in the pathogenesis of Leprosy. Drugs 41(1991)832-856.

9. SOLIVEN, B. C., MASELLI, R. A., JASPAN, J. B., GREEN,A. J., GRAZIANO, H., PETERSEN, NI. and SPIRE, J. P.

Sympathetic skin response in diabetic neuropathy.Muscle Nerve 10 (1987) 711-716.

Leprosy and AIDS in the Amazon Basin

To THE EDITOR:The state of Amazonas in Brazil is a hy-

perendemic area of leprosy. Although therehas been a control program in action forabout the last 20 years, the prevalence rateand the detection rate were 39.4 per 10,000and 67 per 100,000 inhabitants in 1994,respectively. The first case of AIDS in thestate was diagnosed in 1986. Although thereis a low incidence rate of AIDS in the stateof Amazonas (9.5/100,000), 63% of the caseswere diagnosed within the last 3 years (Min-isterio da Saude do Brasil. Boletim Epide-miologico D.S.T./AIDS, Brasilia, 1995. AnoVII). This shows an increased trend of AI DSin the region. Despite an existing possibilityof an interaction between Mycobacteriumleprac and the HIV infection(I -3 . 6 . 7 ), fewclinical reports have been written and theeffects of this co-infection have not yet beendefined( 4 . 5 ).

In this letter, the clinical aspects and pro-gression of four patients who were identifiedas having leprosy and HIV infection [HIV1-HIV 2 antibodies by enzyme immuno-assay (Genelavia-Sanofi, France, and im-munolluorescence)], one of them with AIDSwhich was identified by the presence of Ka-posi's sarcoma, are described.

Case 1. JCLN, a 25-year-old marriedmale, presented with a hypochromic lesionon the left arm, was skin-smear negative,intradermal reaction was Mitsuda positiveand a histopathological examination of thelesion showed tuberculoid infiltrate. This ledto the diagnosis of the tuberculoid form ofleprosy in October of 1992. A drug com-bination treatment, including ofloxacin, wasgiven to the patient who had agreed to takepart in a double-blind trial for a period of6 months. The patient took the treatmentregularly and had no side effects or leprosyreactions. A routine serologic exam showeda positive result for HIV on 27 October1993. Only after that did the patient say thathe had known he was infected with HIVsince 1991 but that he had ignored the factand had not taken any preventative mea-sures. The leprosy lesion has disappeared,and a general clinical exam and laboratoryexams have not shown any abnormalities.

Case 2. VNA, a 27-year-old, male ho-mosexual hairdresser. A diagnosis of bor-derline lepromatous leprosy was made on15 September 1994. The patient presentedwith skin infiltration and disseminatedplaques. The first skin-smear exam showeda bacterial index (131) of 3.2 with 1% of intact