Radial Cutaneous Nerves Research Articles

Ocular Manifestations of Lepromatous Leprosy

This study was done during the study period November 2020 to September 2022, during which 47 patients of leprosy were examined of whom 36 were Lepromatous leprosy in Ophthalmology department if Rajah Muthiah Medical College and Hospital. In our study 80.06% of Lepromatous leprosy patients had ocular manifestations, of whom maximum prevalence was present in 61-75 age group. The major ocular manifestations present were Madarosis (61.11%), Iridocyclitis (50%), Lagophthalmos (11.11%), corneal anesthesia (22.22%), corneal Hypoesthesia (16.67%), exposure keratitis (8.33%) and corneal opacity (8.33). BCVA- 3/60 to PL (U/L) – 18.06% BCVA- 3/60 to PL (B/L)- 2.8% Most of the patients of Lepromatous leprosy had Bilateral Polyneuropathy. The most common nerve affected in Lepromatous leprosy was found to be ulnar nerve and Radial cutaneous nerve. The ocular symptoms occurred more in patients of WHO grade 2 Disability than grade 2 or grade 1. Ocular symptoms occurred mostly in patients who completed Leprosy treatment. Keywords: Lepromatous leprosy, ocular manifestations, leprosy.

Frequently Thickened Nerve in Hansen’s Disease

Background: Leprosy by definition is a chronic granulomatous infection of the skin and superficial nerves in the skin caused by Mycobacterium leprae and Mycobacterium lepromatosis. [1] It most commonly involves the nose, eyes, throat, and sometimes the testicles. The bacilli are most frequently transmitted via droplets, from the nose during close contact with untreated cases of leprosy. Leprosy was first mentioned in 700BC. Leprosy is common in tropical and subtropical Asia, some Pacific countries, Africa, and South America [2]. It is not known how leprosy is transmitted. Although skin lesions and nerve thickening manifest together, they also appear as separate entities. This study aims to find out the frequently thickened nerves in different spectrums of Hansen’s disease.
 Objectives: To determine the frequently thickened nerves in different spectrums of Hansen’s disease.
 Methods: This descriptive study was conducted in Chettinad Hospital and the Research Institute from June 2021 to August 2021. The patients were biopsy-proven Hansen's disease in a different spectrum of the disease, nerve thickening was obtained using palpation method. The Sample size was small due to the prevailing covid situation at the period during which the study was conducted.
 Results: The data collected from the examination of the different spectrum of disease, the pattern of frequently thickened nerves were evaluated. A total number of 30 patients were examined by palpation method among which 10 patients showed ulnar nerve thickening,7 patients showed greater auricular nerve thickening, 4 patients showed radial cutaneous nerve thickening, 9 patients showed sural nerve thickening.
 Conclusion: In our study, the most common thickened nerve was the ulnar nerve, secondary to that was the sural nerve. This study concludes the only examination done by palpation method, further diagnostic studies might increase the accuracy and specificity of the above-collected data.

High occurrence of disabilities caused by leprosy: census from a hyperendemic area in Brazil’s savannah region

Objectives: To describe leprosy-related disabilities, we performed a census including people affected by leprosy in 78 municipalities of Tocantins state in northern Brazil. The study consisted of a review of patient charts, structured questionnaires, and clinical examinations for disabilities of eyes, hands, and feet (August–December 2009), according to WHO standards. Results: A total of 910 individuals diagnosed from 2006 to 2008 were included (clinical examination and application of questionnaires), but information from patient charts was not available in all cases, resulting in different denominators. The majority (783/858; 91.3%) had completed multidrug therapy. The most common clinical findings included: enlarged/painful peripheral nerves (412/910, 45.3%), namely of ulnar (207; 22.7%), posterior tibial (196; 21.6%), peroneal (186; 20.5%), and radial cutaneous nerves (166; 18.2%); reduction/loss of sensibility 201/907 (22.2%) and reduced motor function (185/906, 20.4%). At diagnosis, 142/629 (22.6%) had Grade 1 disability (G1D), and 28/629 (4.5%) had Grade 2 disability (G2D). At the time of the study, 178/910 (19.6%) presented with G1D, and 84/910 (9.2%) with G2D. Disability grading was significantly higher in males (P < 0.01). Subjects with G2D showed claw hands (26; 2.9%), followed by plantar ulcers (23; 2.5%), abrasion/excoriation on the foot (12; 1.3%), claw foot (7; 0.7%), and drop foot (7; 0.7%). Conclusions: Leprosy-related disabilities were common in a highly endemic area. Prevention and rehabilitation measures, especially after release from treatment, should be intensified by the primary health care system. Policy makers need to be aware of an ongoing demand for leprosy control programmes, even in a world of constantly reducing leprosy detection.

Normal threshold values for a monofilament sensory test in sural and radial cutaneous nerves in Indian and Nepali volunteers

The monofilament test (MFT) is a reliable method to assess sensory nerve function in leprosy and other neuropathies. Assessment of the radial cutaneous and sural nerves, in addition to nerves usually tested, can help improve diagnosis and monitoring of nerve function impairment (NFI). To enable the detection of impairments in leprosy patients, it is essential to know the monofilament threshold of these two nerves in normal subjects. The radial cutaneous, sural, ulnar, median and posterior tibial nerves of 245 volunteers were tested. All nerves were tested at three sites on both left and right sides. Normal monofilament thresholds were calculated per test-site and per nerve. We assessed 490 radial cutaneous and 482 sural nerves. The normal monofilament was 2 g (Filament Index Number (FIN) 4.31) for the radial cutaneous and 4 g (FIN 4.56) for the sural nerve, although heavy manual laborers demonstrated a threshold of 10 g (FIN 5.07) for the sural nerve. For median and ulnar nerves, the 200 mg (FIN 3.61) filament was confirmed as normal while the 4 g (FIN 4.56) filament was normal for the posterior tibial. Age and occupation have an effect on the mean touch sensitivity but do not affect the normal threshold for the radial cutaneous and sural nerves. The normal thresholds for the radial cutaneous and sural nerves are determined as the 2 g (FIN 4.31) and the 4 g (FIN 4.56) filaments, respectively. The addition of the radial cutaneous and sural nerve to sensory nerve assessment may improve the diagnosis of patients with impaired sensory nerve function.

Reliability of Clinical Nerve Function Assessment in Peripheral Neuropathies

Sensory and/or motor nerve function impairment as a consequence of neuropathy is often assessed using electroneurophysiological tests. However, in low-resource countries where the required equipment is rarely available, manual muscle strength testing (MMST) and monofilament testing (MFT) offer very reliable alternatives. In six leprosy programmes in four Asian countries, a multi-centre randomised clinical trial (RCT) was carried out to assess the effect of corticosteroids on neuropathy in leprosy-affected people. The sensory and motor nerve function was tested using MMST and MFT, including new test sites for the sural and radial cutaneous nerves (MFT) and the posterior tibial and common peroneal nerves (MMST). The reliability studies of the MMST and MFT tests of the TENLEP (Treatment of Early Neuropathy in LEProsy) trials are presented here. Two assessors in each centre independently used the MFT and MMST in 30 leprosy-affected people. Reliability is good to very good for MFT in nearly all nerves. MMST also shows good to very good agreement, with a few exceptions. Our study confirms that MMST and MFT can be performed reliably, and that the new tests also have acceptable reliability.

Novel presentation of lepromatous leprosy in an erythema gyratum repens‐like pattern

Leprosy can have diverse cutaneous and occasionally perplexing presentations. We report an unusual case of lepromatous leprosy (LL) with annular lesions resembling erythema gyratum repens. A 55-year-old man presented with a symmetrical, hypopigmented, and erythematous rash of bizarre appearance over the lateral aspect of the upper arm, and anterior and posterior aspects of the trunk of two months' duration. He gave a history of self-resolving episodes of bilateral pedal edema, and numbness and pricking sensations in both the hands and feet, which had occurred intermittently over the previous six years. An ulcer measuring 2 cm in size was present over the adjacent surface of the right first and second toes. The bilateral ulnar and radial cutaneous nerves were symmetrically thickened. Slit-skin smears revealed numerous acid-fast bacilli. Skin biopsy from the trunk showed collections of histiocytes, lymphocytes, and plasma cells in the dermis and around the blood vessels. The patient was diagnosed with LL and started on multibacillary multi-drug therapy. Lepromatous leprosy can have varied clinical manifestations and is often a great imitator. However, the skin smear positivity, even in normal skin, symmetrical cutaneous and peripheral nerve involvement, and histopathology in the present patient were indicative of LL. This report highlights a rare presentation of leprosy. Clinicians should be aware of these rare manifestations as lepromatous cases still occur in certain regions.

Complex Regional Pain Syndrome Secondary to Leprosy

Leprosy is a chronic infectious disease caused by Mycobacterium leprae affecting the skin and the nerves. Complex regional pain syndrome (CRPS/Sudeck's dystrophy) is a painful and disabling condition--a triad of autonomic, sensory, and motor symptoms disproportionate to the inciting event (inflammatory, infective, or traumatic nerve damage). A 20-year-old male presented with continuous pain, aggravated by cold and emotions, loss of fine touch and temperature sensation, redness, swelling, along lateral aspect of left hand and forearm with weakness in the grip of 6 months' duration. There was a 5-year history of sensory loss only over left index finger that he ignored. Examination revealed abnormal sensory and autonomic functions along left radial and median nerve distribution that were confirmed by nerve conduction studies suggestive of mononeuritis multiplex. Radial cutaneous nerve biopsy was suggestive of leprosy. Magnetic resonance imaging and ultrasonography showed no compressive etiology; however, MRI showed involvement of brachial plexus. Antileprosy, anti-inflammatory drugs, and steroids were given in view of neuritis because of lepra reaction with supportive measures of physiotherapy, transcutaneous electrical nerve stimulation, to no avail. A surgical median nerve decompression also failed to relieve the pain. Temporary stellate ganglion block improved the pain scale. Thus, excluding all other causes, the final diagnosis was CRPS secondary to leprosy. There is only one reported case of CRPS with leprosy. Leprous neuropathy caused the nerve damage that lead to CRPS type 2. Very rarely leprosy can lead to CRPS. CRPS is a diagnosis of exclusion.

Comparison of the efficacy of supraclavicular approach and infraclavicular approach in ultrasound-guided brachial plexus block

Objective To compare the efficacy of supraclavicular approach and infraclavicular approach in ultrasound-guided brachial plexus block(BPB).Methods One hundred and twenty patients,ASA Ⅰ-Ⅲ,aged 18-80 yr,scheduled for upper extremity surgeries of both gender,were randomized into two groups(n =60):supraclavicular group(group SCB)and infraclavicular group(group ICB).The anesthetic mixture consisted of ropivacaine 0.375％ and lidocaine 1％ in equal volumes with epinephrine 1∶200 000,the total dose was 0.5 ml/kg.The block performance time,duration of anesthesia and success of anesthesia(surgery was accomplished without supplementary block)were recorded.A blinded observer assessed pinprick sensory block in the seven distal nerve territories(axillary,radial,musculocutaneous,median,ulnar,medial antebrachial and medial brachial cutaneous nerves)every 5 min up to 30 min after injection.Success of nerve block,side effects and complications were recorded during and after operalion.Results Group ICB was superior in success rate of anesthesia and nerve block of ulnar,medial antebrachial and medial brachial cutaneous nerves,the rate of parasthesia was lower and the block performance time was longer compared with group SCB(P ＜ 0.05).No major complications occurred in both groups.Conclusion Under ultrasound guidance,infraclavicular BPB is superior to supraclavicular approach. Key words: Nerve block; Ultrasound, interventional; Brachial plexus

Teased fibre study of early nerve lesions in leprosy and in contacts, with electrophysiological correlates.

A teased fibre technique was used to study 19 biopsies of the index finger branch of the radial cutaneous nerve of leprosy patients and contacts. These were compared with four normal nerves. Five nerves were from patients with preclinical nerve lesions, five from leprosy patients with minimal sensory nerve impairment, and five from contacts of lepromatous leprosy. The extent of demyelination in preclinical nerve lesions in leprosy and in contacts of leprosy is recorded. The usefulness of nerve conduction velocity studies in early leprosy patients and in contacts is discussed.

Glue-sniffing neuropathy.

Although industrial exposure to n-hexane is known to cause neuropathy, it is less well recognized that inhalation of n-hexane present in the vapors of some commercial contact cements is also neurotoxic to peripheral nerves. A young man with a long history of addictive glue-sniffing developed severe distal symmetrical polyneuropathy several months after switching to a cement containing n-hexane and gradually improved several months after switching to another cement containing no n-hexane. Fascicular biopsy of radial cutaneous nerve showed striking segmental distention of axons by neurofilamentous masses with secondary thinning of myelin sheath, paranodal myelin retraction, and widening velocities were correspondingly slow. We conclude that n-hexane used as a solvent in some contact cements may be neurotoxic when inhaled to excess and, further, that the neuropathy has characteristic electrophysiological and pathological features.

Mechanism of nerve destruction in tuberculoid-borderline leprosy: An electron-microscopic study

The ultrastructural changes in radial cutaneous nerve biopsies from 3 tuberculoid and 14 tuberculoid-borderline patients were studied. In tuberculoid leprosy the nerve parenchyma was almost entirely replaced by tuberculoid granuloma. In nerves from borderline-tuberculoid leprosy many axons showed segmental demyelination and Wallerian degeneration. The nerve tissue was gradually replaced by proliferating collagen fibrils and inflammatory granulomata. M. leprae were rare and when present they were found in phagolysosomes of Schwann cells and macrophages. Schwann cells were surrounded and occasionally infiltrated by lymphocytes and macrophages. It was suggested that “sensitized Schwann cells” were the target of a hypersensitivity reaction resulting in their degeneration or death which in turn produced segmental demyelination or Wallerian degeneration.