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Orthopaedic Aspects of Leprosy

- Discussion:
    - causative organism of leprosy is M. leprae;
          - acid-fast, obligate, intracellular gram-positive bacillus that reproduces maximally at 27°C to 30°C;
    - frequent subacute polyarthritis involving the small joints of the hands and feet;
    - organism infects the skin and cutaneous nerves, its principal target being the Schwann-cell basal lamina;
    - direct bacterial infection may lead to osteomyelitis or periostitis;
    - dx: may require sural nerve biopsy;
          - Fite's modification of the Ziehl–Neelsen acid-fast stain for mycobacteria may show bacilli in Schwann cells;
          - hematoxylin and eosin stain: inflammatory infiltrate w/ plasma cells and lymphocytes and poorly formed aggregates of histiocytes;
          - electron micrograph: loss of unmyelinated axons, manifested by the presence of so-called empty Schwann-cell stacks;
          - ref: Value of nerve biopsy in the diagnosis and follow-up of leprosy: the role of vascular lesions and usefulness of nerve studies in the detection of persistent bacilli.

- Exam:
    - doess not follow the anatomic distribution of the subcutaneous sensory nerves, of the mixed nerve trunks, of the sensory roots, or of the distal symmetrical sensory loss
    - nerves are often involved in subcutaneous regions (bacteria thrive in cooler regions of the body);
          - ulnar nerve is often involved at the elbow (treatment is submuscular transposition);
          - median nerve may be involved at the wrist;
    - hand involvement;
          - painful dysesthesias
          - sensory loss more pronounced on the dorsal than on the palmar surfaces;

- Treatment:
    - dapsone and rifampin

Bone changes in leprosy: a correlation of clinical and radiographic features.

Clinical and laboratory studies of arthritis in leprosy.

Rheumatic manifestations of leprosy: clinical aspects.

Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 1-2004. A 49-year-old woman with asymmetric painful neuropathy.

Temperature-linked sensory loss. A unique pattern in leprosy.