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Competing Interests: Les auteurs déclarent n’avoir aucun lien d’intérêts.

Introduction: Tuberculosis is the most common mycobacteriosis in sub-Saharan Africa. Cutaneous tuberculosis is rare and underdiagnosed due to its clinical polymorphism and to the smallness of technical equipment. This study aims to describe the epidemiological, clinical, histopathological aspects of cutaneous tuberculosis in Bamako (Mali)., Methods: We conducted a cross-sectional descriptive study from January 1991 to December 2008. The study was performed in the Department of Dermatology at the National Center for Disease Control and in the Department of Pneumophtisiology at the Hospital of Point G. The patients with tuberculosis confirmed by histological and/or biological examination were included in the study., Results: Out of 4269 patients? medical records, 61 cases of cutaneous tuberculosis were identified (1.43%). Men accounted for 59% of the cases (36 patients) and women 41% (25 cases); sex-ratio was 1.44. The age of the patients ranged from 3 months to 61 years, with an average age of 27.56 ± 36 years. The average length of follow-up was 10.9 ± 10 months. The identified clinical forms were scrofuloderma (41 cases), ulcerative form (13 cases), verrucous form (4 cases), and tuberculous Lupus (3 cases). Tuberculosis was associated with HIV in 7 cases, with leprosy in 3 cases., Conclusion: Cutaneous tuberculosis is underdiagnosed in Mali. Efforts are needed to improve the accessibility and the technical equipment available in the Departments, in order to conduct an extensive interdisciplinary study on this pathology.

Leprosy still affects 240,000 persons every year in the world. It is a particularly common cause of neuropathy and severe disabilities in developing countries. With increasing migration, new cases of leprosy are regularly diagnosed in developed countries, where it still remains rare and so underestimated. Cutaneo-nevritic leprosy is the most frequent form of leprosy. It may be diagnosed by the clinical features and the cutaneous histology and bacteriology. Neuritic leprosy without obvious skin lesions is reported in 5 to 15% of leprosy patients. It must be suspected in persons from areas of endemic disease presenting with nerve thickening and associated nerve deficit. Nerve biopsy is essential for diagnosis. However search for bacilli in cutaneous samples may be of great help and avoid nerve biopsy. Acute and severe neuritis occurs during reactional states, reversal reaction (Type 1) and erythema nodosum leprosum (Type 2). Multidrug therapy is advocated. The treatment of acute neuropathy needs a supplementary medical and sometimes surgical treatment., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Leprosy is one of the six diseases that the WHO considers as the major threat in developing countries. Damage to nerves can occur before, during, and after treatment and can result in disabilities and long-term disfigurement, which is associated with stigma. Considered exotic and rare in European countries, it is important for neurologists to be able to make the diagnosis of leprosy early in order to rapidly alleviate patient suffering and prevent and reverse nerve damage. Leprosy must be considered in the differential diagnosis of peripheral neuropathy, even in the absence of skin lesions and especially when present in a patient from an endemic country. Immune response and mechanisms involved in nerve damage are not clearly understood. There is no predictive test for the extent of nerve damage and no good evidence on the best treatment., (Copyright © 2012. Published by Elsevier Masson SAS.)

Leprosy, known since antiquity, is a world infectious disease due to Mycobacterium leprae. The transmission is probably via nasal droplets. The clinical range, from tuberculoid to lepromatous leprosy is a result of variation in the cell-mediated immune response, with a chronic inflammation in skin and peripheral nerves. Diagnosis of leprosy is clinical with anesthetic skin lesion and skin smears detect acid fast bacilli. Besides the classification of patients due to the Ridley scale which is clinically useful, WHO proposed is a simple field classification based on the number of skin patches (paucibacillary or multibacillary). Despite an effective multidrug therapy, leprosy has not been eliminated and remains an important health problem.

Introduction: In dark skin patients, hypopigmentation is the most disfiguring condition. Very few studies on hypochromic disorders have been conducted in specialized health centers. The present study is aimed to describe the etiologies of hypochromic patches in dermatological area, in Bamako., Methods: We carried out a cross sectional study in the Dermatology Clinic of the "Centre National d'Appui à la lutte contre la Maladie (CNAM, Ex Institut Marchoux)". All acquired hypochromic patches (HP) were selected. HP was defined as a "skin patch lighter in pigmentation than normal surrounding skin with a diameter of at least 1 cm". The diagnosis was mainly based on clinical findings., Results: The prevalence of HP was 3.42% and the main causes were seborrheic dermatitis (23.3%), pytiriasis alba (20.15%), vitiligo (18.9%), pityriasis versicolore (18.5%) and leprosy (12.6%)., Conclusion: There are many causes of HP including leprosy, a disease though rare to date, but still prevalent in dermatological area.

Leprosy elimination (<1/100 000) is almost reached all around the world, although, but disabled people are still a lot, and they need rehabilitation as soon as possible. The different lesions (neurological, dermatologic and joint) must be treated in order to protect from handicap. Physical rehabilitation medicine can help with a global and polyvalent coverage. Therapeutic education and reinsertion are an important part.

The multiple variant of aero-digestive foreign bodies' pathology determine many complex aspects with regard to their physiopathology, nature, and their location. The presence of a medical handicap or any particular condition could increase morbidity and expose to major risks. We are reporting here about 4 cases including an esophagus foreign body in a leprosies patient, an esophago-gastric case in a mental disorder patient, and two laryngeal-tracheal-bronchial cases during epileptic episodes. From the rarity of such accidents in an adult to their happening during a loss of consciousness or a delirious state, the clinical history is always missing. The symptoms are atypical and may misguide. The classical penetration syndrome cannot be reported. Only a clinical examination carefully conducted and completed with targeted para clinical examinations can help make early diagnosis. Endoscopy of the Esophagus on one hand, and endoscopy of the trachea and lungs on the other hand were used to extract these foreign bodies.

A follow up study was performed in the rehabilitation centre for patients with leprosy in Hôchiminhville - Vietnam. All patients had claw-hand deformity due to ulnar and median nerve intrinsic paralysis. Thirty-two affected hands (128 long fingers) were included in the study. A Bunnel-Littler tendon transfer procedure was performed using a four-tailed graft of the flexor digitorum superficialis of the third finger. Clinical evaluation included anatomical measurements of interphalangeal and metacarpal joints in complete extension and in the intrinsic position. In the open hand assessment, 48.5% reported good results, 14.8% medium results and 36.7% poor results. With the hand in the intrinsic position, 53.9% achieved good results, while 33.6% achieved medium results and poor in 12.5%. Poor functional outcome is related to a failure of this procedure and seems to be due to extensor tendon laxity, with or without stiffness of the interphalangeal joints. There were many anatomical deformities (27.3%) found at the time of follow up, notably boutonniere (51.4%) and mallet finger deformities (31.4%) The fourth and fifth fingers had the worst results. We have therefore decided to change our protocol for claw-hand correction and use the Bouvier test in deciding on our surgical indications. Preoperative physiotherapy is absolutely necessary to reduce stiffness of the interphalangeal joints.

Immune reconstitution syndrome (IRIS) is an unusual inflammatory reaction to an opportunistic infection in an HIV-positive patient. This syndrome occurs when immunity is restored in the first months of an effective highly active antiretroviral treatment (HAART). First, we described all patients with a cutaneous form of IRIS. Then, between 1992 and 2004 we conducted a retrospective cohort study comparing Herpes Zoster and Herpes Simplex infections among untreated patients, patients treated by HAART for < or = six months, and patients treated for > six months. We observed three cases of atypical leprosy and three original observations: two of these were fistulisation of lymph node histoplasmosis and tuberculosis, the third one reports the recurrence of a treated cutaneous leishmaniasis. Multivariate analysis showed that, after controlling for age, sex and CD4 counts, patients receiving HAART for < or = six months were more likely to develop Herpes Zoster or herpes simplex infections (p < 0.005). Herpes Simplex and Herpes Zoster infections are the two most frequent dermatological manifestations in our tropical setting. Although mycobacterial infections are more rarely observed than in visceral IRIS, the increased incidence of leprosy may be quite significant when the availability of HAART spreads to developing countries.

Leprosy, a chronic infectious disease caused by mycobacterium leprae affects an estimated 700,000 persons each year. Clinically, leprosy can be categorized as paucibacillary or multibacillary disease. Leprosy is important largely because of the deformities, disabilities and handicap it causes in a proportion of those affected by the disease. There are surgical procedures and techniques to correct or limit the deterioration of these conditions. In the past these surgical procedures were only performed in special institutions for treating leprosy and their complications. However, with the widespread use of multidrug therapy (PCT) and the consequent reduction in the prevalence of leprosy, there is progressive integration of the care of people affected by leprosy into the general health services. Surgery, as in intervention in the management of leprosy and its complications is used in patients who are already under anti-leprosy treatment, or after the have completed it satisfactorily. Therefore, preventive surgery like nerve decompression and corrective surgery should not be practiced in places where there is no leprosy program. This paper describes the nerve decompression for preventing paralytic deformities. Procedures for correction of claw deformity of finger and thumb resulting from ulnar or combined ulnar and median nerve paralysis, so commonly seen in leprosy-affected persons are given separately. In order to carry out these procedures, many involving tendon transfers with or without tendon grafting, the surgeon has to be well versed in the structural and functional anatomy of the hand and should training in hand surgery. Furthermore, supportive physiotherapy and if possible, occupational therapy services for pre and post-operative management of the hand should be available. If the corrective procedures are carried out in the absence of any of these requirements, the venture is bound to result in failure, worsen the hand disability as well as make any subsequent correction very much more difficult.

Practice of multidrug therapy in leprosy (combination Dapsone + Rifampicine + Clofazimine) established since 1981, has significantly reduced the incidence of the disease. However, immunosuppression due to treatment of multi-drugs therapy induced adverse reactions with glucocorticoid and the change in host immune response due to the leprosy itself, might increase the risk of parasitic infections. To test this hypothesis, we carried out a case-control study at the "Institut Marchoux" in Bamako. Stool and urine samples from all patients included in the study were examined for parasites identification. In addition, we performed thick and thin blood film to identify malaria infection and skin biopsy (snip) to detect onchocerciasis. A total of 121 cases of leprosy and 219 controls aged 10-84 years old were included in the study from March 1999 to February 2000. Sixty two percent (n = 121) of cases were treated with glucocorticoid. The prevalence of infection due to Entamoeba coli and Entamoeba histolytica were higher in cases than in controls (p = 0.02). The prevalence of infection due to hookworms was higher in cases than in controls. There was no difference of the infections to the other intestinal parasites. Three cases of cryptosporidiosis and one case of isosporosis were observed in leprosy group vs none in the control group. There was no significant difference between cases and controls with regard to prevalence of Schistosoma haematobium, Trichomonas vaginalis and Onchocera volvulus. The prevalence of Plasmodium falciparum was 4.9% (6/121) in the leprosy case and 7.8% (17/219) in the control group. In conclusion, despite the corticotherapy and immunosuppression due to leprosy, there was no difference in prevalence of pathogenic parasites. Entomoeba coli, Entamoeba histolytica which have significantly higher prevalence among the cases were not pathogen therefore there was no higher risk of severe intestinal parasitosis among the cases of leprosy. Treatment with glycocorticoid in patients with leprosy did not suggest any impact on the prevalence of this parasitic infections. In addition, multidrug therapy did not show any effect on the carriage of Plasmodium falciparum.

Purpose: Only leprosy resource centres undertake surgery for neuritis. Patients' accessibility to this surgical procedure is poor because these centres are often far from their homes. The aim of our work is to study the feasibility of neuritis surgery in the field., Methods: A surgeon trained in this surgery was recruited by Bom-Pastor hospital in Brazilian Amazonia, which is located 400 km away from the leprosy resource centre. Patients operated from May 1996 to December 1997 were enrolled in this retrospective study., Results: A total of 45 operations were carried out during 17 procedures on 13 patients, among which 12 were multibacillary cases. The decompression surgery was performed with a median delay of 1 year after leprosy diagnosis and 3.5 months after the neuritis diagnosis. Among 17 operations, 14 were performed for painful neuritis of recent onset unsuccessfully treated with corticoids or recurring during the month after corticoids were withdrawn. The other three operations were performed for long-standing neuritis with paralysis and deformity. Pain was relieved in all the cases of recent neuritis, except for one patient who suffered from a serious steroid-dependant erythema nodosum leprosum. An improvement of motor function was observed in one out of three patients with long-standing neuritis. Adverse effects were few: a scar infection with a rapid recovery and a keloid scar. Two neurites recurred 2 and 10 months after the surgery., Conclusions: In an endemic leprosy region, field access to surgery for neuritis appears to prove real progress in the management of leprosy neuritis.

Leprosy is one of the most ancient diseases recognized in the history of man. It has been progressively eradicated from many countries. However, the disease remains a major problem of public health in a dozen of countries where it still represents an archetype of the tropical infectious pathology.

Infective neuropathies constitute a leading cause of neuropathies in the world. The number of patients with nerve lesions related to leprosy remains high despite decreasing number of new cases requiring multidrug regimens. Peripheral neuropathies associated with HIV infection may be found in up to 50% of patients. Neuropathies may be related to the inflammatory reaction against viral antigens, immunodepression, opportunistic infections, and iatrogenic complications of anti-viral drugs. Hepatitis C virus infection has been found in cryoglobulinemic neuropathies. This virus should be screened for exploration of all neuropathies. Rare causes of neuropathy, such as poliomyelitis and diphtheria, and treatable neuropathies such as Lyme disease, should not be forgotten.

Leprosy still remains a dreaded disease despite the possibilities of permanent cure, the efficacy of surgical corrections, and its forthcoming disappearance. The authors conducted several surgical missions in Benin-Africa--over 4 years and report an interesting rate of control in the survey of patients as the results of their procedures were reviewed in 84% of them. Leprosy represents the perfect example of the difficulties of any humanitarian involvement with apparent contradictions between the aims of the medical wishes and the presence of a dreaded symbol that--fortunately or not--allow the existence of the many associations involved in the fight against leprosy.

The aim of the study was to compare the results of the medical treatment alone and of the medico-surgical treatment on leprous neuritis. The patients were followed-up during 2 years, with regular neurological evaluations. The statistical study was performed using the Tukey test. Ninety-three nerves (ulnar, median, common peroneal and posterior tibial) with a deficit of less than 6 months duration have been studied in 31 leprosy patients. All the patients were treated by steroids but in some of them a nerve surgical decompression was performed. An improvement of the sensitive and motor deficit was observed in both groups. No significant statistical differences appeared between the 2 groups according to the nerve involved, the duration of the deficit, the form of leprosy and the type of antibacillary treatment. However, the medico-surgical treatment had a significant better result on pain and on major but incomplete nervous involvement. This study included a limited number of nerves, thus, it would be useful to perform others randomized assays to better define the indications of surgical decompression in the management of leprous neuritis.

To determine potential usefulness of antimicrobial agents and to guide their prescription in the treatment of leprosy plantar ulcers, we conducted an in vitro study about germs' nature and sensitivity to antibiotics. We took samples of plantar ulcers secretion from 107 patients at Marchoux Institute. 92.5% of those ulcers were infected. These samples revealed 145 strains of micro-organisms among those, Staphylococcus aureus (70 strains) and genus Pseudomonas (41 strains) were the most frequent. These bacteria were resistant to several antibiotics currently used at Marchoux Institute (tetracycline, penicillin, cotrimoxazol and erythromicin). Antibiotics, efficient at 80% on tested strains, were expensive for patients. They cannot be recommended for the treatment of local infections. These results outline that the main treatment in plantar ulcers is based upon antiseptic solutions and keeping feet at rest. Antibiotherapy in case of extension of local infection would be based on the results of a previous study of sensitivity.

Our study concerns 244 new cases of leprosy diagnosed in the Bamako district in 1994. 154/244 patients could be contacted and were examined in the Leprosy Department of the Marchoux Institute in Bamako. Results showed that the presence of leprosy induced physical disabilities was associated with male gender (59%), advanced age (68%) and multibacillary disease (68%). Disabilities were also more frequent among patients having a rural or manual occupation at the time of screening or afterwards. There was a significant increase (p < 0.001) in the prevalence of disabilities when comparing patients at the time of diagnosis (29%) and thereafter (48%). This means that in 40% of disability cases, lesions developed during or after the treatment. Disabilities were predominantly observed in hands (33%) and feet (29%) with more frequent lesions in lateral popliteal, superior ulnar and posterior tibial nerves. Our results seem to demonstrate the inadequacy of preventive measures and management. This stresses the need for adequate prevention and therapy of leprosy induced disabilities in order to obtain proper eradication of leprosy induced health problems.

A common problem of osteitis and septic arthritis is the recurrent bone infection after surgical debridement, a problem frequently encountered in patients with sequela leprosy. In these cases the authors propose the use of an ancient method of post surgical wound care based on the treatment with ordinary granulated sugar. The hyperosmolar climate created this way in the wounds inhibits the bacterial growth, enhances bacterial death and therefore permits the growth of granulation tissue in order to recover the debrided nude bones. At ILAD (Leprosy Institute of Dakar), 36 osteitis and septic arthritis were treated and healed during the last 2 years from March 1995 to March 1997 using this technic. All the wounds healed in the mean-time of 44 days. Only two of them needed a second debridement and healed afterwards. Up to now the method using ordinary sugar was applied in the treatment of infected wounds, eschars and postsurgical infections. Our experience shows that it also can be indicated to treat bone infections. This method is easy to apply also under often difficult field conditions and is very cheap.

We performed a cross-sectional study of populations from two areas of Mali, in May and June 1996. The aim of the study was to assess the extent to which leprosy causes physical disability in Mali. One area was rural (Circle of Bougouni), the other urban (Bamako District). We used a cluster sampling method, with 500 households selected for study in each of the two areas. All members of the households randomly selected were included in the study. For all survey sites, the number of households was proportional to the number of inhabitants. The total study population was 8,175, including 172 cases of physical handicap, 76 in Bamako and 96 in Bougouni. The prevalence of physical handicap was 21 per 1,000 inhabitants (25.3 per 1,000 in rural areas and 17.3 per 1,000 in the city). The difference in the prevalence of physical handicap between the two areas was statistically significant (p = 0.01). Ten per cent of the disabilities were caused by leprosy. The most common causes of disability other than leprosy were trauma and poliomyelitis. Leprosy mostly caused disabilities in rural areas. In both areas, leprosy caused more disabilities in men and boys (64% of cases) than in women and girls. The frequency of disabilities caused by leprosy increased with age, whereas the frequency of handicaps with other causes decreased with age. This study shows that leprosy is still a major cause of disability in countries in which it is endemic, such as Mali. Disability prevention measures and physical rehabilitation programs should be incorporated into the national program for the elimination of epilepsy.

The introduction of a program for the treatment of plantar ulcers (PU) in field conditions in Senegal was studied. The program was complementary to the Health Education and Protective Footwear to Prevent Disability (POD) initiatives within the Senegalese anti-leprosy program. The wound care given in health centers was coded and simplified. Access to hospitals was made easier for those patients requiring surgery. More than 30% of patients with PU were treated each year, with a mean of 62% cured. An increasing number of leprosy patients have been admitted to regional hospitals for surgery. Never before have patients with signs of leprosy had access to general hospitals. This study emphasizes the need for regular supervision of the individuals treating wounds.

Practically leprous plantar ulcers (PU) are difficult to treat and heal under field condition. Considering the important number of patients showing a PU, the directors of national leprosy control programmes are determined, within the programmes on prevention of disabilities (POD), to treat the PU in the field. Therefore it appears to be essential to codify and simplify their treatment thus enabling it to be effective. The healing of PU being the only criteria of effectiveness of the technique. Four clinical stages were defined, each corresponding to a precise way of treatment using only essential and basic products at low cost. During the trainings about the treatment techniques and attitudes much emphasize is given on the discharge of the PU, on the trimming of the wound and on the products to use according to PU's evolutionary stage.

This paper deals with the results observed in 21 ancient leprosy patients suffering from lagophthalmos (13 of whom suffered from bilateral lagophthalmos) and treated by the Edgerton-Montandon surgical procedure which associates lateral canthopexy and tarsorraphy. Eighteen of the 21 treated patients were reviewed at one month after the procedure and, overall, results could be evaluated for 30 eyes. Improvement was noted in all of the 30 eyes and, globally, the residual palpebral fissure (during voluntary closing of the eyes by the patient) decreased from 6.7 mm before the procedure to 1.8 after the procedure. The following recommendations may be proposed. For young patients with intact corneal sensation, the Gillies procedure remains the procedure of choice to correct lagophthalmos. For older patients with corneal anesthesia, at high risk of blindness, the Edgerton-Montandon procedure should be recommended.

Due to a decrease in the prevalence of leprosy, discussion of its differential diagnosis assumes increasing importance. Research on the early diagnosis of leprosy, before the onset of nervous lesions, the appearance (or improved definition) of certain diseases and the expansion of intercontinental migration are some of the factors which have induced changes in the conditions of leprosy diagnosis. The most frequent and most sensitive differential diagnosis of leprosy have been reviewed: hypochromic diseases, tropical infections diseases, systemic diseases, deforming diseases, cutaneous lymphoma and AIDS. The difficulties posed by forms of leprosy revealed by reactional manifestations are stressed. Today, as in previous times, positive and differential diagnosis of leprosy is based on the following simple practices: study of lesion, sensitivity, bacilloscopy and the examination of the peripheral nervous system. Cutaneous histology is the complementary reference examination.

Patients treated and cured on the bacteriological level by multidrug therapy may nevertheless present handicaps, such as deformities resulting from the disease, which have personal and social consequences. It is actually the handicap and disability from which most patients suffer and which concern populations. The number of persons suffering from such handicaps worldwide has been estimated at 4 million. Therefore, the main goal is to gradually integrate the activities of the prevention of disabilities and physical rehabilitation programme (PIRP) into the national leprosy control programme (PNL). The persons involved in the implementation of the programme outline the activities planned under the PIRP, detailed objectives, priorities, the means by which they will be implemented, the content of training programmes, assessment criteria and documents available.

A survey of the prevention of disability policy and activities in a random sample of 200 ILEP assisted projects was conducted in 1995. This was followed by a workshop of field experts in different aspects of prevention of disability who work in different geographical regions. The survey findings and state of current knowledge on prevention of disability were reviewed during the workshop and recommendations on the planning, implementation, and evaluation of simple and effective prevention of disability developed. Prevention of disability includes complex activities, such as nerve decompression and reconstructive surgery, however these recommendations focus on the simple techniques and approaches which can be implemented through leprosy control programmes, primary health care and community-based rehabilitation. These recommendations have been approved by the ILEP Medical Commission, and reported in the ILEP Medical Bulletin (N degree 8, December 1995).

Between 1983 and 1994, 66 Senegalese leprosy patients were seen for cauliflower growths developed in chronic plantar ulcer (CPU), (2 patients had each 2 tumors). 68 biopsies for pathological examination were taken: the diagnosis of squamous cell carcinoma was effectively made in 39 cases (38 patients) and that of pseudo-epitheliomatous hyperplasia in the remaining 29 cases (28 patients). The mean annual frequency of cauliflower growths was 0.45 per 100 CPU. Among these tumors, the percentage of carcinoma was 57%. Of the 38 patients with a carcinoma, 5 refused amputation and all of them died. The 33 others were amputated and of these 8 died as a direct result of their carcinoma (24%). In the case of the 28 patients with hyperplasia, amputation was carried out on 18 patients and local excision on 10. In the months following the operation 8 recurrences were observed in 10 of the patients on whom excision had been carried out. These recurrences were treated by amputation. This gives a total of 93% of amputations in the cases of hyperplasia. These facts lead as to conclude that at least in countries where pathological examination is not available below knee amputation is the most reasonable action to take in the proliferative tumors developed on a CPU.

In 1990 Kapolowé was, without a doubt, the site of the only surgical centre in Zaire dealing with handicaps which developed in as an after-effect of leprosy. It would be useful to explain the hazards involved in such a venture for reasons which do not pertain to medicine but, rather, to particularly trying socio-political circumstances. The best surgical expertise was thrown out for political reasons. Insecurity and economic hardships practically halted movement and, consequently, the wider application of such expertise. During a mission in 1994, there was a partial resumption of activities. The surgical team was reinstalled and made operational. It had been possible to state that multidrug therapy (MDT) had always ensured that the disabled leprosy patients, living in groups, and treated before 1990 under regular supervision, did not experience serious relapses. That fact corroborates earlier information relating particularly to surgical decompression. Although most of them were able to resume a certain measure of professional activity, social factors must still be borne in mind and the concept of partial permanent disability must be applied.

Of 584 leprosy patients known at the Institut de Léprologie Appliquée de Dakar because they suffered a nerve lesion with or without chronic plantar ulcer (CPU), 242 (41%) could be followed-up during a mean period of time of 8.2 years (range: 5 and 10 years) by the means of the mobile disability prevention team (health education, medical care and shoe workshop). Every two months a visit of the patients, at their home town, was organized, with the purpose to assess whether they could actually put into practice the foot and hand as having been trained for. At the same time, further advice and encouragement were given to the patients. Adapted footwear was brought to the patient, at reduced fee, the foot prints and special moulds having been taken during the previous visit. The local health worker were responsible for light surgical cares. Among the 242 followed-up patients: of 107 without CPU at beginning, 90 (84%) remained so, of 135 with CPU at beginning, 57 (42%) were cured, of 135 with CPU at beginning, 74 (55%) remained stable (no worsening), the last 21, of whom 17 showed severe foot deformities but without CPU, worsened (all presented one or more CPU at the last control). Of the 242 patients, 221 (91%) remained stable or showed substantial improvement. Therefore, it must be emphasized that careful follow-up of patients is essential to insure the improvement or care of CPU as well as to prevent the onset, worsening or reappearance of CPU. Such follow-up must consist of cares, health education and special shoe wearing.

Corneal disease is the second most common cause of blindness in tropical countries after cataract. It mainly strikes children who are exposed to numerous infectious agents against which they are unprotected due to the absence of basic health care. In high risk groups, the incidence of childhood corneal-related blindness is more than 20 times higher than in developed countries. There are many causes of corneal-related blindness. Endemic trachoma persists in some areas and inflammatory forms can lead to blindness. Eradication requires instillation of antibiotics in the eye, improvement of sanitary conditions, and campaigns against promiscuity. Xerophthalmia can induce blindness by perforation of the cornea in children with vitamin A deficiency. Measles, herpes simplex keratitis, and corneal ulcer that progresses to bacterial or fungal infections, or to amebic keratitis are also major causes of corneal-related blindness. The incidence of onchocerciasis is decreasing thanks to treatment with ivermectin and programs to control simulium. Neonatal gonococcal ophthalmia and leprosy-associated ocular disease can also lead to blindness. This overview of the various causes illustrates the close correlation between the level of life and living conditions and the occurrence of corneal-related blindness in tropical areas.

In leprosy, the early detection of peripheral nerve damage is essential for the prevention of disability. To date, there is no consensus on what is the best clinical test to reveal such abnormalities. In this prospective study we examined the effectiveness of five clinical tests to assess radial cutaneous nerve (RCN) damage (the most frequently involved). Light touch was assessed by two nylon threads (based on the Semmes-Weinstein monofilaments testing technique) bent on the skin at a pressure of 0.5 (N. 4 nylon) and 0.2 gram (N. 5 nylon). Pinprick and cooling sensations were examined by a needle and a drop of ether. The nerve thickness was assessed by palpation. Sensory findings were then compared to sensory nerve conduction values of the RCN and a sensitivity analysis was performed. The patient group consisted of 108 consecutive new leprosy sufferers (138 RCN) who attended the Institut de Léprologie Appliquée de Dakar during one year. Diagnosis and classification were based on Ridley and Jopling's criteria (clinical examination, skin smears and biopsy). Normal values were determined among 22 healthy subjects (44 RCN). The best tests in term of sensitivity were palpation (.60), N. 5 nylon (.65) and N. 5 + palpation (.79). Their positive predictive values were .84 (palpation), .94 (N. 5 nylon) and .83 (N. 5 + palpation). The best tests in term of area under the curve were palpation (.66), N. 5 nylon (.71) and N. 5 + palpation (.78). The results remain the same for the lepromatous or tuberculoid leprosy patients.(ABSTRACT TRUNCATED AT 250 WORDS)

In leprosy, ulnar neuritis is considered to be selectively localised at the elbow and is often treated by surgical decompression when pain and/or neurological deficit occurs. The aim of this prospective study is to assess the prevalence, localisation and severity of ulnar nerve damage in leprosy. Motor nerve conduction velocity (MNC) was measured at 3 different segments: arm, elbow and forearm, and was expressed both in meters/second and percentage of the mean normal values found in our laboratory or as reported in other studies. The patient group consisted of 123 consecutive new leprosy sufferers (228 ulnar nerves only) who attended the Institut de Léprologie Appliquée de Dakar over the period of one year. Diagnosis and classification were based on Ridley & Jopling's criteria, including skin and nerve biopsy. Mean MNC was reduced by 13.5 m/s at the arm, 19.8 m/s at the elbow and 7.8 m/s at the forearm as compared to the mean normal values. Increased distal latency as an isolated finding was rare (0.9%). Mean MNC was more reduced in the BL, LL (lepromatous) than in the TT, BT (tuberculoid) subgroups, despite similar disease durations (22.3 +/- 18.7 months and 24.2 +/- 26.4 months respectively (n.s.). Using different normal MNC values did not affect the conclusion: we did not see any selective slowing of ulnar MNC at the elbow suggesting that nerve damage is not primarily related to mechanical factors.

The clinical expression of leprosy is primarily cutaneous but its serious neurologic manifestations are maiming. Mutilations mainly of limb ends are due to peripheric nerves compression and may appear before or during the clinical treatment of the illness. Their appearance which is not automatically related to multiple Hansen's bacilli, may be prevented surgically by nervous decompression. The authors report their experiences of 466 nervous decompressions of 123 patients (89 men and 34 women), among them, 14 were pauci-bacillary and 109 multi-bacillary. They conclude that very good results (complete recovery or improvement of sensitivity, disappearing of pain) have been obtained through simple and easy-to-learn surgeries.

Between 1988 and 1992, 21 biopsies for pathological examination were taken from 20 Senegalese leprosy patients suffering from chronic plantar ulcers (CPU) suspected of malignant transformation. The diagnosis of squamous cell carcinoma was effectively made in 13 cases and that of pseudoepitheliomatous hyperplasia in the remaining 8 cases. The mean period of time between the onset of CPU and that of malignant transformation was 10 years (range: 1 to 15 years); the mean annual frequency of the malignant transformation was 2 per 1,000 CPU. In countries where pathological examination is not available, below knee amputation could be considered whenever main clinical signs of malignant transformation are present. In countries where pathological examination is available, the therapeutic decision may differ according to the diagnosis: below knee amputation supplemented with block dissection of inguinal lymph nodes whenever possible in cases of carcinoma; below knee amputation depending on the function status of the foot and on the volume of tumor in case of pseudo-epitheliomatous hyperplasia.

The authors consider the evolution of the treatment of leprotic neuritis based on homogenous series of numerous observations (a minimum of 250-300). These observations are well registered and documented with some results dimensioned by the classical A. L. E. R. T. tests carried out at intervals of time and verified by comparison between series only medical treatment and series of medico-surgical treatment. Considering some remote results and some comparative series, the indications of the exclusive medical treatment have been well defined, and the ones of the surgical decompression have been reduced. The early case finding of a leprotic neuritis by the mean of easy methods as well as its monitoring during its early specific treatment is essential. By this way we get an important proportion of functional results: satisfactory (50 p.c.) or interesting (20 p.c.). In the case of painful hypertrophia, the complementary decompression secure not only the functional recovery of mortricity, but also the epicritic sensibility.

The author is reviewing the literature about the association HIV infection and leprosy. So he concludes: 1) there is no correlation between leprosy incidence and HIV infection incidence, despite similarity as far as immuno-system is concerned. 2) Effect of HIV infection on leprosy demands further studies of nervous leprosy pathology. 3) Tendency to increase of such and association is foreseeable, speaking of epidemiocity in developing countries as well as in leprosy foci in Southern Asia and India.

Inflammatory neuropathy is the term used for all neuropathies associated with an inflammatory infiltrate of the nerves and/or nerve roots. Broadly speaking, there are two types of inflammatory neuropathies: those caused by an identified infectious agent, and those of uncertain origin for which an autoimmune process is usually blamed. Among the neuropathies of infective origin, leprosy is the most important owing to its frequency and to the physiopathological and therapeutic problems it still poses to clinicians and researchers, since the form and severity of nerve lesions depend on cellular immunity to the bacillus' antigen rather than on the bacillus itself. Retroviral infections, caused by the virus of AIDS more than by the virus of tropical spastic paraplegia, are responsible for numerous neuropathies the mechanisms of which are discussed here. The principal inflammatory neuropathies of uncertain origin are polyradiculitis and its different forms, and the heterogeneous group of neuropathies associated with Sjögren's syndrome.

The authors report on two cases of dermal neoplasia in foot trophic disorders observed in leprous subjects. The report includes the description of the clinic and histologic data as well as the surgical technique used; finally, it underlines the importance of a precocious diagnostic so as to obtain a good therapeutic result.

A leprosy survey was conducted from 1982 to 1985 among 2650 semi-sedentarized Pygmies in two camp-villages in the Central African Republic. Leprosy is endemic there, with an estimated prevalence rate of 1.05% and an annual detection rate of 0.2%. In view of its close relations with other neighbouring ethnic groups this Pygmy community can be considered as a target population the study of which provides indications on the transmission and typical course of leprosy in the region and also as a potential focus of contamination. However, the concurrent presence of endemic tuberculosis made it necessary during the survey to look for clinical associations of leprosy and tuberculosis in patients so that the standard multidrug treatment schedules comprising rifampicin could be adjusted accordingly.

The orofacial lesions of untreated leprosy have long been known. Our study concentrated on the bucco-dental and facial status of 97 leprosy patients given multidrug therapy. The number of decayed teeth and of teeth missing due to extraction proved high. Clinical manifestations of leprosy in the facial region are, however, rare and lesions of the oral mucosa, while more frequent, always exhibit scarring.

Previous studies documented that T-cell deficient nude mice failed to control M. leprae infection. In the present investigation we monitored the growth of M. leprae for up to 15 months in the SCID C.B.-17 mouse, a host deficient in both T and B lymphocytes. At 8 months post-infection 10(8) organisms/foot-pad were recovered from SCID mice vs 5 x 10(6) in normal BALB/c mice. Thereafter the number of bacilli decreased rapidly in mice infected with high-dose inoculum (10(7)); however, at all doses SCID mice eventually cleared M. leprae. During infection both T and B cells as well as serum Ig remained as low as in uninfected mice; however, in the spleen MAC-1+ cells which include macrophages and NK cells were substantially increased. These results suggest that MAC-1+ cells are involved in the anti-mycobacteria-1 defence mechanisms adopted by SCID mice to compensate their deficiency in T and B cells.