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Due to aging and aftereffects of leprosy, many of them are now struggling with hearing loss and visual impairment. The purpose of this study was to investigate and analyze the present situation of hearing level and hearing aid among residents in leprosy sanatorium. We have been carrying out hearing screening for the all ex-patients in three national sanatoriums, Nagashima-Aisein (since 2011), Oku-Komyo-en (since 2012), and Matsuoka-Hoyo-en (since 2014). The results of audiometry and questionnaire in 2014 were analyzed. Eligible persons who took pure tone audiometry were 198, and their age ranged between 59 and 99, mean 82.95. Their average hearing level of better hearing ear was 39.3 ± 17.2 dB. Since this result is not different from previous reports, which mentioned about average hearing level in elder persons, history of leprosy may not affect with hearing. According to the questionnaire, not only hearing level but also the awareness of hearing disability may lead to need for hearing aid. Also, it was considered that each communicative condition in sanatorium could have effect on self-assessment of hearing disability.

Thalidomide is a TNF-alpha inhibitor and has been administrated for erythema nodosum leprosum (ENL, Type II leprosy reaction) which is one of leprosy reactions and can cause serious illness to patients oflepromatous pole among the immune spectrum. Twenty live cases (at May, 2011) were identified to whom thalidomide had been administrated since 1978 for their ENL reactions. Data were collected from their clinical records in order to evaluate the usage and effectiveness of thalidomide in National Sanatorium Oku-Komyoen, Okayama, Setouchi-city, Japan. Individual data includes bacillary index (BI), total dose, average daily dose, maximum daily dose, minimum daily dose, methods of thalidomide administration and change of symptoms of ENL. Results: No adverse effect was found among 20 cases. Average daily dose of 20 cases was 19 mg. Regarding to the maximum daily dose, in 3 cases (15%) more than 100 mg, in 3 cases (15%) 50 mg, and in 14 cases (70%) less than 40 mg was administrated. Dose was gradually tapered in most cases. From clinical records, thalidomide was found effective for ENL in 19 cases and clinicians concerned were trying to adjust the proper dose of the drug carefully depending on the current symptoms, because there was no guideline of thalidomide administration for ENL. This data suggests that even less than 50-100 mg as the initial daily dose was still effective, though 50-100 mg daily dose is recommended in the current guideline of Japan (2011) and more dose had been administrated in USA and India.

The leprosy sequelae especially the handicap of eyes and hands makes difficult to maintain the oral health status. So, leprosy sequelae patients are controlling themselves by creative and original methods. However even such efforts have hardly reached the level to stop of caries and periodontal disease. More support is required in order for them to maintain the oral health status. Therefore, in National Sanatorium Nagashima Aiseien, we started the periodic preventive system containing oral check-up, mouth cleaning, and early detection early treatment 15 years before. It is the report about this activity. First, the leprosy sequelae handicap which makes oral control difficult is described. Secondly, our periodic preventive system in National Sanatorium Nagashima Aiseien is explained. In order to evaluate this activity, the number of patients and the contents of dental treatment were compared. Furthermore, the number of remaining teeth was compared with the adult Japanese. Our periodic preventive system was received and they have many remaining teeth now. It is sure that this activity for 15 years was successful.

For the last 5 years, not a single new case of leprosy has been reported among native Japanese people, but several new cases of leprosy have been reported every year among foreigners in Japan. Because most leprosy patients consult doctors not for skin rashes but for the neurological symptoms of leprous neuropathy, every neurologist should be well aware of the clinical features of leprous neuropathy. The finding that the clinical pictures of leprous neuropathy differ greatly between patients from the main Japanese islands and those from Okinawa is of clinical importance the former comprise the lepromatous type while the latter are of the borderline group. The clinical features of leprous neuropathy among people from leprosy-prone areas in the world wide are usually of the tuberculoid type or of the borderline group. Further, the clinical pictures of each type of leprous neuropathy are so distinct that these conditions can be diagnosed with the simple classical neurological examination. One of the most important issues in managing leprosy patients with neurological deficits is protection of the areas of analgesia caused by leprous neuropathy from injuries or burns. Protection against entrapment neuropathies of thickened peripheral nerve trunks, which are quite likely to be compressed during various activities of daily living, is also important.

In Japan people affected by leprosy who were forced to admit to national leprosy sanatoria under leprosy prevention/segregation law (1953) have ever been promoted to return to live in community, after destruction of the law in 1996. In this paper two cases are shown with some comments who had already been discharged from leprosy sanatoria and came late to OPD of National Suruga Sanatorium for consultations of their leprosy related conditions. One case is a 60 year-old male who developed squamous cell carcinoma (SCC) from chronic planter ulcer. The other is a 69 year-old female who developed relapse after more than 20 years BI negativity. In these cases, periods until consultation to our clinic were one year and five months, and five years and five months respectively. One reason is that there is no follow-up system of leprosy related conditions for ex-patients in current medical service of Japan. Another reason may be that patients hesitated to consult local doctors for their leprosy related conditions. Since national leprosy sanatoria will come to be closed in near future, services should be available for leprosy related conditions, such as prevention of disability (POD), prevention of worsening disability (POWD), early detection of relapse and leprosy reaction, in general medical service of Japan.

A 77-year-old man with Hansen's disease was referred to our hospital because of a small nodular lesion detected adjacent to the pleura in the right lower lobe (S10) on chest CT. He had lost all ten fingers due to Hansen's disease and was using a prosthetic limb after amputation of the right lower leg. Although the patient had an 11-year history of shoulder and back pain and was suspected of having interstitial pneumonia 6 years previously, no detailed examination had been conducted. Bronchoscopy did not yield a definitive diagnosis, and a lung biopsy was performed under thoracoscopic guidance. Histological examination of the resected nodule with colliquative necrosis revealed palisading granulomas with multinucleated giant cells and plasma cell infiltration with formation of lymphoid follicles. Since serum levels of both anti-MMP3 and anti CCP antibodies were elevated, rheumatoid arthritis (RA) with rheumatoid lung was diagnosed. Therefore, the nodule was considered a rheumatoid nodule. Since diagnosis of rheumatoid arthritis is difficult when lacking characteristic joint manifestations, it is important to include rheumatoid nodules as a differential diagnosis and to measure RA specific autoantibodies, to make a comprehensive diagnosis for non-specific necrotizing granulomas.

The number of ex-leprosy patients has reduced rapidly who were forced to be admitted under leprosy prevention/segregation law and are staying at national sanatoriums with different disabilities due to different physical and social reasons for long time in Japan. Most of them have been of clinically cured status for decades after effective chemotherapy. Some have still been suffering from acute or chronic neuralgic pains which are supposed to be long standing consequences of nerve damage of leprosy and getting medications for long period. Pharmacy department of National Suruga Sanatorium has studied the amount of prescriptions of some medicines for last 11 years, which were thought to be prescribed for pain including neuralgic pain. There seem to be some tendencies of medications during last decade. VitaminB12 (Mecobalamine) is one of the commonest drugs for neuralgic pain at this sanatorium and the amount of prescription had almost been unchanged through the years. Prescription of non-steroid anti-inflammatory drugs (NSAIDs) increased year by year, which may reflect the increasing age of ex-patients who need more pain killers for their painful joints or back. Loxoprofen is the most popular pain killer here and increased by ten times for last decade. The number of prescription for Pentazocine and Hydroxyzine Hydrochloride injection increased for last several years, which reflects a few patients who were still suffering from severe chronic neuralgia for years. It is desirable that a standard regimen for chronic neuralgic pain as a consequence of nerve impairment in leprosy will be developed as soon as possible.

Neuropathic pain has been known to be refractory to traditional analgesics, such as opioids and non-steroidal anti-inflammatoy drugs. Some mechanisms of the development of neuropathic pain have been proposed; 1) sprouting of A beta fibers to the superficial layer of the dorsal horn, 2) ectopic discharge in the dorsal root ganglion and/or in neuroma at the nerve stump, 3) spinal sensitization. Ectopic discharge has been reported to be inhibited by Na+ channel blocker, such as lidocaine, and anticonvulsant. Lidocaine and anticonvulsant are used in the management of neuropathic pain. Activation of NMDA receptor is usually involved in the development of spinal sensitization and NMDA receptor antagonist, such as ketamine, is used in the management of neuropathic pain. Recently, alpha2delta subunit blocker, new class of anticonvulsant, is introduced to the management of neuropathic pain. alpha2delta subunit is the subunit of Ca2+ channel and modulate the influx of Ca2+. This Ca2+ influx induces release of neurotransmitter in the neuron. alpha 2 delta subunit blockers, such as gabapentin and pregabalin, may reduce the release of neurotransmitter and elicit analgesic effect in the treatment of neuropathic pain.

At this sanatorium, the number of foot bottom ulcer patients was 13 and the tenure of the foot bottom ulcer was average 11 years. According to the treatment that was not unified, we thought about the cause of the prolongation. Therefore, we made evaluation and care method sheet ("foot care sheet") of the ulcer for the unification. We used the foot pressure measurement system (F-scan) to 4 patients for the pressure dispersion of the ulcer. We devised the protection law of the ulcer, and an ulcer did not require pressure more than 5 kilos/cm2. We recorded the size of the ulcer, weight of the liquid from ulcer, a photograph to care sheet once a week. I performed ulcer protection law and management with the foot care sheet to 4 patients for average 4 months. As a result, the ulcers of 3 patients out of 4 patients became small.

"Leprosy control and Basic health service Project" was terminated at March 2005 within the scope of the period. I was assigned to develop the Plantar protect footwear for neuropathic feet, which called "Myanmar Sandals" in common. These sandals are not made by new technologies but made by basic knowledge. I would like to report about this activity as which is a part of distinguished strategy of ODA (Official Development Assistance) for developing country, but not as the technical report of these sandals. There is only one National Leprosy Hospital in Myanmar. At the time this project started, there were only two footwear technicians for the people who had disabilities by after effect of Hansen's disease in this country. And, it would appear that the number of the people is over 50,000. Furthermore, the budget of national hospital is not enough to refill necessary consumable supplies and materials. Although, I should instruct new technique which like making in Japan in ordinary circumstances, I could not think that such technical transfer by using costly imported materials woud bring beneficial effect and be continued. We were bound to be anxious about such situations when we made the plan. As a result of examining a plan based on these situations, we reached the conclusion that development of the simplified ready-made footwear was pressing need.

Leprosy causes several ocular disorders, and it also causes aftereffect with high frequency in various ways. Primary impairment is the ocular disturbance caused with direct invasion of nerve and ocular tissue by Mycobacterium leprae. Secondary impairment is the complication of nerve paralysis and residual inflammation due to primary disorder. Main work at Japanese national leprosariums has been the control of primary and secondary impairment in recent years. Clinical ophthalmic study in the leprosarium revealed a increase of age-related ocular disease in addition to aftereffect of leprosy. Severe sequelae due to sensory and functional disturbance will require suitable applications of advanced clinical technologies.

No more deformities which are the cause of social stigma by early detection and chemotherapy! Let patients learn how to avoid getting deformed to keep normal ADL & QOL. Fight against the nerve damage and stop the progressive deformities by organizing the team approach. Instead of intense efforts of taking care by well organized team work, deformities are resulted inevitably in some cases. Let their deformities be out of the way of their keeping normal community lives without any prejudice, respecting their human rights and dignity.

The proportion of glomerulonephritis, often a sequence of arteriolitis, among the sequelae of Hansen's disease after the introduction of chemotherapy increased markedly in Japan and nullified that of once prevalent tuberculosis after 1960s. However, most significant aftermath of the disease for numbers of years in the past have been peripheral nerve injuries worldwide for which effective countermeasures are yet to be developed. In this brief autopsy cases study from 1960s to 1990s, we confirmed the presence of cases in which arteriolitis and resulted infarction of peripheral nerves and not M. leprae itself were shown to be the major cause of axonal damages. There were also cases in which the accumulation of the bacilli without vascular changes did not damage the axons. The cases as these could not be solitary but should be rather common in this time of chemotherapy. If so, the methods to reconstruct nerves and blood vessels by promoting those regeneration should be developed to cope with the situation for surgeon, assisted by pathologists.

A 31-year-old man from Myanmar with leprous neuropathy was reported. The progress of the disease was subacute but the painful symptom at the time of the onset was acute. Multiple mononeuropathy was diagnosed by the biopsy findings of the left superficial radial nerve. He was admitted to our hospital with the complaint of the weakness of his left hand and fingers which were very painful and got worse in several weeks. Motor palsy was observed in his left ulnar, median, and radial nerves, and there was the hypesthesia or anesthesia in his left hand, forearm and the medial side of his left upper arm. On nerve conduction studies, the amplitudes of CMAP and SNAP severely diminished or not detected. The pattern was compatible with multiple mononeuropathy. The biopsy of the left superficial radial nerve was performed. The pathological findings were the destruction of nerve fascicles, replacement of nerve fibers with inflammatory cells, and Mycobacterium leprae was found with the specific stain. These findings confirmed the diagnosis of the leprous neuropathy. Leprous neuropathy is one of the commonest causes of infectious neuropathy in the world, especially in Southeast Asia. These days many foreign workers from that area are staying in Japan, and the chances to see the disease are increasing. We have to recognize leprous neuropathy as a candidate for the multiple mononeuropathy of acute onset with painful dysesthesia similar to vascular neuropathy.

Clarithromycin(CAM), Roxithromycin(RXM), Minocycline(MINO) and Fosfomycin(FOM) has anti-inflammatory action and immunomodulatory activity, while the anti-mycobacterium leprae activity is shown. CAM and RXM suppress the rat carrageenin edema, and MINO suppresses the rat adjvant arthritis. There is the immunosuppression on adrenocorticosteroid while the inflammatory cytokine is suppressed. CAM, MINO, FOM suppresses the inflammatory cytokine, while it has the immunomodulatory activity. Fusidic acid(FA) suppresses the inflammatory cytokine with the action of being similar to cyclosporin A, and it has the immunomodulatory activity. New macrolides derivatives, CAM and RXM showed the inflammatory regulation, and MINO showed the anti-inflammatory activity with FA. The combination chemotherapy can be enforced, while peripheral neuropathy is prevented by the control of the leprosy reaction.

One of the most important points in the treatments of patients with leprosy is to heal the disease without sequelae including sensory loss. For this purpose, every available means should be performed. The treatments of patients with leprosy at the RyukyuUniversity Hospital were reported in this study. Most of the medications were similar to that of multi drug therapy(MDT) recommended by WHO. Some modified MDT was applied to some patients for prevention of the various sequelae caused by the peripheral nervous disorders. In addition, some assistant treatments were also performed at our outpatient clinic such as administrations of drugs for the improvement of the peripheral circulation expecting the bacteriostatic effect caused by rising temperature (2-3 degrees C) of the skin lesions and expecting the recovery of the damaged peripheral nerves for the same purpose.

We have examined in leprosy in Bangladesh the change in the rate of peripheral nerve damage before and after the treatment. In the well-organized NGO program where the early diagnose is given, the damage rate improves slightly during the treatment. But among the MB cases, it has been found that the damage rate taken at the time of patient's first check-up still stays high. Furthermore, during the treatment of MB cases, 72% cases show the episode of neuritis, and even during two years of observation period after treatment, 15% cases show the same episode. Among the recurrent cases of last ten years in Oku-Komyo-en, we have looked into the ways of drugs prescribed for the treatment of previous recurrent term in the double recurrent cases. In these prescription, the amount of each dosage was relatively a little and the prescription period was rather long. In RFP, prescription frequency was relatively high, and in DDS and CLF, they were low. We think that the treatment of leprosy in Japan should be based on WHO's regimen. However before making Japanese regimen, it is necessary to discuss more when to finish the treatment.

In 1973, Narita reported that the rate of demented patients above 65 years was about 2% at the sanatorium--Tama Zenshoen, which was much lower than that of the average aged people (4-5%). The reason for that was thought to be due to the acquirement of strong mind under loneliness and difficulties faced by the patients through social enforcement to live in isolation. From that report on the low percentage of dementia among the Japanese Hansen patients reemed to be widely accepted. Fifteen years later in 1988, Narita reported that the rate of demented patients above 65 years was 3.2% in males and 3.6% in females indicating still a low rate at Tama Zenshoen. In 1994, however, Narita found unexpectedly that the percentage of dementia among patients above 80 at Tama Zenshoen was higher than the average aged population. Therefore in this report, we tried to analyze the reason for this difference. In addition to Tama Zenshoen patients, we also investigated those of another Hansen disease sanatorium namely Nagashima Aiseien which has similar structural organization as Tama Zenshoen. A comparison of dementia between these two was carried out, taking patients above 65 years as the study group (Used GBS scale based on Karasawa's method). In Tama Zenshoen, the rate of patients with dementia was 18.6% in males and 31% in females. Above 80 years those were 54.4% in males and 75.9% in females. The reason for the above high rate of dementia may be probably due to the passage of long years (40 to 50 years) after the enforcement to live in isolation causing the weakening of the spirit. The patients might have got some mental support if they had offspring, but they had no way to have any under the forced contraception. On the contrary, in Nagashima Aiseisen, the percentage of patients with dementia was low, namely 3.6% in males and 9.1% in females. In those patients above 80 years, it was 2.7% in males and 6.8% in females, those were almost similar to the average normal population (6%). Such a big difference was quite surprising. The reason behind this difference, may be due to the construction of the houses for the disabled persons. Both Nagashima Aiseien and Tama Zenshoen, have small individual rooms. In Tama Zenshoen, patients are able to visit their close neighbor, only after changing their shoes or with the aid of wheel chairs, but in Nagashima Aiseien, the corridors connecting quarters allow the patients to move easily to his neighbors with bare feet or even with crawl. Therefore, in Nagashima Aiseien, the number of patients who have social contacts with their neighbors is much greater in number which make them mentally active, thus eliminating the major factors affecting dementia. We can conclude that such communication between friends and co-mates make them alert and keep the spirit in the aged.

Nephropathy as the sequences of Hansen's disease before and after the introduction of chemotherapy was compared referring to the report by Hayashi in 1943 and the summary of the autopsy reports from 1978 to 1981 at National Hansen's disease hospital Zenseien. Unlike the high rates of tuberculosis as the cause of death before the introduction of chemotherapy (41.3%) those thereafter decreased to be negligible. On the other hand the comparison of the rates of nephropathy with the same way as that of tuberculosis was impossible since the description about nephropathy by Hayashi was not sufficient to characterize each nephropathy since he included arteriolitis, glomerulonephritis and interstitial nephritis together in the term of nephritis. Death rate due to nephritis among Hansen's disease patients according to Hayashi at that time was 21.2% which was twice as many comparing to that in the other cases. According to the report about the cases of Zenseien those reported to have glomerulonephritis was 37.3% though those were not necessarily listed as the cause of death. Also the nephropathy including fibrinoid angitis with occasional microaneurysmal dilatation of afferent arteries, glomerulitis, sclerosis and stricture of efferent arteries likewise ischemic acute tubular necrosis possibly as the result of these angiopathy seemed to be present. These vascular changes partially resemble to that of microscopic periarteritis nodosa but seems to be common in the smaller arteries. In conclusion, unlike the case of tuberculosis the rate of nephritis including glomerulitis, arteriolitis and interstitial nephritis as Hayashi used as his criteria does not seem to have decreased. Therefore, the critical analysis of the nephropathy especially of that relating to the arteriolitis should be done to obtain the knowledge to suppress its occurrence.

We studied leg pain experienced under spinal anesthesia in leprosy patients. Seven of twenty patients complained of the leg pain a few minutes after spinal block. The pain was localized in the parts of deafferentation or phantom limb, and was relatively mild and controllable. We consider that the inhibitory system is inactivated when the somatic impulse is blocked by spinal anesthesia, and as a result the abnormal burst activity of dorsal horn produced by peripheral nerve damage of leprosy causes phantom pain.

Human leukocyte antigens (HLA) were analyzed in Japanese leprosy patients to ascertain whether immunogenetic differences exist between leprosy patients with episcleritis (ES) and those without it. The subjects were 79 Japanese leprosy patients, including 33 patients with a past history of ES, and 49 patients without ES. Controls were 114 healthy subjects. A standard microcytotoxicity test was used for typing HLA-A, -B, -C, -DR and -DQ antigens. HLA-DRB1 and DQB1 genotypings were performed by using the polymerase chain reaction (PCR)-single strand conformation polymorphism and PCR-restriction fragment length polymorphism methods. The occurrence of HLA-Cw3 was significantly greater in the patients with ES (66.7%) than in those without ES (43.5%; odds ratio = 2.6, p < 0.05). The occurrence of HLA-DR4 was significantly lesser in the patients with ES (15.2%) than in those without ES (39.1%; odds ratio = 0.28, p < 0.05) and the controls (46.5%; odds ratio = 0.21, p < 0.005). At the genomic level, the occurrence of HLA-DRB1*0405, DQB1*0401, and DQB1*0302 was significantly lesser in the patients with ES (0%, 0% and 6.1%, respectively) than in those without ES (15.2%, 13.0%, and 26.1%, respectively; odds ratio = 0.07, 0.09 and 0.18, p < 0.05). HLA-DRB1*0405 and DQB1*0401 were also significantly lesser in the patients with ES than in the controls (29.8% and 29.8%; odds ratio = 0.04, p < 0.0001). Our results suggest that HLA-Cw3 causes susceptibility to episcleritis in Japanese patients with leprosy, whereas DR4 (DRB1*0405), DQB1*0401, and DQB1*0302 provide some protection against leprous episcleritis.

The author analyzed the results of cataract surgery performed in 25 eyes of 22 leprosy patients. All the eyes were treated by phacoemulsification-aspiration technique with intraocular lens implantation. The subjects consisted of 15 eyes of 14 leprosy patients with past history of uveitis and 10 eyes of 8 leprosy patients without uveitis. The mean follow-up time after surgery was 20 months and 23 months, respectively. In 93% of eyes with uveitis and 90% of eyes without uveitis, the postoperative vision improved by 2 lines or more. Postoperative complications were higher among patients with uveitis (93%) compared with patients without uveitis (40%). But no serious complications were encountered in patients with uveitis.

We examined 24 dermatologically cured leprosy patients with ongoing uveitis (UV+) and 22 age and type matched controls (UV-) to study the late phase leprous UV. All patients have been skin smear negative for more than 10 years. The history of chemotherapy, 5 years before and after a accomplishing bacterial negativity, was evaluated and represented by "SCORE". It was found that anti-PGL-I and anti-LAM-B antibodies were significantly higher in UV+ group compared to the controls. The mean SCORE of chemotherapy in UV+ group was significantly lower than in the controls. Iris pearls were seen in 10 cases or 42% out of 24 UV+ patients. No iris pearls were seen in control group. These results suggest that insufficient chemotherapy and consequent incomplete elimination of bacilli are the risk factors for leprous UV in the quiescent stage of the disease.

A 67-year-old patient has had exanthema in the lower right limb since 51 years ago (16 years old at onset), which underwent repeated remission and recurrence. At present, he has bilateral symmetrical widespread infiltrating exanthema and asymmetrical marked neuralhypertrophy, and has been diagnosed typical LLs (His father had the same disease). The exanthema recurred several years ago, and the patient is being treated for Hansen's disease. He had a dark brown flat elevation with a rough surface and the size of a small finger tip in his right abdominal skin for approximately 20 years. A biopsy was performed, and the specimen was fixed in 10% formalin and paraffin sections were prepared for histopathologic examination. A part of the specimen was processed forscanning electron microscopic examination. Seborrheic keratosis was diagnosed by H & E staining. Acid-fast (FITE) staining, immunohistochemical staining (keratin, S-100 protein, anti-PGL antibody and anti-BCG antibody) and scanning electron microscopy revealed the presence of bacteria (M. leprae) in the dermal foam cells, the matrix with a banded structure and the squamous epithelial cells which normally lack phagocytosis function. Compared to the basal cells of normal epidermis, the basal cells located adjacent to the dermis affected with seborrheic keratosis showed increased proliferation and more marked characteristics of a germinative cell. The degree of differentiation of the basal cells appeared regressed, and they probably possessed augmented phagocytic activity. The phagocytosed bacteria were probably carried by the epidermal cell cycle toward the surface layer. However, bacteria could not be found in the stratum corneum, probably due to an association with the lysosome.

In order to investigate the role of immunogenetic factors in the pathogenesis of uveitis in leprosy, human leukocyte antigens (HLA) were analyzed among leprotics with and without uveitis. The subjects were 85 Japanese leprosy patients, 44 with uveitis and 41 without uveitis. Controls were 138 healthy subjects. A modified two-stage complement dependent microcytotoxicity test was used for typing HLA-A, -B, -C, -DR and -DQ antigens. The occurrence of HLA-DR2 antigen was significantly increased in patients as a whole (69.4%), and in the patients with uveitis (79.5%) as compared with the control subjects (35.5%). The association with DR2 was even stronger in the patients with uveitis (odds ratio = 7.1, Pc < 0.000005) than in the patients as a whole (odds ratio = 4.1, Pc < 0.0001). On the other hand, HLA-DR53 antigen was significantly decreased in the patients as a whole (43.5%) and in the patients with uveitis (36.4%) as compared with the control subjects (69.6%). No significant difference in the distribution of HLA antigens was observed in the patients without uveitis. Our results suggest that HLA-DR2 contributes to the susceptibility to uveitis in Japanese leprosy patients.

Thymic cysts were diagnosed by thoracotomy in two women with leprosy, both 64 years old, within 12 months. Both were asymptomatic and an abnormal mediastinal shadow on an annual screening chest radiograph was a clue to the diagnosis in both cases. According to retrospective studies it took at least six or seven years for the thymic cysts to become large enough to be detected. Real-time echography was effective in the diagnosis of a cystic lesion in one case. Thymic cysts are important cystic lesions rarely found in the anterior mediastinum. A resective operation is thought to be indispensable to differentiate them from thymomas accompanied by large cystic degeneration and from thymic cysts accompanied by malignancies.

Hospital-acquired pneumonia is one of the most important fatal respiratory diseases in the elderly. Prompt and precise empiric therapy is essential for recovery. Fourteen isolates from twelve elderly lepromatous leprosy patients (9 men, 3 women, mean age of 75.8 years) with hospital-acquired pneumonia were studied. Subsequently, empiric therapy with gentamicin and beta-lactams for nosocomial pneumonia in the elderly was examined. Fourteen types of bacteria isolated from expectorated sputum specimens consisted mainly of ten strains of gram-negative bacilli (71%) six of Klebsiella pneumoniae, one each of Citrobacter freundii, Enterobacter agglomerans, Serratia liquefaciens, and Aeromonas hydrophilia and four strains of gram-positive cocci (29%) two of Staphylococcus sp., one each of Streptococcus sp. and Streptococcus pneumoniae. Methicillin-resistant Staphylococcus aureus and Pseudomonas sp. were not detected. Resistance rates of the etiologic agents to the antibiotics showed that gentamicin was 7.7%, ceftazidime 0%, and cefmetazole 23.1%. Cephalosporins were superior to penicillins. As a result of empiric therapy, six elderly leprosy patients with nosocomial pneumonia were cured and one improved temporarily. This study shows the necessity of specific empiric therapy for hospital-acquired pneumonia in a hospital with many elderly patients. The combination of gentamicin and beta-lactams is of value as an initial antibiotic therapy for hospital-acquired pneumonia in the elderly.

Eyes from autopsy cases of leprosy patients (29 eyes from 16 cases) were examined histologically. In some cases immunohistochemical methods were used. In the lepromatous type, ocular complications such as keratitis and iridocyclitis were often found. In the tuberculoid type, such complications were seldom encountered. In the active stage, lepra cells and "foamy cells" showed positive reaction to acid-fast staining and anti-BCG antibody but in the silent stage they did not react. All foamy cells in both the active and the silent stage showed positive reaction to KP1, but they did not react to lysozyme or alpha 1-antitrypsin. These results suggest that the foamy cells originated from macrophages, but that their biological activity was low.

A roentgenographic examination was made for the limbs of leprosy patients with calcinosis in whom atrophic cutaneous sclerosis and subcutaneous induration or infiltration were observed. The observation results are summarized as follows. 1. Atrophic cutaneous sclerosis was one of a sequela in lepromatous lesion, especially in case of ENL, and it was observed to occur frequently at the extended sides of 1/3distal part from the forearm and the crus mainly. The atrophied cutaneous surface was tinged with lustrous red. It was able to observe calcium deposition directly just under the skin and/or in the shallow subcutaneous region from the roentgenogram of the site. The roentgenographic patterns were demonstrated as if many granules were scattered, and also the dendric and reticular platy-expansions were detected in some cases. The enucleated parts seemed to be similar to the cancellous bone. It might be said that dystrophic calcinosis cutis developed by inducing histological disorder is one of the origin of such a calcinosis, because the skin in these regions is deficient in the mobility and tends to provoke the circulatory disorder in case of chronic inflammation as discerned in lepromatous lesion. 2. An induration in subcutaneous tissue is lipid lump being as it was when chaulmoogra oil was injected and not undergo absorption of the oil. The lipid lumps enveloped in the tunic were observed in the site of lateral upperarm and the front of femur. They seemed to be remained almost all as it was. It was observed that the lipid lumps, as such, were adjacent to the outer layer of fascia, but not in the muscle. And there are some cases where the oil flowed from the injection site through the hypodermis and got the lipid lumps formed in the forearm and/or the crus. Roentgenogram of that showed the existence of calcinosis regardless of size which transmissivity of X-ray had an irregular pattern. The enucleated lipid lumps were easily cut to pieces by scalpel. 3. It may be said that the calcinosis observed in atrophic cutaneous sclerosis due to lepromatous lesion or lipid lump of unabsorbed chaulmoogra oil makes it necessary for its healing to be 10-20 years. 4. Roentgenogram at that time revealed no abnormality as to serum calcium, phosphorous and/or alkaline phosphatase values.

As of the year 1991 there were 358 leprosy patients in National Leprosarium Matsuoka Hoyo-En, including 223 patients (62.3%) who had received the injections of chaulmoogra oil before. Calcinosis cutis caused probably from the injections was noted on 73 patients (32.7%): 67 lepromatous and 6 tuberculosis cases. It has never been reported before that the T type patient suffering from calcinosis cutis was observed in the cases of the chaulmoogra oil injection in Japan. The detectable positions of calcinosis cutis were mostly at the injected sites, that is, outside the right brachium followed by bilateral-branchia and crura. In the group of patients with calcinosis cutis, the anti-PGL antibody was negative for the most part. Urinalyses, peripheral blood figure analyses, histopathological tissue examinations of calcium deposition, X-ray diffraction patterns, differential thermal and gravitational analyses, and chemical analyses were performed on all patients with this disease. Further, as the result of this study six patients with calcinosis cutis caused by sulpyrine was also found. The major component of the deposit by the drug was calcium phosphate. These calcinosis cutis were considered to be of trophopathic calcinosis based on the disorder of subcutaneous tissue due to the injections of respective drugs: chaulmoogra oil and sulpyrine.