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Objective: To establish peripheral nerve cross-sectional area (CSA) reference values (absolute values, measures of asymmetry, and measures of focality) for healthy individuals in Brazil. Materials and Methods: Sixty-six healthy volunteers underwent high-resolution ultrasound of the peripheral nerves. We obtained CSA measurements for three peripheral nerves, at specific locations: the median nerve, in the carpal tunnel (MT); the ulnar nerve, at the cubital tunnel site (UT) and at the pre-tunnel site (UPT); and the common fibular nerve, near the fibular head (FH). We calculated the CSA indices between the same sites on different sides (∆CSAs) and between the ulnar nerve tunnel and pre-tunnel sites on the same side (∆TPT). Results: A total of 132 neural sites were analyzed, and the following CSA values (mean ± SD, median) were obtained: MT (6.3 ± 1.9 mm2, 6.0 mm2); UT (6.2 ± 1.6 mm2, 6.1 mm2); UPT (5.6 ± 1.7 mm2, 5.4 mm2); and FH (10.0 ± 3.7 mm2, 9.9 mm2). The ∆CSA values (mean ± SD, median) were as follows: MT (0.85 ± 0.7 mm2, 0.95); UT (0.81 ± 0.62 mm2, 0.95); UPT (0.61 ± 0.51 mm2, 0.5); and FH (1.0 ± 0.77 mm2, 1.0). The ∆TPT (mean ± SD, median) was (1.0 ± 0.8 mm2, 1.0). Conclusion: Among individuals in Brazil, peripheral nerve CSA values tend to be higher among males and to increase with aging. However, the same does not appear to hold true for the ∆CSA or the ∆TPT, the exception being the difference between the right and left UT. Differences in CSA values greater than 2.5 mm2 between sides or between sites along the same nerve can indicate asymmetry or focal thickening in neuropathy, respectively. Resumo Objetivo: Estabelecer valores de referência da área de secção transversa (AST) dos nervos periféricos (valores absolutos e medidas de assimetria e de espessamento focal) para amostra de indivíduos brasileiros saudáveis. Materiais e Métodos: Sessenta e seis voluntários brasileiros saudáveis foram submetidos a ultrassonografia de alta resolução de nervos periféricos. As medidas da AST dos seguintes nervos periféricos foram obtidas em: mediano no túnel do carpo (MT), ulnar no túnel cubital (UT), pré-túnel ulnar (UPT) e fibular comum na cabeça da fíbula (FH). Os índices CSA foram obtidos entre os mesmos sítios em lados diferentes (∆CSA) e entre os sítios distal e proximal do nervo ulnar (∆TPT). Resultados: As seguintes médias ± desvio-padrão e mediana da AST foram obtidas para os 132 sítios dos nervos periféricos analisados: MT (6,3 ± 1,9 mm2; 6,0 mm2), UT (6,2 ± 1,6 mm2; 6,1 mm2), UPT (5,6 ± 1,7 mm2; 5,4 mm2) e FH (10,0 ± 3,7 mm2; 9,9 mm2). A média ± desvio-padrão e as respectivas medianas do ∆CSA em mm2 foram: 0,85 ± 0,7 [0,95] para MT, 0,81 ± 0,62 [0,95] para UT, 0,61 ± 0,51 [0,5] para UPT, 1,0 ± 0,77 [1] para FH, e 1,0 ± 0,8 [1,0] para ∆TPT. Conclusão: Os valores de AST tendem a ser maiores no sexo masculino, aumentando os valores absolutos das medianas das ASTs com o envelhecimento, mas não nos seus índices, ∆CSA e ∆TPT, exceto a diferença entre a AST dos nervos ulnares nos lados direito e esquerdo. Diferenças de valores de AST entre lados ou pontos no mesmo nervo maior que 2,5 mm2 podem significar neuropatia com assimetria e espessamento focal.

Generalized verrucosis is a clinical manifestation of human papillomavirus infection. Patients with generalized verrucosis present with over 20 verrucae distributed over various anatomical sites. The disorder occurs in association with several genetic syndromes with immunodeficiency, including GATA2 deficiency. We report a 12-year-old boy with GATA2 deficiency and generalized verrucosis that worsened after cyclosporine use following bone marrow transplant. Systemic treatment with acitretin and topical application of trichloroacetic acid, likely along with immune reconstitution, led to complete remission.

INTRODUCTION We sought to compare median nerve elasticity between leprosy patients (LPs) and healthy volunteers (HVs) using ultrasound elastography (UE). METHODS Two radiologists independently measured the strain ratio of the median nerve/flexor digitorum superficialis muscle (MN/FDSM) of 18 LP and 18 HV using real-time freehand UE. Statistical analysis included intra-class correlation coefficients (ICC) and Mann-Whitney test. RESULTS The MN/FDSM strain ratios of the LP and HV were 2.66 ± 1.30 and 3.52 ± 0.93, respectively (P

We report the ultrasound findings of a typical case of nerve abscess due to leprosy in an 11-year-old boy. The patient had previously undergone pediatric multibacillary leprosy multidrug therapy (MDT) in accordance with World Health Organization guidelines. He presented to our service with bilateral ulnar neuritis with no response to prednisone (1 mg/kg). Right ulnar nerve ultrasound revealed nerve hypoechogenicity, fascicular pattern disorganization, marked fusiform thickening, and a round anechoic area suggestive of intraneural abscess. Intense intraneural power Doppler signal was detected, indicating active neuritis. Intravenous methylprednisolone had a poor response and the patient was submitted to ulnar nerve decompression, which confirmed nerve abscess with purulent discharge during surgery. As the patient weighed more than 40 kg, treatment with a pediatric dose was considered insufficient and adult-dose MDT was prescribed, with improvement of nerve pain and function. Although leprosy is rare in developed countries, it still exists in the USA and it is endemic in many developing countries. Leprosy neuropathy is responsible for the most serious complications of the disease, which can lead to irreversible impairments and deformities. Nerve abscess is an uncommon complication of leprosy and ultrasound can efficiently demonstrate this condition, allowing for prompt treatment. There is scant literature about the imaging findings of nerve abscess in leprosy patients. Radiologists should suspect leprosy in patients with no other known causes of neuropathy when detecting asymmetric nerve enlargement and nerve abscess on ultrasound.

Background Leprosy diagnosis is mainly based on clinical evaluation, although this approach is difficult, especially for untrained physicians. We conducted a temporary campaign to detect previously unknown leprosy cases in midwestern Brazil and to compare the performance of different serological tests. Methods A mobile clinic was stationed at the main bus terminal in Brasília, Brazil. Volunteers were quizzed and given a clinical exam to allow categorization as either patients, known contacts of patients or non-contacts, and blood was collected to determine anti-PGL-I and anti-LID-1 antibody titers by ELISA and by the NDO-LID rapid test. New cases of leprosy and the impact of performing this broad random surveillance strategy were evaluated. Accuracy values and concordance between the test results were evaluated among all groups. Results Four hundred thirty-four individuals were evaluated, and 44 (10.1%) were diagnosed with leprosy. Borderline forms were the most frequent presentation. Both tests presented higher positivity in those individuals with multibacillary disease. Serological tests demonstrated specificities arround 70% for anti-PGL-1 and anti-LID ELISA; and arround 40% for NDO-LID. Sensitivities ranged from 48 to 62%. A substantial agreement between NDO-LID and ELISA with concomitant positive results was found within leprosy patients (Kappa index = 0.79 CI95% 0.36–1.22). Conclusions The unexpectedly high leprosy prevalence in this population indicates ongoing community-based exposure to Mycobacterium leprae antigens and high rates of subclinical infection. All tests showed low specificity and sensitivity values and therefore cannot be considered for use as stand-alone diagnostics. Rather, considering their positivity among MB patients and non-patients, these tests can be considered effective tools for screening and identifying individuals at high risk who might benefit from regular monitoring., Author summary Leprosy is a disease that affects the skin and peripheral nervous system, caused by Mycobacterium leprae (M. leprae), that to survive hides itself within the host cells and grows slowly. Its diagnosis is difficult and requires trained physicians. Laboratorial tests are frequently negative depending on individual response. M. leprae transmission is mainly man to man, because this is very important diagnosis and treatment of patients for breaking the transmission chain. We conducted a temporary campaign to detect previously unknown leprosy cases in midwestern Brazil and to compare the performance of different serological tests (anti-PGL-I and anti-LID-1 antibody titers by ELISA and by the NDO-LID rapid test). Four hundred thirty-four individuals were evaluated, and 44 (10.14%) were diagnosed with leprosy. Each test presented higher positivity in those individuals with multibacillary disease. For leprosy diagnosis, serological tests demonstrated specificities arround 70% for anti-PGL-1 and anti-LID ELISA; and arround 40% for NDO-LID. Sensitivities ranged from 48 to 62%. Anti-PGL-I and anti-LID-1 ELISA sensitivity values were 30.1% and 23.7% respectively, while NDO-LID sensitivity was 51.6% among contacts and non-contacts. The low specificity and sensitivity values of serological tests establish that they cannot be considered stand-alone diagnostics considering the importance of clinical manifestations in leprosy. Rather, we suggest using such tests as a means to triage potential patients for follow-up clinical examinations.

Background Previous studies have shown that leprosy multi-drug therapy (MDT) does not stop the progression of nerve function impairment. There are no prospective studies investigating the evolution of nerve anatomic abnormalities after treatment. We examined leprosy patients aiming to investigate the evolution of nerve ultrasonography (US) abnormalities and the risk factors for poor outcomes after MDT. Methodology/Principal findings We performed bilateral US of the ulnar (U), median (M) and common fibular (CF) nerves in 9 paucibacillary (PB) and 64 multibacillary (MB) patients before and after MDT. Forty-two patients had leprosy reactions (type 1, type 2, acute neuritis) during the study. We analyzed nerve maximum cross-sectional areas (CSA), echogenicity and Doppler signal. Poor outcomes included a post-treatment CSA above normal limits with a reduction of less than 30% (U, M) or 40% (CF) from the baseline, echogenicity abnormalities or intraneural Doppler in the post-treatment study. We found that PB and patients without reactions showed significant increases in CSA at CF, whereas MB and patients with reactions had CSA reduction in some nerves after treatment (p0.05) and in the patients with reactions compared to those without (66.7% and 38.7%; p, Author Summary Leprosy can lead to functional and anatomical changes in the peripheral nerves. Previous studies have shown that the anti-bacterial treatment cannot stop the progression of nerve function abnormalities; to our knowledge, there are no previous prospective studies investigating the evolution of nerve anatomical abnormalities. Seventy-three leprosy patients underwent bilateral ultrasonography of the ulnar, median and common fibular nerves before and after treatment. We analyzed thickening and asymmetry measurements, nerve architecture (echogenicity abnormalities) and vascularization (Doppler signal). We observed worsening of thickening in the common fibular nerve in the paucibacillary and in the patients without reactions. On the other hand, we observed reduction in the thickening and asymmetry measurements for some nerves in the multibacillary and in the patients with reactions. Although we observed reduction in the measurements of these two groups, they presented higher frequencies of echogenicity abnormalities, indicating that these reductions might have been due to evolution to nerve fibrosis and atrophy. The frequencies of Doppler signal were similar between the pauci and multibacillary patients. We observed association between Doppler signal and the presence of acute neuritis. Our results indicate that the nerve anatomic abnormalities assessed by ultrasonography can worsen after treatment despite the patient classification and the presence of reactions.

To evaluate ultrasonographic (US) cross-sectional areas (CSAs) of peripheral nerves, indexes of the differences between CSAs at the same point (∆CSAs) and between tunnel (T) and pre-tunnel (PT) ulnar CSAs (∆TPTs) in leprosy patients (LPs) and healthy volunteers (HVs). Seventy-seven LPs and 49 HVs underwent bilateral US at PT and T ulnar points, as well as along the median (M) and common fibular (CF) nerves, to calculate the CSAs, ∆CSAs and ∆TPTs. The CSA values in HVs were lower than those in LPs (p < 0.0001) at the PT (5.67/9.78 mm2) and T (6.50/10.94 mm2) points, as well as at the M (5.85/8.48 mm2) and CF (8.17/14.14 mm2) nerves. The optimum CSA- receiver operating characteristic (ROC) points and sensitivities/specificities were, respectively, 6.85 mm2 and 68-85% for the PT point, 7.35 mm2 and 71-78% for the T point, 6.75 mm2 and 62-75% for the M nerve and 9.55 mm2 and 81-72% for the CF nerve. The ∆CSAs of the LPs were greater than those of the HVs at the PT point (4.02/0.85; p = 0.007), T point (3.71/0.98; p = 0.0005) and CF nerve (2.93/1.14; p = 0.015), with no difference found for the M nerve (1.41/0.95; p = 0.17). The optimum ∆CSA-ROC points, sensitivities, specificities and p-values were, respectively, 1.35, 49%, 80% and 0.003 at the PT point, 1.55, 55-85% and 0.0006 at the T point, 0.70, 58-50% and 0.73 for the M nerve and 1.25, 54-67% and 0.022 for the CF nerve. The ∆TPT in the LPs was greater than that in the HVs (4.43/1.44; p 80%) and ∆TPT had the highest specificity (> 90%). New sonographic peripheral nerve measurements (∆CSAs and ∆TPT) provide an important methodological improvement in the detection of leprosy neuropathy.

As consequências mais graves da hanseníase resultam do acometimento neurológico. Recentemente a ultrassonografia (US) têm ganhado importância na avaliação da neuropatia hansênica. O objetivo deste trabalho foi avaliar por US nervos periféricos de pacientes com hanseníase antes e após o tratamento. Buscou-se caracterizar alterações ao diagnóstico e evolução da doença, controlando os efeitos de fatores confundidores e investigando fatores de risco para progressão das alterações (classificação, episódios reacionais, sexo, tempo de evolução). Foram sistematicamente examinados por US os nervos ulnares (regiões pré-túnel cubital UPT e túnel UT), medianos e fibulares comuns bilateralmente para mensuração das áreas de secção transversa (CSA) e cálculo das medidas de assimetria delta CSA (diferença absoluta entre CSAs dos lados direito e esquerdo de cada nervo) e delta Utpt (diferença absoluta entre CSAs de UPT e UT ipsilaterais); também foram analisadas alterações qualitativas (ecogenicidade e Doppler). Foram avaliados 100 pacientes antes do tratamento, sendo 14 paucibacilares (3 indeterminados, 11 tuberculoides) e 86 multibacilares (31 dimorfo-tuberculoides, 34 dimorfo-dimorfos, 13 dimorfo-virchowianos, 8 virchowianos); destes, 73 completaram a avaliação pós-tratamento. Considerando que alterações em pelo menos uma das medidas avaliadas refletem neuropatia, observou-se frequências similares de neuropatia pré-tratamento nos paucibacilares (PB) (35,7 a 57,1%) e multibacilares (MB) (50 a 65,1%). O nervo mais frequentemente acometido nos PB foi o fibular comum, enquanto que nos MB foi o ulnar. As médias de CSA foram maiores nos MB do que nos PB em todos os nervos (p0,05) e com reações hansênicas (odds ratio: 4,67; intervalo de confiança 95%: 1,17-18,64; p0.05) and in patients with previous leprosy reactions (odds ratio 4.67; 95% confidence interval 1.17-18.64; p

Background Neurological involvement occurs throughout the leprosy clinical spectrum and is responsible for the most feared consequences of the disease. Ultrasonography (US) provides objective measurements of nerve thickening and asymmetry. We examined leprosy patients before beginning multi-drug therapy aiming to describe differences in US measurements between classification groups and between patients with and without reactions. Methodology/Principal Findings Eleven paucibacillary (PB) and 85 multibacillary (MB) patients underwent nerve US. Twenty-seven patients had leprosy reactions (type 1, type 2 and/or acute neuritis) prior to US. The ulnar (at the cubital tunnel–Ut–and proximal to the tunnel–Upt), median (M) and common fibular (CF) nerves were scanned to measure cross-sectional areas (CSAs) in mm2 and to calculate the asymmetry indexes ΔCSA (absolute difference between right and left CSAs) and ΔUtpt (absolute difference between Upt and Ut CSAs). MB patients showed greater (p, Author Summary Leprosy is an infectious disease that affects the peripheral nerves, leading to nerve thickening, asymmetry and dysfunction; therefore, early detection of leprosy neuropathy is important for preventing deformities and disabilities. We examined peripheral nerve involvement using ultrasonography (US) in 96 leprosy patients prior to treatment, aiming to better understand differences in neuropathy patterns between leprosy classification groups and between patients with and without leprosy reactions. Patients underwent bilateral US of the ulnar (at the cubital tunnel and proximal to the tunnel), median and common fibular nerves to measure thickening and asymmetry. We found that nerve thickening was more severe in patients with a high bacillary load (multibacillary) and in those with previous reactions. Nerve asymmetry measurements were greater in the patients with previous reactions. Asymmetry did not differ significantly between the paucibacillary and multibacillary patients, demonstrating that asymmetry is a characteristic of leprosy neuropathy regardless of its classification.

A hanseníase é uma doença infecciosa, de período de incubação longo, 3 a 5 anos, causado pelo Mycobacterium leprae, que atinge principalmente a pele e os nervos periféricos tendo elevado potencial incapacitante. Em 2018 foram registrados 208.619 casos no mundo. A Índia ainda é o país mais afetado com 120.334 casos novos seguido pelo Brasil com 28.660 casos. Os coeficientes de detecção geral são mais elevados na região centro-oeste e norte. A região nordeste ocupa o 3º lugar na detecção geral em menores de 15 anos. Pernambuco está classificado quanto a endemicidade como muito alto na detecção geral (2.338 casos novos) e muito alto (6,77) em menores de 15 anos. O diagnóstico da hanseníase é essencialmente clínico e pobre em exames complementares. Sendo assim imprescindível a necessidade do treinamento dos profissionais que atuam na vigilância em saúde, na atenção básica e demais níveis de atenção no que se refere às diretrizes para vigilância, à assistência e à eliminação da hanseníase como problema de saúde pública. O objetivo dessa pesquisa é analisar a eficácia destes treinamentos, comparando os dados epidemiológicos dos municípios e do estado como um todo antes e após as capacitações. Os municípios participantes não silenciosos apresentaram uma média de 5 diagnósticos por profissional capacitado, enquanto os que eram silenciosos tiveram uma média de 7 diagnósticos por profissional capacitado. No diagnóstico em menores de 15 anos os números de casos novos nesta faixa etária não refletiram benefícios destas capacitações na atenção primária. O diagnóstico nesta faixa etária requer expertise sendo muitas vezes difícil até mesmo para os especialistas. Ainda existe um diagnóstico tardio da doença. Observamos um aumento na média dos números de casos novos com GIF 2 nas macrorregiões III e IV nos municípios que enviaram profissionais para capacitação. Na avaliação de contatos o estado de Pernambuco mantém-se estável em sua linha de tendência em precário, aproximadamente 70%. Leprosy is an infectious disease that has long incubation period of 3 to 5 years, caused by the Mycobacterium leprae, which affects mostly the skin and peripheral nerves and has high disabling potential. In 2018, 208.619 new cases were recorded in the world. India is still the most affect country, with 120.334 new cases followed by Brazil with 28.660 new cases, where the general detection coefficients are higher in the midwest and north regions. The northeast region is third on the general detection in children under 15 years ranking. Pernambuco is labeled as very high on the endemicity (2.338 new cases) and also on children under 15. Leprosy diagnosis is mostly clinic and poor in complementary exams. Because of that, it is indispensable the need of professional training for those who work in health surveillance, in primary healthcare and other levels of care on what refers to the guidelines for surveillance, care and disposal aiming for the leprosy elimination as a public health problem. The main purpose of this research is analyze the efficiency of theses trainings, comparing the epidemiological data of the cities and the state as a whole before and after training. The participating non-silent cities had an average of 5 diagnoses per trained professional, while those that were silent had an average of 7 diagnoses per trained professional. In the diagnosis of children under 15, the number of new did not reflect the benefits of these training courses in primary care. Diagnosis in this age group requires expertise and it is difficult even for specialists. There is still a late diagnosis of the disease. We observed an increase in the average number of new cases with GIF 2 in macro-regions III and IV in the cities that sent professionals for training. In the assessment of contacts, the state of Pernambuco remains stable in its precarious trend line, approximately 70%.