Friday, November 17, 2017

(LML) Dactylitis and Cold Abscess in Leprosy

Leprosy Mailing List – November 17,  2017

Ref.:    (LML) Dactylitis and Cold Abscess in Leprosy

From:  Wim Theuvenet, Annick Mondjo and  Khalid Al Aboud

Question Wim Theuvenet:


Thank Dr. Khalid for sharing this case (LML, November 15, 2017. As dig. I and V are both involved I personally wonder whether there is not a "horse shoe" abscess with a communicating flexor tendon sheath infection=pannaritium, which communicates with each other at wrist level? Indication for ultrasound examination and a consultation of a Hand Surgeon for exploration/ histology/ cultures incl. mycobacteria?


The underlaying cause may be any sort of infection. Have once seen this in T.B! Please keep us informed on the outcome!


Best regards,


Willem J.Theuvenet, M.D, Ph.D

Plast. Rec. Hand Surgeon and Leprologist

Question Annick Mondjo:


I would like to ask Dr. Khalid the following questions:

-       What is the aspect of pathological examination? and

-       What about the evolution of these disseminated painful nodules?


For me this case is primarily clinically leprosy evoke/revealed by an ENL.

Dr Annick Mondjo

Directeur du Programme de Lutte contre les Maladies Infectieuses

Ministère de la Santé

BP 50 Libreville



Reaction Khalid Al Aboud:



Dear Pieter and colleagues,


Many thanks for the comments of Dr. Theuvenet and Dr Annick. The patient was a visitor on Haj for a short period; and we could not investigate her thoroughly. After she went back to her home country we did not hear from her anymore. We are also not aware if she continued her treatment after leaving from here.


She had indolent multiple nodules on the body and predominantly on the face, and was not diagnosed before. ENL is a valid point but a patient with ENL usually has systemic symptoms like pain or fever and usually precipitated by treatment.

Therefore, I thought ENL is unlikely in this case.


With my thanks and regards,




LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link:

Contact: Dr Pieter Schreuder <<

Thursday, November 16, 2017

(LML) Steroid Dependency and the use of Methotrexate

Leprosy Mailing List – November 16,  2017

Ref.:   (LML)  Steroid Dependency and the use of Methotrexate

From:  Terence J Ryan, Oxford, UK

Dear Pieter,

Thank you for distributing my comments (LML, November 13, 2017).

I should have included a recently published ill effect of an herbal.

-       Gonui M, Keseroglu H and Hacinecipoglu F (2016). A Case of methotrexate intoxication in a patient with psoriasis who drank beetroot juice during methotrexate treatment. Clinical and Experimental Dermatology 41:893-895

One should always ask about what health foods are being taken.

In a world where the Traditional Health Practitioner is first on call I am in favour of their education rather than any attempt to abolish their practice. A recent (2016) publication (Supplement On Integrated Medicine by SR Narahari and myself ) of the Indian Current Science discusses this at length and includes an article on Leprosy by David Chandler.

Terence J Ryan

LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link:

Contact: Dr Pieter Schreuder <<

Wednesday, November 15, 2017

(LML) Dactylitis and Cold Abscess in Leprosy

Leprosy Mailing List – November 15,  2017

Ref.:    (LML) Dactylitis and Cold Abscess in Leprosy

From:  Kalid Al Aboud, Makkah, Saudi Arabia


Dear Dr. Schreuder and colleagues,


Leprosy has a protean clinical feature. I wish to share you the occurrence of dactylitis and Cold abscess in a 48 old Indonesian patient, affected by leprosy, who came to Makkah to perform Hajj (see the attached figure). She presented with generalized erythematous nodules, predominantly affecting the face. Classification BL/LL. She was not known to have leprosy or  treated before. On the thenar aspect of the palm we found a fluctuating abscess-like swelling, but without tenderness or heat.


I feel these 2 clinical signs are not commonly recognized and I found few reports about these features in Pubmed (see references below)


Dactylitis or sausage digit is inflammation of an entire digit (a finger or toe), and can be painful. The word dactyl comes from the Greek word "daktylos" meaning "finger". In its medical term, it refers to both the fingers and the toes.


Dactylitis can occur in seronegative arthropathies such as psoriatic arthritis, ankylosing spondylitis and sickle cell disease as result of a vaso-occlusive crisis with bone infarcts, and in infectious conditions including tuberculosis and leprosy. In reactive arthritis, sausage fingers occur due to synovitis. In sickle-cell disease it manifests itself for the first time in 6-9 month old infants (as their protective foetal haemoglobin, HbF, is replaced with adult haemoglobin and the disease manifests) and is very often the presenting sign of the disorder.


Cold abscess refers to an abscess that lacks the intense inflammation usually associated with infection. This may be associated with infections due to bacteria like tuberculosis and fungi like blastomycosis that do not tend to stimulate acute inflammation. Alternatively, cold abscesses are typical in persons with hyperimmunoglobulin E syndrome, even when infected with an organism like Staph aureus which causes typical ("hot") abscesses in others. Signs of acute inflammation are absent, so the abscess is not hot and red as in a typical abscess filled with pus. Cold abscesses are generally painless cysts that may be subcutaneous, ocular, or in deep tissue such as the spine.




1.Multifocal scrofuloderma overlying tuberculous dactylitis in an immunocompetent child.

Bhat YJ, et al. Indian J Dermatol Venereol Leprol. 2015 Jul-Aug.


2.Borderline Hansen complicated by a metastatic cold abscess.

Sethi S, et al. Lepr Rev. 2015.


3.Multiple cold abscesses in a borderline lepromatous patient on multidrug therapy.

Kulkarni V, et al. Indian J Lepr. 1989.


4.Dactylitis.A page on Wikipedia ; available at


5.Cold abscess.A page on Wikipedia ;available at



Dr Khalid Al Aboud

Consultant Dermatopathologist 


Head of Public Health Dept.

King Faisal Hospital


Saudi Arabia

LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link:

Contact: Dr Pieter Schreuder <<



Tuesday, November 14, 2017

(LML) INFOLEP monthly overview of new publications on leprosy, November 2017


Leprosy Mailing List – November 14,  2017

Ref.: (LML) INFOLEP monthly overview of new publications on leprosy, November 2017  

From:  Jiske Erlings, Amsterdam, the Netherlands

Dear Pieter,

Greetings from Infolep!

Do you know that the Infolep ( portal gives you access to over 27,200 publications on leprosy? The purpose of this monthly newsletter is to inform you about 
recent publications on leprosy and related subjects. Do you have any leprosy research or training material you would like to share? Please send me an e-mail.

Feel free to contact me to receive the full text versions if a link to the full text is not provided. Assistance with your literature research is also possible.

With kind regards,

Jiske Erlings,
Infolep Information officer





Highlighted publications



A guide for surveillance of antimicrobial resistance in leprosy: 2017 update
WHO SEARO, 2017. Download PDF

Leprosy Review
Volume 88, issue 3, October 2017. Read online

Disease Control Priorities, Third Edition : Volume 6. Major Infectious Diseases.
World Bank report, 2017. Read online

TB Stigma measurement and elimination
IJTLD Volume 21, Supplement 1, 1 November 2017. Read online



New publications



Multidrug-resistant tuberculosis and leprosy: An unsolved mystery.
Al-Mendalawi MD. Lung India. 2017 Nov-Dec;34(6):579-580.
Download PDF

Analysis of CTLA-4+49A/G gene polymorphism in cases with leprosy of Azerbaijan, Northwest Iran.
Almasi S, Aliparasti MR, Naghili B, et al. Infect Genet Evol. 2017 Nov 2. pii: S1567-1348(17)30381-7.
Read abstract

Insights from the Genome Sequence of Mycobacterium lepraemurium: Massive Gene Decay and Reductive Evolution.
Benjak A, Honap TP, Avanzi C, et al. MBio. 2017 Oct 17;8(5).
Download PDF

Neglected tropical diseases in Brazilian children and adolescents: data analysis from 2009 to 2013.
Brandão E, Romero S, da Silva MAL, et al. Infect Dis Poverty. 2017 Nov 3;6(1):154.
Download PDF

Positive Diagnosis of Ancient Leprosy and Tuberculosis Using Ancient DNA and Lipid Biomarkers.
Donoghue H, Taylor G, Stewart G, et al. Diversity. 2017; 9(4):46.
Download PDF

Empowerment Leprosy Sufferer Patients in Kupang City.
Elim RV. Jurnal Pengabdian Masyarakat Peternakan. 2017; 2(1):54-60.
Read abstract

Effectiveness of rifampicin chemoprophylaxis in preventing leprosy in patient contacts: a systematic review of quantitative and qualitative evidence.
Ferreira SMB, Yonekura T, Ignotti E, et al. JBI Database System Rev Implement Rep. 2017; 15(10):2555-2584.
Read abstract

Peripheral Nerve Stimulation for Painful Mononeuropathy Secondary to Leprosy: A 12-Month Follow-Up Study.
Freitas TDS, Fonoff ET, Marquez Neto OR, et al. Neuromodulation. 2017 Oct 29.
Read abstract

Towards global elimination of leprosy.
Hatami H. Journal of health in the field. 2017; 5(2).
Download PDF

Leprosy in pre-Norman Suffolk, UK: biomolecular and geochemical analysis of the woman from Hoxne.
Inskip S, Taylor MG, Anderson S, et al. J. Med. Microbiol. 2017.
Read abstract

Role of mast cells in leprosy- A study of 62 cases.
Jindal S, Manjari M, Girdhar M. Journal of evolution of medical and dental sciences. 2017; 6(75):5328-5331.
Download PDF

Leprosy presenting with iridocyclitis: A diagnostic dilemma.
Kaushik J, Jain VK, Singh Parihar JK, et al. J Ophthalmic Vis Res. 2017; 12(4):437-439.
Download PDF

Possible cases of leprosy from the Late Copper Age (3780-3650 cal BC) in Hungary.
Köhler K, Marcsik A, Zádori P, et al. PLoS One. 2017 Oct 12;12(10):e0185966.
Download PDF

Emerging concept on peripheral nerve damage in leprosy.
Kumar V. International journal of research studies in medical and health sciences. 2017; 2(7):8-18.
Download PDF

Molecular detection of multi drug resistant Mycobacterium leprae from Indian leprosy patients.
Lavania M, Singh I, Turankar RP, et al. J Glob Antimicrob Resist. 2017 Oct 30. pii: S2213-7165(17)30197-2.
Read abstract

Early human migrations (c. 13,000 years ago) or Post-contact Europeans for the earliest spread of Mycobacterium leprae and Mycobacterium lepromatosis to the Americas.
Mark S. Interdiscip Perspect Infect Dis. 2017.
Download PDF

The Physicochemical Basis of Clofazimine-Induced Skin Pigmentation.
Murashov MD, LaLone V, Rzeczycki PM, et al. J Invest Dermatol. 2017 Oct 14.
Read abstract

T-cell regulation in Erythema Nodosum Leprosum.
Negera E, Walker SL, Bobosha K, et al. 2017; 11(10):e0006001.
Download PDF

Clinico-pathological features of erythema nodosum leprosum: A case-control study at ALERT hospital, Ethiopia.
Negera E, Walker SL, Girma S, et al. PLoS Negl Trop Dis. 2017; 11(10):e0006011.
Download PDF

Diffuse Multibacillary Leprosy of Lucio and Latapí with Lucio's Phenomenon, Peru.
Ramal C, Casapía M, Marin J, et al. Emerg. Infect. Dis. 2017; 23(11).
Download PDF

Autochthonous Leprosy without Armadillo Exposure, Eastern United States.
Rendini T, Levis W. Emerging Infect. Dis. 2017; 23(11):1928.
Download PDF

Prevalence of leprosy cases.
da Santos DAS, Spessatto LB, Melo LS, et al. Journal of nursing UFPE on line. 2017; 11(Suppl. 10):4045-4055.
Download PDF

Economic Access of Lepers.
Sekarningrum B, Muljadji Y, Yunita D. Review of Integrative Business and Economics Research. 2017; 6(s1):395-401.
Download PDF

A hypothetical role for Notch signaling pathway in immunopathogenesis of leprosy.
Serrano-Coll H, Acevedo-Saenz L, Cardona-Castro N. Med. Hypotheses. 2017; 109:162-169.
Read abstract

Detection of Mycobacterium leprae in nasal samples of contactants younger than 15 years old of leprosy cases.
Silva CS, Lourenço DSD, Campelo TA, et al. Sociedade Brasileira De Microbiologia. 2017.
Read abstract

Target-Pathogen: a structural bioinformatics approach to prioritize drug targets in pathogens.
Sosa EJ, Burguener G, Lanzarotti E, et al. Nucleic Acids Res. 2017 Nov 2.
Download PDF

Leprosy Associated with Atypical Cutaneous Leishmaniasis in Nicaragua and Honduras.
Soto LA, Caballero N, Fuentes LR, et al. Am J Trop Med Hyg. 2017 Oct;97(4):1103-1110.
Read abstract

IL-37 and leprosy: A novel cytokine involved in the host response to Mycobacterium leprae infection.
de Sousa JR, Prudente RL, Dias Junior LB. Cytokine. 2017.
Download PDF

Histomorphometric approach to differentiate skin lesions of tuberculoid leprosy from sarcoidosis.
Utino FL, Damiani GV, Garcia M, et al. J Cutan Pathol. 2017 Oct 25.
Read abstract

Mycobacterium lepromatosis Lepromatous Leprosy in US Citizen Who Traveled to Disease-Endemic Areas.
Virk A, Pritt B, Patel R, et al. Emerging Infect. Dis. 2017; 23(11):1864-1866.
Download PDF

The safety of influenza vaccine in clinically cured leprosy patients in China.
Zheng Y, Chen L, Zou J, et al. Hum Vaccin Immunother. 2017 Oct 31:0.
Read abstract



Journals & Newsletters



Disability, CBR & Inclusive Development:

Hansenologia Internationalis:

Indian Journal of Leprosy: 

Leprosy Review:
Leprosy Review Repository (1928-2001) :

Plos Neglected Tropical Diseases:
Revista de Leprología:
WHO Goodwill Ambassador's Newsletter for the elimination of leprosy:




Websites & Services



Global Leprosy Programme

LML - Leprosy Mailing List - a free moderated email list that allows all persons interested in this theme to share ideas, information, experiences and questions.

InfoNTD - Information on cross-cutting issues in Neglected Tropical Diseases (NTDs)

LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link:

Contact: Dr Pieter Schreuder <<


Monday, November 13, 2017

(LML) Steroid Dependency and the use of Methotrexate

Leprosy Mailing List – November 13,  2017

Ref.:   (LML)  Steroid Dependency and the use of Methotrexate

From:  Terence J Ryan, Oxford, UK

Dear Pieter,


Folic acid antagonists (editor: type of drug that stops cells from using folic acid to make DNA and may kill cancer cells - NCI Dictionary of Cancer terms- like for example MTX) have been in use for at least 8 decades. First for Leukaemia and then for Rheumatoid arthritis. It was the subject of the first Medical debate between the UK and USA using Telstar (editor: Telstar is the name of various communications satellites)

-        It was following this, that an Oxford study cautioned about side effects (Ryan et al 1964 British Journal of Dermatology 76 No12 :255-264).

-       After our first death we published further warnings (Ryan et al 1967, British Journal of Dermatology77(letter) page283).

-       With Harvey Baker I did a study of its use in over 100 cases of Generalised Pustular Psoriasis most of to whom it was given after high doses of steroids had suppressed the pituitary.

-       In 1974, I published with Millward Sadler about Methotrexate induced liver disease in Psoriasis (British journal of Dermatology 1974).

-       Harvey Baker and I discussed the prognosis in a paper on Generalised pustular psoriasis in Ryan and Bake r(1971) BJD(1971)85 407-411.

These papers are no longer read because in the UK methotrexate is considered a safe drug once all precautions have been undertaken.

For us beginners folic acid antagonists were a risk in an era of steroid over-usage, drugs like Tetracycline damaging the liver, and inappropriate diets and herbal remedies not yet understood. In the field of Leprosy management they are still a risk and must be used only by those who are fully familiar with the literature.

In as early as 1971, we were as we stated  less  prejudiced against methotrexate than steroids. However, I quote from our 1971 paper:

 "Provided the patient is not debilitated, and methotrexate is well tolerated, such toxicity as occurs is likely to be mild and quickly reversible. In this series methotrexate was certainly responsible for two deaths and partly responsible for four, but these data reflect the dangers of giving the drug to patients who are already desperately ill, who are likely to be on several drugs including steroids and may have a toxic marrow depression or hepatitis."


Today in India especially I would add tuberculosis as a contraindication to steroids but not to methotrexate, but I could be wrong; as was our experience in the days of the use of the Osler Pavilion in Oxford spontaneous remission of diseases was the aim of prolonged admission for several diseases. It is not thought of today.

Our experience at that time was that we believed that we had evidence that steroids prevented improvement in generalised pustular psoriasis (and the process of withdrawal was its principle cause) or erythroderma, until they were withdrawn. As I read my lengthy discussion in the 1964 paper I am impressed by the idea that drugs are of questionable value in some conditions and that the treated group had a more severe disease as a consequence and no or less frequent prolonged remissions. It led to us to stating that:

 "It is probably in the patients interest to stay in hospital for 3 months or even longer, with little active treatment in anticipation of spontaneous remission without treatment".  


It is a sad fact that in the UK we no longer have either the beds or nursing experience for this to be tested. In India I remember at least a few Charitable care homes where the nursing was of a high standard where little active treatment would have been possible.

My experience in the Cochrane Annex at Oxford with my late colleague Colin Macdougall is that several of the cases of ENL he published had either renal or liver problems.

Terence J Ryan

LML - S Deepak, B Naafs, S Noto and P Schreuder

LML blog link:

Contact: Dr Pieter Schreuder <<