Comments on the case report titled "Polyneuritic leprosy presenting with bone changes prior to onset of florid skin lesions" published in Indian J Dermatol Venereol Leprol 2001:67;31-32.

Sunil Dorga¹ , Bhushan Kumar²

¹ Dept. of Dermatology, Venereology and Leprosy, PGIMER, Chandigarh-160 012, India
² Dept. of Medical Microbiology, PGIMER, Chandigarh-160 012, India

Correspondence Address:
Sunil Dorga
Dept. of Dermatology, Venereology and Leprosy, PGIMER, Chandigarh-160 012
India

To the Editor,

It was interesting to go through the case report with fascinating title "Polyneuritic leprosy presenting with bone changes prior to the onset of florid skin manifestations" published in Indian J Dermatol Venereal Leprol 2001:67:31-32. We have certain comments and queries and we would like the authors to address them.

i) In the introduction authors mentioned that according to "leprologists elsewhere" nerve involvement without major manifestations on the skin is not feasible. This seems to be author′s own interpretation, since no such statement is given in the Handbook of Leprosy by Jopling as quoted by the authors.

ii) In the description of the patient, authors have mentioned that patient had swelling of right foot associated with difficulty in walking and weakness of right foot following a trauma 5 months back. According to them it was a 10x10cm tender swelling with irregular borders. The authors fail to give any specific cause of this tender swelling persisting for 5 months and its any possible relation to polyneuritic leprosy.

iii) Then contradicting the accepted definition of neuritic leprosy without any obvious skin lesions, the authors state that patient had ill-defined hypopigmented lesion(s) on right leg with shiny skin and hair loss. It is also not clear whether sensory loss was over the lesions also (with or without) in the area of distribution of peripheral nerve trunk...

iv) What was the indication of doing VDRL test in the patient?

v) X-ray of the right foot showed areas of osteoporosis with an area of new bone formation, which may be due to any other disease (tender swelling) but to the best of our ability is not due to leprosy. Moreover it is too short a period (5 months) for any kind of leprosy to produce such a gross change.

vi) Authors cannot use the term "Indeterminate stage" loosely according to their own convenience. This is generally used in relation to early cutaneous manifestations of leprosy where the disease has not become classifiable in any of the established special forms. The use of word ′early′ as used by the authors is not in relation to the age of lesion/duration of disease, but in relation to the degree of advancement of disease. Indeterminate lesions are very unstable found commonly in children, flat with vague and indefinite margins and not easily recognised as lesions of leprosy. They do not produce any systemic manifestations like the ones as reported in this.

vii) Bullous lesions at acral parts are not exactly due to decreased threshold to pain as stated by the authors. They occur in long standing cases spontaneously due to friction, and trophic and vasomotor changes secondary to involvement of the autonomic fibres are hall mark of leprosy.

ix) There is no doubt that osteoporosis and atrophic changes of bones can occur in the phalanges, and tarsals. To the understanding of anyone the type of bone changes described in the present case should mostly produce resorption of foot rather than a big tender swelling.

x) The statement that "as per classification by westerners the polyneuritic leprosy is mostly a cutaneous form unrecognized or the disease, which has been incompletely treated", is totally wrong and is not supported by any standard publication. The classification of neuritic cases is based mostly on number of nerves affected indicating type of disease (borderline tuberculoid to borderline lepromatous) and the result of lepromin test, which provided information on the likely histological findings in the affected nerve. Number of nerves involved (with or without skin lesions), forms an important basis for selecting a particular regimen for treating leprosy.

xi) How are the authors so sure that bony changes occurred prior to onset of leprosy on skin? We also fail to understand the meaning of this terminology of ′polar form of leprosy on skin.′

After going through this article we were concerned to learn about the prevailing knowledge of leprosy as a disease in a country like India which bears burden of up to 70% of the leprosy case load in the world. Such misinformative and academically poor quality of material can be misleading for the younger dermatologists and aspiring postgraduates and can prove hazardous in patient care. It is high time that the Chief Editor ensures the proper review of each article to be published. We hope that authors will take our comments in the spirit; they are meant to be as this is a topic of common interest for all of us.