Ultrasonography of Leprosy Neuropathy: A Longitudinal Prospective Study

<div><p>Background</p><p>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.</p><p>Methodology/Principal findings</p><p>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 (p<0.05). Despite this reduction, we observed a greater frequency of poor CSA outcomes in the MB compared to the PB (77.8% and 40.6%; p>0.05) and in the patients with reactions compared to those without (66.7% and 38.7%; p<0.05). There was significantly higher odds ratio (7.75; 95%CI: 1.56–38.45) for poor CSA outcomes only for M nerve in patients with reactions. Poor echogenicity outcomes were more frequent in MB (59.4%) compared to PB (22.2%) (p<0.05). There was significant association between poor Doppler outcomes and neuritis. Gender, disease duration, and leprosy classification were not significant risk factors for poor outcomes in CSA, echogenicity or Doppler.</p><p>Conclusions/Significance</p><p>US nerve abnormalities can worsen after treatment despite the leprosy classification or the presence of reactions.</p></div

CSA results before and after treatment in PB and MB patients.

<p>CSA results before and after treatment in PB and MB patients.</p

Asymmetry measurements (ΔCSA and ΔUtpt) before and after treatment in patients without and with reactions.

<p>Asymmetry measurements (ΔCSA and ΔUtpt) before and after treatment in patients without and with reactions.</p

CSAs, ΔCSAs and ΔUtpt results for all patients and for those with at least one abnormal measurement for each variable.

<p>Patients were classified according to the WHO operational classification.</p

Asymmetric Nerve Enlargement: A Characteristic of Leprosy Neuropathy Demonstrated by Ultrasonography

<div><p>Background</p><p>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.</p><p>Methodology/Principal Findings</p><p>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<0.05) CSAs than PB at Ut (13.88±11.4/9.53±6.14) and M (10.41±5.4/6.36±0.84). ΔCSAs and ΔUtpt were similar between PB and MB. The CSAs, ΔCSAs and ΔUtpt were similar between PB patients with reactions compared to PB patients without reactions. MB patients with reactions showed significantly greater CSAs (Upt, Ut and M), ΔCSAs (Upt and Ut) and ΔUtpt compared to MB patients without reactions. PB and MB showed similar frequencies of abnormal US measurements. Patients with reactions had higher frequency of nerve thickening and similar frequency of asymmetry to those without reactions.</p><p>Conclusions/Significance</p><p>This is the first study to investigate differences in nerve involvement among leprosy classification groups using US before treatment. The magnitude of thickening was greater in MB and in patients with reactions. Asymmetry indexes were greater in patients with reactions and did not significantly differ between PB and MB, demonstrating that asymmetry is a characteristic of leprosy neuropathy regardless of its classification.</p></div

Frequency of poor CSA outcomes after treatment in patients without and with reactions.

<p>Frequency of poor CSA outcomes after treatment in patients without and with reactions.</p

Patient flowchart reporting numbers of individuals at each stage of study.

<p>Legend: DM: diabetes mellitus; HIV: human immunodeficiency virus; US: peripheral nerve ultrasonography; MDT: multi-drug therapy.</p

CSA results before and after treatment in patients without and with reactions.

<p>CSA results before and after treatment in patients without and with reactions.</p

CSAs, ΔCSAs and ΔUtpt results. Patients were classified according to the Ridley-Jopling classification.

<p>CSAs, ΔCSAs and ΔUtpt results. Patients were classified according to the Ridley-Jopling classification.</p

Clinical data for the patients included in the study.

<p>Clinical data for the patients included in the study.</p