leprosy mailing list1 diagnosis of leprosy 1 salvatore noto, pieter a m schreuder leprosy mailing...

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leprosy mailing list 1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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leprosy mailing list33 Peripheral nerve involvement in leprosy thickened; small and hard; irregular in consistency; tender; spontaneous pain; nerve function deficit (sensory, motor, autonomic). leprosy mailing list

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Page 1: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 1

Diagnosis of leprosy

1

Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010

The second cardinal sign of leprosy

Page 2: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 2

The 2nd cardinal sign of leprosy

“Enlarged peripheral nerve”

2

Page 3: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 33

Peripheral nerve involvement in leprosy

• thickened;

• small and hard;

• irregular in consistency;

• tender; 

• spontaneous pain;

• nerve function deficit (sensory, motor, autonomic). 

leprosy mailing list

Page 4: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 4

Peripheral nerves affected in leprosy

1. supra orbital n.2. facial n. 3. great auricular n.4. supra clavicular n. (rare) 5. radial n.6. ulnar n.7. radial cutaneous n.8. median n.9. femoral cutaneous n. (rarely obvious) 10. lateral popliteal (common peroneal) n.11. superficial peroneal n.12. sural n.13. posterior tibial n.

Page 5: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Routinely palpated nerves “of predilection” in leprosy

1. Great auricular n.

2. Ulnar n.

3. Radial cutaneous n.

5. Median n.

6. Lateral popliteal n.

7. Posterior tibial n.

leprosy mailing list

Page 6: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Examination of nerves• Peripheral nerves may be thin or large, soft or hard, tender or painful, at sites of predilection;

• Record size “–” or “+” or “++” is adequate;

• Record pain or tenderness. Record texture as normal, soft, firm or hard.

Be gentle, look at the patient’s face as you palpate nerves; he will wince if they are tender. (Hastings R, 1985)

Page 7: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 7

Supra orbital nerve

Page 8: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 8Palpation of the supraorbital nerve Courtesy of S. Noto

Page 9: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 9

Cervical plexus, and branch of the supra-

orbital nerve

Large cervical plexus and branch of the supra-orbital nerve associated with small lesions beside the eye.

Leprosy patient in Hong Kong.

Courtesy of Grace Warren

Page 10: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 10

Great auricular nerve

Page 11: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Leprosy, enlarged great auricular nerve.

Courtesy of S. Noto

Page 12: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Leprosy, enlarged great auricular nerveCourtesy of B. Naafs

Page 13: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 13

BL leprosyEnlarged great auricular nerve

Courtesy of B. Naafs

Page 14: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 14

Ulnar nerve

Page 15: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 15Palpation of the left ulnar nerve Courtesy of S. Noto

Page 16: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Leprosy, enlarged ulnar nerves

Have you ever seen large ulnar nerves at the elbow? Well here they are. Her right more than the left. But as yet she has no obvious neural deficit in the hands (G. Warren).

Courtesy of Grace Warren

Page 17: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Radial cutaneous nerve

Page 18: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Palpation of the radial cutaneous nerve(see next slide)

• The left hand of the examiner is palpating the right radial cutaneous nerve of the patient while it courses from the lateral border of the radius onto the dorsum of the hand. Note the patient’s forearm, wrist and hand position.

Page 19: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Palpation of the radial cutaneous nerve Courtesy of B. Naafs

Page 20: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 20

Enlarged radial cutaneous nerveLeprosy, patient from Brazil

Courtesy of S. Noto

Page 21: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 21

Enlarged radial cutaneous nerveLeprosy, patient from Brazil

Courtesy of S. Noto

Page 22: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 22

Median nerve

Page 23: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Leprosy The drawings show the position of the enlarged median and radial cutaneous nerves

Courtesy of A. Salafia, India

Median nerve

Page 24: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Leprosy, enlarged left median nerve

Courtesy of B. Naafs

Page 25: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Lateral popliteal nerve (common peroneal n.)

Page 26: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Palpation of enlarged lateral popliteal nervesCourtesy of B. Naafs

Page 27: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 27Palpation of the lateral popliteal nerves. Patient’s knees are slightly bent.

Courtesy of S. Noto

Page 28: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 28

Superficial peroneal nerve

Page 29: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 29

Superficial peroneal n.

Large superficial peroneal nerve, often easily palpable. This one also nodulated. This would imply small abscesses in the nerve. Patient does not complain of pain or discomfort.

Courtesy of Grace Warren

Page 30: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Enlarged superficial peroneal and sural nerves (and loss of sensation) Courtesy of B. Naafs

Page 31: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Posterior tibial nerve

Page 32: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Palpation of the posterior tibial nerve

Courtesy of B. Naafs

Page 33: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 33

Any cutaneous nerve

Page 34: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Thigh nerves

Courtesy of Grace WarrenLarge superficial nerve on a thigh with a hypopigmented lesion in association

Page 35: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

leprosy mailing list 35Any nerveCourtesy of B. Naafs

Page 36: Leprosy mailing list1 Diagnosis of leprosy 1 Salvatore Noto, Pieter A M Schreuder Leprosy mailing list, May 2010 The second cardinal sign of leprosy

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Check all nerves!

Courtesy of B. Naafs