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The Diagnosis of Leprosy - Part II . The 2 nd cardinal signs of leprosy

The Diagnosis of Leprosy - Part II . The 2 nd cardinal signs of leprosy. Salvatore Noto, Pieter A M Schreuder and Bernard Naafs Leprosy mailing list, October 2011. 1. The 2 nd cardinal sign of leprosy. “Enlarged peripheral nerve”. 2. Peripheral nerve involvement in leprosy. thickened;

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The Diagnosis of Leprosy - Part II . The 2 nd cardinal signs of leprosy

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  1. The Diagnosis of Leprosy - Part II.The 2ndcardinal signs of leprosy Salvatore Noto, Pieter A M Schreuder and Bernard Naafs Leprosy mailing list, October 2011 LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign 1

  2. The 2nd cardinal sign of leprosy “Enlarged peripheral nerve” LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign 2

  3. Peripheral nerve involvement in leprosy thickened; small and hard; irregular in consistency; tender;  spontaneous pain; nerve function deficit (sensory, motor, autonomic). LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign 3

  4. Peripheral nerves affected in leprosy • supra orbital n. • facial n. • great auricular n. • supra clavicular n. (rare) • radial n. • ulnar n. • radial cutaneous n. • median n. • femoral cutaneous n. (rarely obvious) • lateral popliteal (common peroneal) n. • superficial peroneal n. • sural n. • posterior tibial n. LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  5. Great auricular n. Ulnar n. Radial cutaneous n. 4. Median n. 5. Lateral popliteal n. 6. Posterior tibial n. Routinely palpated nerves “of predilection” in leprosy LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign 5

  6. 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) LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  7. Supra orbital nerve LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  8. Courtesy of S. Noto Palpation of the supraorbital nerve LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  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 LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  10. Great auricular nerve LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  11. Leprosy, enlarged great auricular nerve. Courtesy of S. Noto LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  12. Courtesy of B. Naafs Leprosy,enlarged great auricular nerve LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  13. BL leprosy Enlarged great auricular nerve Courtesy of B. Naafs LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  14. Ulnar nerve LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  15. Palpation of the left ulnar nerve Courtesy of S. Noto LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  16. Leprosy, enlarged ulnar nerves Courtesy of Grace Warren 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). LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  17. Radial cutaneous nerve LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  18. 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. LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  19. Courtesy of B. Naafs Palpation of the radial cutaneous nerve LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  20. Courtesy of S. Noto Enlarged radial cutaneous nerve Leprosy, patient from Brazil LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  21. Enlarged radial cutaneous nerve Leprosy, patient from Brazil Courtesy of S. Noto LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  22. Median nerve LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  23. Median nerve Courtesy of A. Salafia, India Leprosy The drawings show the position of the enlarged median and radial cutaneous nerves LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  24. Leprosy, enlarged left median nerve Courtesy of B. Naafs LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  25. Lateral popliteal nerve (common peroneal n.) LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  26. Palpation of enlarged lateral popliteal nerves Courtesy of B. Naafs LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  27. Palpation of the lateral popliteal nerves. Patient’s knees are slightly bent. Courtesy of S. Noto LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  28. Superficial peroneal nerve LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  29. Superficial peroneal n. Courtesy of Grace Warren 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. LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  30. Courtesy of B. Naafs Enlarged superficial peroneal and sural nerves (and loss of sensation) LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  31. Posterior tibial nerve LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  32. Palpation of the posterior tibial nerve Courtesy of B. Naafs LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  33. Any cutaneous nerve LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  34. Thigh nerves Courtesy of Grace Warren Large superficial nerve on a thigh with a hypopigmented lesion in association LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  35. Courtesy of B. Naafs Any nerve! LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

  36. Courtesy of B. Naafs Check all nerves! LML October 2011 - The diagnosis of leprosy - Part II. The 2nd cardinal sign

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