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

2. leprosy mailing list2 The 2 nd cardinal sign of leprosy “Enlarged peripheral nerve” 2

3. 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

4. 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.

5. leprosy mailing list55 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

6. 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)

7. leprosy mailing list7 Supra orbital nerve

8. leprosy mailing list8 Palpation of the supraorbital nerve Courtesy of S. Noto

9. leprosy mailing list9 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

10. leprosy mailing list10 Great auricular nerve

11. leprosy mailing list11 Leprosy, enlarged great auricular nerve. Courtesy of S. Noto

12. leprosy mailing list12 Leprosy, enlarged great auricular nerve Courtesy of B. Naafs

13. leprosy mailing list13 BL leprosy Enlarged great auricular nerve Courtesy of B. Naafs

14. leprosy mailing list14 Ulnar nerve

15. leprosy mailing list15 Palpation of the left ulnar nerve Courtesy of S. Noto

16. leprosy mailing list16 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

17. leprosy mailing list17 Radial cutaneous nerve

18. leprosy mailing list18 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.

19. leprosy mailing list19 Palpation of the radial cutaneous nerve Courtesy of B. Naafs

20. leprosy mailing list20 Enlarged radial cutaneous nerve Leprosy, patient from Brazil Courtesy of S. Noto

21. leprosy mailing list21 Enlarged radial cutaneous nerve Leprosy, patient from Brazil Courtesy of S. Noto

22. leprosy mailing list22 Median nerve

23. leprosy mailing list23 Leprosy The drawings show the position of the enlarged median and radial cutaneous nerves Courtesy of A. Salafia, India Median nerve

24. leprosy mailing list24 Leprosy, enlarged left median nerve Courtesy of B. Naafs

25. leprosy mailing list25 Lateral popliteal nerve (common peroneal n.)

26. leprosy mailing list26 Palpation of enlarged lateral popliteal nerves Courtesy of B. Naafs

27. leprosy mailing list27 Palpation of the lateral popliteal nerves. Patient’s knees are slightly bent. Courtesy of S. Noto

28. leprosy mailing list28 Superficial peroneal nerve

29. leprosy mailing list29 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

30. leprosy mailing list30 Enlarged superficial peroneal and sural nerves (and loss of sensation) Courtesy of B. Naafs

31. leprosy mailing list31 Posterior tibial nerve

32. leprosy mailing list32 Palpation of the posterior tibial nerve Courtesy of B. Naafs

33. leprosy mailing list33 Any cutaneous nerve

34. leprosy mailing list34 Thigh nerves Courtesy of Grace Warren Large superficial nerve on a thigh with a hypopigmented lesion in association

35. leprosy mailing list35 Any nerve Courtesy of B. Naafs

36. leprosy mailing list36 Check all nerves! Courtesy of B. Naafs