Leprosy physical examination: Difference between revisions

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{{Leprosy}}
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{{CMG}}; {{AE}} {{JS}} {{KS}}


==Overview==
==Overview==
Paucibacillary Hansen's disease is milder and characterized by one or more hypopigmented skin [[macule]]s. Multibacillary Hansen's disease is associated with symmetric skin lesions, [[nodule]]s, [[plaques]], thickened dermis, and frequent involvement of the nasal mucosa resulting in nasal congestion and [[epistaxis]].
Although the findings on [[physical examination]] may vary depending upon the subytpe of leprosy, common findings include [[Hypopigmentation|hypopigmented]] [[skin lesions]], thickened [[dermis]], and [[loss of sensation]].
 
==Physical Examination==
Leprosy may have different presentations, depending on the [[immune response]] of the host. The disease often affects the [[skin]], [[nerves]], and [[mucous membranes]] in different patterns and with different intensities. The possible physical findings of the disease include:<ref name="pmid16450473">{{cite journal| author=Elinav H, Palladas L, Applbaum YH, Gilead L, Moses AE, Cohen-Poradosu R| title=Plantar ulcers and eyebrow-hair paucity. | journal=Clin Infect Dis | year= 2006 | volume= 42 | issue= 5 | pages= 684-5, 722-4 | pmid=16450473 | doi=10.1086/502983 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16450473  }} </ref><ref name=CDC>{{cite web | title = Hansen's Disease (Leprosy) Signs and Symptoms | url = http://www.cdc.gov/leprosy/symptoms/index.html }}</ref><ref name="pmid16707521">{{cite journal| author=Daniel E, Ffytche TJ, Kempen JH, Rao PS, Diener-West M, Courtright P| title=Incidence of ocular complications in patients with multibacillary leprosy after completion of a 2 year course of multidrug therapy. | journal=Br J Ophthalmol | year= 2006 | volume= 90 | issue= 8 | pages= 949-54 | pmid=16707521 | doi=10.1136/bjo.2006.094870 | pmc=PMC1857220 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16707521  }} </ref><ref name="EichelmannGonzález González2013">{{cite journal|last1=Eichelmann|first1=K.|last2=González González|first2=S.E.|last3=Salas-Alanis|first3=J.C.|last4=Ocampo-Candiani|first4=J.|title=Leprosy. An Update: Definition, Pathogenesis, Classification, Diagnosis, and Treatment|journal=Actas Dermo-Sifiliográficas (English Edition)|volume=104|issue=7|year=2013|pages=554–563|issn=15782190|doi=10.1016/j.adengl.2012.03.028}}</ref>
 
===Appearance of the Patient===
* [[Fatigue]] is often present
* [[Weight loss]] is often present
* [[Anhidrosis]] may be present
 
===Vitals===
* [[Fever]] may be present
 
===Skin===
* Painless cuts, [[wounds]] and [[burns]] are often present, predominantly on the [[hands]], [[arm]]s, [[legs]] and [[feet]]
* In ''tuberculoid'' or ''paucibacillar'' leprosy, larger [[Hypopigmentation|hypopigmented]] or [[erythematous]] [[macules]] are often present
* In ''borderline tuberculoid'' or ''paucibacillar'' leprosy, [[macules]] are often sharply defined with a central clearing, more numerous than the in previous category and generally located unilaterally.
* In ''mid-borderline'' and''lepromatous'' or ''multibacillar'' leprosy, central area of the lesions is often [[anesthetic]]
* In ''borderline lepromatous leprosy'', [[lesions]] are often [[erythematous]] [[macules]] and/or [[papules]], symmetrically distributed throughout the [[body]]. [[Nodular]] lesions are often present and there may be areas of normal [[skin]] between the [[lesions]], however, the margins of the [[lesions]] are diffuse, instead of well-defined.
* In ''lepromatous leprosy'', lesions are often generalized throughout the [[body]] and may be of [[macular]], [[papule|papular]] or [[nodular]] origin. There is often loss of [[body hair]], particularly of the [[eyebrows]] and [[eyelashes]]
* In ''indeterminate leprosy'', [[lesions]] are often [[Hypopigmentation|hypopigmented]] or [[erythematous]] [[macules]] with [[loss of sensation|diminished sensation]]
 
===Head===
* [[Facial paralysis]] may be present
* Lack of [[eyebrows]] and [[eyelashes]] may be present
* Lumps are often present, predominantly on the [[face]]
 
===Eyes===
* [[Lagophthalmos]] is often present
* Dry [[cornea]]s are often present
* [[Corneal abrasion]] is often present
* [[Corneal ulcer|Corneal ulceration]] is often present
* [[Blindness]] may be present
 
===Ears===
* [[Nodular]] thickening of the [[earlobe]]s may be present
 
===Nose===
* [[Saddle nose]] may be present, particularly in ''lepromatous leprosy''
* A [[perforated nasal septum]] may be present
* Invasion of the [[nasal mucosa]] may be present, particularly in ''lepromatous leprosy'', leaden to [[Nasal congestion|nasal stuffiness]]
* [[Epistaxis]] may be present
 
===Extremities===
* [[Weakness]] of the [[hands]] and [[feet]] may be present
* Claw [[fingers]] are often present
* [[Foot drop]] is often present
* [[Edema]] of the [[hands]] and [[feet]] may be present
* [[Fractures]] may be present
 
===Neurologic===
* [[Sensory loss|Sensory]] and/or [[Motor neuron|motor]] loss are often present, predominantly in [[skin lesions]] and in territories located distal to enlarged [[peripheral nerves]]:
:* In ''tuberculoid leprosy'' this often occurs in the vicinity of the [[skin lesion]]
:* In ''lepromatous leprosy'' this loss is often more generalized
* [[Paresthesias]] are often present, predominantly in the [[hands]] and [[feet]]
* [[Tenderness|Tender]] and/or enlarged [[peripheral nerves]] are often present
* Painful [[neuropathy]] may be present
====Skin====
=====Extremities=====
<gallery>
Image:Neural leprosy01.jpg|.Neural leprosy <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
Image:Neural leprosy02.jpg|.Neural leprosy <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
 
 
Image:Neural leprosy03.jpg|.Neural leprosy <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
 
 
 
Image:Neural leprosy04.jpg|.Neural leprosy <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
 
 
Image:Neural leprosy05.jpg|.Neural leprosy <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
 
 
Image:Neural leprosy06.jpg|.Neural leprosy <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
Image:Neural leprosy07.jpg|.Neural leprosy <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
 
 
 
</gallery>
 
==Gallery==
 
<gallery>
Image:Leprosy-1.jpg|Enlargement of the great auricular nerve following attack by Mycobacterium leprae. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-2.jpg|Inflammatory cutaneous lesion on the thorax classifies as tuberculoid, paucibacillary form of leprosy. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-3.jpg|Nodular lepromatous or multibacillary leprosy. Presence of cutaneous nodules and missing eyebrows. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-4.jpg|Pathologic changes associated with lepromatous or multibacillary leprosy. Note active ulcerative lesion on the plantar surface of left toe. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-5.jpg|Pathologic characteristics associated with a case of lepromatous or multibacillary leprosy. Note absence of eyebrows. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-6.jpg|Cutaneous changes of lepromatous leprosy. Note reddish-brown nodules atop the left ala. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-7.jpg|Borderline, or dimorphous leprosy with bilateral involvement of the buccinator muscles, as well as dermatomyositis. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-8.jpg|Tuberculoid or paucibacillary leprosy lesion with hypopigmented cutaneous plaque lateral to right nipple. Note elevated scaly borders. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-9.jpg|Complications of lepromatous or multibacillary leprosy. Note saddle-nose deformity following disintegration of nasal cartilage and lack of eyebrows. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-10.jpg|Active cutaneous lesion on left hand consistent with tuberculoid or paucibacillary leprosy. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-11.jpg|Borderline, or dimorphous leprosy with bilateral involvement of the buccinator muscles, as well as dermatomyositis. See PHIL 15504, for another view of this patient’s face. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-12.jpg|Lepromatous leprosy exhibiting erythema nodosum leprosum. Note numerous cutaneous erythematous blotchy lesions on patient’s back, right shoulder, and upper arm. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-13.jpg|Tuberculoid or paucibacillary leprosy with inflammatory lesion on the outer left ear. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-14.jpg|Erythema necroticans or “Lucio's phenomenon”, or “spotted leprosy of Lucio”.  <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-15.jpg|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-16.jpg|Lepromatous leprosy. Note few cutaneous facial nodules. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-17.jpg|Lepromatous leprosy. Note erythema nodosum leprosum. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-19.jpg|Tubercular or paucibacillary leprosy, with asymmetrically-distributed solitary skin lesion. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-20.jpg|Lepromatous leprosy revealing staphyloma of left eyeball (protrusion of the wall of the eyeball, exhibiting a dark coloration) potentially leading to degeneration of globe. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-21.jpg|Lepromatous or multibacillary leprosy. Late stage with digits almost fully resorbed, except for the index finger, and the proximal remnant of the thumb. Note granulomatous inflammatory lesion on palmar surface. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-22.jpg|Late stage nodular lepromatous or multibacillary leprosyrds. Note digits of both hands have been eroded over the course of the illness and skin shows numerous cutaneous nodules. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-23.jpg|Nodular lepromatous or multibacillary leprosy. Note cutaneous nodules upon the forehead, nose, cheeks, lips, and chin, as well as diminished eyebrows. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-24.jpg|Complications of lepromatous or multibacillary leprosy. Note saddle-nose deformity following disintegration of the nasal cartilage and lack of eyebrows, and mottled coloration of the sclerae bilaterally. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-25.jpg|Complications of nodular lepromatous or multibacillary leprosy. Note cutaneous nodules on forehead and left cheek, as well as stricture of both nares, and nasal exudate. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-26.jpg|Complications of lepromatous or multibacillary leprosy. Note raised cutaneous nodules on forehead, nose, and cheek. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-29.jpg|Tubercular leprosy. Note swellings of the intercostal nerves visible at the skin surface above the areas representing the locations of the respective underlying intercostal nerves. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-31.jpg|Hands of leprosy patient. Note severe mutilation, and degeneration of all fingers. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
Image:Leprosy-32.jpg|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes. <SMALL><SMALL>''[http://phil.cdc.gov/phil/  Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.]''<ref name="PHIL">{{Cite web | title = Public Health Image Library (PHIL), Centers for Disease Control and Prevention | url = http://phil.cdc.gov/phil/}}</ref></SMALL></SMALL>
 
</gallery>


==References==
==References==
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[[Category:Disease]]
[[Category:Disease]]
[[Category:Dermatology]]
[[Category:Dermatology]]
[[Category:Infectious disease]]
 
[[Category:Tropical disease]]
[[Category:Tropical disease]]
[[Category:Leprosy]]
[[Category:Leprosy]]
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[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
[[Category:Neglected diseases]]
[[Category:Neglected diseases]]
[[Category:Needs content]]

Latest revision as of 18:10, 18 September 2017

Leprosy Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2] Kiran Singh, M.D. [3]

Overview

Although the findings on physical examination may vary depending upon the subytpe of leprosy, common findings include hypopigmented skin lesions, thickened dermis, and loss of sensation.

Physical Examination

Leprosy may have different presentations, depending on the immune response of the host. The disease often affects the skin, nerves, and mucous membranes in different patterns and with different intensities. The possible physical findings of the disease include:[1][2][3][4]

Appearance of the Patient

Vitals

Skin

Head

Eyes

Ears

Nose

Extremities

Neurologic

  • In tuberculoid leprosy this often occurs in the vicinity of the skin lesion
  • In lepromatous leprosy this loss is often more generalized

Skin

Extremities

Gallery

References

  1. ↑ Elinav H, Palladas L, Applbaum YH, Gilead L, Moses AE, Cohen-Poradosu R (2006). "Plantar ulcers and eyebrow-hair paucity". Clin Infect Dis. 42 (5): 684–5, 722–4. doi:10.1086/502983. PMID 16450473.
  2. ↑ "Hansen's Disease (Leprosy) Signs and Symptoms".
  3. ↑ Daniel E, Ffytche TJ, Kempen JH, Rao PS, Diener-West M, Courtright P (2006). "Incidence of ocular complications in patients with multibacillary leprosy after completion of a 2 year course of multidrug therapy". Br J Ophthalmol. 90 (8): 949–54. doi:10.1136/bjo.2006.094870. PMC 1857220. PMID 16707521.
  4. ↑ Eichelmann, K.; González González, S.E.; Salas-Alanis, J.C.; Ocampo-Candiani, J. (2013). "Leprosy. An Update: Definition, Pathogenesis, Classification, Diagnosis, and Treatment". Actas Dermo-Sifiliográficas (English Edition). 104 (7): 554–563. doi:10.1016/j.adengl.2012.03.028. ISSN 1578-2190.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 "Dermatology Atlas".
  6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 6.15 6.16 6.17 6.18 6.19 6.20 6.21 6.22 6.23 6.24 6.25 6.26 6.27 "Public Health Image Library (PHIL), Centers for Disease Control and Prevention".


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