Leprosy physical examination: Difference between revisions

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Revision as of 22:26, 7 July 2014

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

Overview

Physical examination will depend on the class of leprosy in each patient and may include findings such as hypopigmented skin lesions, usually macular or papular, thickened dermis, loss of sensation or peripheral nerve thickening, with common evolvement of the nasal mucosa.

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

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, arms, legs and feet
In tuberculoid or paucibacillar leprosy, larger 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 andlepromatous 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, papular or nodular origin. There is often loss of body hair, particularly of the eyebrows and eyelashes
In indeterminate leprosy, lesions are often hypopigmented or erythematous macules with 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 corneas are often present
Corneal abrasion is often present
Corneal ulceration is often present
Blindness may be present

Ears

Nodular thickening of the earlobes may be present

Nose

Saddle nose may be present, particularly in lepromatous leprosy
Perforated nasal septum may be present
Invasion of the nasal mucosa may be present, particularly in lepromatous leprosy, leaden to 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 and/or motor loss are often present, predominantly in skin lesions and on the territories located after 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
Tender and/or enlarged peripheral nerves are often present
Painful neuropathy may be present

Gallery

Enlargement of the great auricular nerve following attack by Mycobacterium leprae.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Inflammatory cutaneous lesion on the thorax classifies as tuberculoid, paucibacillary form of leprosy.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Nodular lepromatous or multibacillary leprosy. Presence of cutaneous nodules and missing eyebrows.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Pathologic changes associated with lepromatous or multibacillary leprosy. Note active ulcerative lesion on the plantar surface of left toe.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Pathologic characteristics associated with a case of lepromatous or multibacillary leprosy. Note absence of eyebrows.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Cutaneous changes of lepromatous leprosy. Note reddish-brown nodules atop the left ala.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Borderline, or dimorphous leprosy with bilateral involvement of the buccinator muscles, as well as dermatomyositis.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Tuberculoid or paucibacillary leprosy lesion with hypopigmented cutaneous plaque lateral to right nipple. Note elevated scaly borders.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Complications of lepromatous or multibacillary leprosy. Note saddle-nose deformity following disintegration of nasal cartilage and lack of eyebrows.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Active cutaneous lesion on left hand consistent with tuberculoid or paucibacillary leprosy.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
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.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous leprosy exhibiting erythema nodosum leprosum. Note numerous cutaneous erythematous blotchy lesions on patient’s back, right shoulder, and upper arm.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Tuberculoid or paucibacillary leprosy with inflammatory lesion on the outer left ear.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Erythema necroticans or “Lucio's phenomenon”, or “spotted leprosy of Lucio”. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous leprosy. Note few cutaneous facial nodules.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous leprosy. Note erythema nodosum leprosum.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Case of lepromatous or multibacillary leprosy, with photomicrograph revealing histopathologic changes in human testicular tissue, including a large number of “foam cells”.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Tubercular or paucibacillary leprosy, with asymmetrically-distributed solitary skin lesion.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous leprosy revealing staphyloma of left eyeball (protrusion of the wall of the eyeball, exhibiting a dark coloration) potentially leading to degeneration of globe.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
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.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]
Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.Adapted from Public Health Image Library (PHIL), Centers for Disease Control and PreventionPublic Health Image Library (PHIL), Centers for Disease Control and Prevention^[5]

References

↑ 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.
↑ "Hansen's Disease (Leprosy) Signs and Symptoms".
↑ 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.
↑ 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.
↑ ^5.00 ^5.01 ^5.02 ^5.03 ^5.04 ^5.05 ^5.06 ^5.07 ^5.08 ^5.09 ^5.10 ^5.11 ^5.12 ^5.13 ^5.14 ^5.15 ^5.16 ^5.17 ^5.18 ^5.19 ^5.20 ^5.21 ^5.22 ^5.23 ^5.24 ^5.25 ^5.26 ^5.27 ^5.28 ^5.29 ^5.30 ^5.31 ^5.32 ^5.33 "Public Health Image Library (PHIL), Centers for Disease Control and Prevention".

Template:WikiDoc Sources

[pmid16450473-1] 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.

[CDC-2] "Hansen's Disease (Leprosy) Signs and Symptoms".

[pmid16707521-3] 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.

[EichelmannGonzález_González2013-4] 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.

[PHIL-5] 5.00 ^5.01 ^5.02 ^5.03 ^5.04 ^5.05 ^5.06 ^5.07 ^5.08 ^5.09 ^5.10 ^5.11 ^5.12 ^5.13 ^5.14 ^5.15 ^5.16 ^5.17 ^5.18 ^5.19 ^5.20 ^5.21 ^5.22 ^5.23 ^5.24 ^5.25 ^5.26 ^5.27 ^5.28 ^5.29 ^5.30 ^5.31 ^5.32 ^5.33 "Public Health Image Library (PHIL), Centers for Disease Control and Prevention".

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@@ Line 83: / Line 83: @@
 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Cutaneous changes of lepromatous leprosy. Note reddish-brown nodules atop the left ala.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Cutaneous changes of lepromatous leprosy. Note reddish-brown nodules atop the left ala.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Cutaneous changes of lepromatous leprosy. Note reddish-brown nodules atop the left ala.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Cutaneous changes of lepromatous leprosy. Note reddish-brown nodules atop the left ala.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Cutaneous changes of lepromatous leprosy. Note reddish-brown nodules atop the left ala.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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-18.jpg|Case of lepromatous or multibacillary leprosy, with photomicrograph revealing histopathologic changes in human testicular tissue, including a large number of “foam cells”.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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-27.jpg|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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-28.jpg|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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-30.jpg|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Lepromatous or multibacillary leprosy. Note wrinkling of the face, especially the midface involving nose and cheeks, and around the eyes.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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|Cutaneous changes of lepromatous leprosy. Note reddish-brown nodules atop the left ala.<SMALL><SMALL>Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention''[http://phil.cdc.gov/phil/ 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>