Leprosy physical examination

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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]

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:

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
• A 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 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
• Tender and/or enlarged peripheral nerves are often present
• Painful neuropathy may be present

Skin

Extremities

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  .Neural leprosy Adapted from Dermatology Atlas.

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  .Neural leprosy Adapted from Dermatology Atlas.

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  .Neural leprosy Adapted from Dermatology Atlas.

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  .Neural leprosy Adapted from Dermatology Atlas.

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  .Neural leprosy Adapted from Dermatology Atlas.

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  .Neural leprosy Adapted from Dermatology Atlas.

• .Neuralleprosy Adapted from Dermatology Atlas.[5]

  .Neuralleprosy Adapted from Dermatology Atlas.

Gallery

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  Enlargement of the great auricular nerve following attack by Mycobacterium leprae. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  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 Prevention.

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  Nodular lepromatous or multibacillary leprosy. Presence of cutaneous nodules and missing eyebrows. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  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 Prevention.

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  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 Prevention.

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  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 Prevention.

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  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 Prevention.

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  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 Prevention.

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  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 Prevention.

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  Active cutaneous lesion on left hand consistent with tuberculoid or paucibacillary leprosy. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  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 Prevention.

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  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 Prevention.

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  Tuberculoid or paucibacillary leprosy with inflammatory lesion on the outer left ear. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  Erythema necroticans or “Lucio's phenomenon”, or “spotted leprosy of Lucio”. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  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 Prevention.

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  Lepromatous leprosy. Note few cutaneous facial nodules. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  Lepromatous leprosy. Note erythema nodosum leprosum. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  Tubercular or paucibacillary leprosy, with asymmetrically-distributed solitary skin lesion. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  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 Prevention.

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  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 Prevention.

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  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. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  Nodular lepromatous or multibacillary leprosy. Note cutaneous nodules upon the forehead, nose, cheeks, lips, and chin, as well as diminished eyebrows. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  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. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  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. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  Complications of lepromatous or multibacillary leprosy. Note raised cutaneous nodules on forehead, nose, and cheek. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  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. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  Hands of leprosy patient. Note severe mutilation, and degeneration of all fingers. Adapted from Public Health Image Library (PHIL), Centers for Disease Control and Prevention.

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  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 Prevention.

References

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