Ediciones > Año 1956 > Artículo No. 1 2

Some observations on borderline Leprosy
Jacinto Convit; Carlos Sisirucá
Int. J. of Lep. 24: 375-381, 1956.
REVISTA: Publicaciones - Dr. Jacinto Convit

NUMERO: Año 1956

TITULO: Some observations on borderline Leprosy

AUTORES: Jacinto Convit; Carlos Sisirucá

RESUMEN: The inclusion of the borderline group in the clasaification adopted by the Madrid Congress (1), as previously done by the WHO Expert Committee on leprosy ( •). was a valuable eontribution to the understanding of leproay, both beca use ot the !requent oecur~nee of such cases and becauae it strengthens the individualization and tixation of the polar types. Wadc (•) has urged leprologists to publish atudiea of cases of this group.

PALABRAS CLAVE:

Separale /tom the JNTERNAT. J. I.EPROSV INTERN ArfiON AL JOURNAL OF LEPROSY VOLUME 24, NUMBER 4 ÚCTOBER·DECEMBEB, 1966 SOME OBSERVATIONS ON BORDERLINE LEPROSY JACINTO CoNVJT, M. D. CARLOS StSIRUCA, M. D. ANO PBI>RO LAn:NTA, M. D. Leproas¡ Divirio11, Mixútt&#39;fl of H ealUt. G~td SocitJl K&#39; f!l/Grf!, Ct!f&#39;I2Ca6, <&#39;M the CBbo Blanco LeproNrium, MBiqtutilJ Venc~melll The inclusion of the borderline group in the clasaification adopted by the Madrid Congress (1), as previously done by the WHO Expert Committee on leprosy ( •). was a valuable eontribution to the understanding of leproay, both beca use ot the !requent oecur~nee of such cases and becauae it strengthens the individualization and tixation of the polar types. Wadc (•) has urged leprologists to publish atudiea of cases of this group. In the hope of contributing to information about this intereating form of leprosy the following account of our obaervations ia given. In total, there have been studied 286 cases of borderline form from the dífferent dependencies of the Leprosy Division, namely, the Central Dispensary in Caracas, the Cabo Blanco Leprosarium, the Isla de Providencia Leprosarium, and the different regional dispensarles. These cases represent 3.2 per eent of the 8,872 known cases of leprosy existing in Venezuela as of J&#39;une 1956. Of the total, 100 cases were hospitalized at Cabo Blanco. The othcr 186 cases were reported by the leprologiats of the leprosy aervice in the interior, who are familiar with the borderline eondition. They sent to the service&#39;s central office clinical records, ineluding the resulta of baeteriologieal examinations and lepromin tests, and also biopsy specimens by means of which the diagnoaes were confinned. MATEIUAL ANO HETHODS The material on whieh the presut report is bued con.alsta of U.e 100 euea thllt were hospitaliJed and studied thoroughly by aL Their distribution u reprdt age and ae.x is shown In Table l. Two-thjrda of the cases were of reactive nature, on~third nonrea.ctivc. With ~ to their prin~lpal elinical featurea they may be grouped as followt : R7ñ 376 1 nfcnw./.irm(tl .Jom·1ur.l of ],,·¡n·osy u~n.clit· e Cr.u<t>l1 (oS} Wi1 h ~~&#39;&#39;Cl&#39;l&#39; irnpaitml·nt of general health ...................... . 16 cases Wi1 h mnrler;Jtf&#39; imptdmwnt of 11:(&#39;1\f&#39;nal hP;tlth ...................... 31 ca~cK Withoul impni t·meut oC ¡.:c:l1CI&#39;al lwallh .............. ..................... 21 cases ,vo ,treactit·~ Cu~cd (J!l) With infiltrating , rliffusc- lesion!&#39; .............................................. 10 c-aM":s With infilt111ting, !JIIIqul··like lt.:~iuns ........................................ 2~ ca S<&#39;!I TABLL l.-1\ gt and ~u dis!·ribt1tio&#39;ll of th.e 100 borderli"q ~ases l!lwdifd. - -- --- --· A~ )..[ !11(• FP.m:\ln . ·- - · (}-1·1 .-&#39; 1 15-29 ..,. &#39; ) 16 30-14 1·1 12 .J.) - 5\1 1 1 7 fi ll l\hd ó \ T f . li 3 ·- - ·--·- TOTAI.X Gl ~\) 1 -- Total 6 41 2tl !S u - ·- 100 ~ 1956 CUn.í~al strrd11.-Thc cvolution o! the caS\&#39; S was folluwed dinicall)&#39; frum thc initial cxamination m their prPsent sla~o.ooe, with dcw:k-d dc:1c riptions oC their lesioJtl!, te.sts (or sen~o¡·y chanl{f&#39;ll, htSlamin tc:;t>~, and complt~ment{lt&#39;}&#39; laboratory tests including in AOnl<&#39; casl&#39;s <-l~ttophc>t·~si~ :&#39;ol~th)&#39; l<-ne bluc injections were mad<&#39; in one Jrl"OU(l. 81l.(&#39;tcrio/~,flil&#39;fll tr>< I.~.-Smrar.~ mar!(&#39; hy the ~crnpc&#39;<i -i ncísicm mcthod W<"re taken fl-om active le!;ions nnol al so f n•m ap¡)al&#39;cnUy hcalthy Rkm. SmcarR from tho l Ja¡;¡¡J CU\&#39;Íly Wf"!J&#39;r. made by ~;c n\¡oing, ;~ftcr clcani n~-t thc mucouíl mcmbrunt:. All smctHll werc ~tain<&#39;<i !or add-fast badlli. lmmrmclcgi~:.al lr ~ t:J.-S tanoa rd lc¡womifl, ancl in some ca&<&#39;& the Dharmr-ndratype bacillar}&#39; lept&#39;Omin, WN&#39;C u~rd for thc Mit.suda l<&#39;st, which wa e applied at dif· !ot·ent si tes. The rell<lin¡.,rs wPre made aftc1· 24 and 48 hours and aftel&#39; 21 rlay11. Tubct"Culin t~sts with PPO were nlso madc. llí:;.tolfJgil&#39;ul c.rnmi nations.-~1 nt<-l·iai for· skin biCI(I!lÍ(&#39;l! u·as t.aken fronr lcsions of differ<-nt asp<"Cts, the ~ections l&#39;t&#39;~larl~· !&#39;Ca im~l wilh hcma.{.()JC)&#39;Iin and eosin a nd in somP. cases with SurlRn IV. Fitc··~ 1947 mdhod was usr.d for .stuinin.g lmcill i in thc ~ectiom. Fl?\nJNCS Facfcs dim.omha .. -We use this t(&#39;rm to designate the lesions oí thc face. In many cases where wc nre dr.;\ling with infiltration!\ thcsc lcsions -takcn <lS 1\ wh olc, on the for<.>head. between the eyebrows, on thc bridge of the n osc, ancl on the chiu , togethcr with those of the cheeks- give a bnt-like figour·c that i!-1 easily t·t~o~rtli~able. \Ve have founrl it in 6:1 Jlf&#39;l&#39; cent of the cases. llypochromic lw.lo.- Thc prescnce of a hypvt.:hromic halo arouml sorne Jc¡; ion!&#39;., cspecially thc infi1trntcd ones, S(&#39;cn in 27 pcr cent of lhc cases, is a sign that s}wulcl be tnkcn into consideration in the <1 iágnosis of thc borderline group. Wc interprct itas the condítion secondaa·y to the ¡)rOCeas Convit, Suiruca a:nd !Ape?Ua: Borderline Leprosy 377 of regression, which begins in the outward part of the infiltrated lesion and increases as the regression progresses. However, in sorne cases it is also found in conneetion with very active lesions and gives the impression of being a peripheral disturbanc~ of pigmentation. Hypoch·romic patches.-We refer espedally to those hypopigmented areas of the skin that are secondary to the regression of in!iltrated Jesions. They vary with resped to number, size, form and the definition of the borde1-. lt is almost the rule that they are numerous and occupy extensive areas, regardless of whether the skin is atrophied or not, and they can be present together with active, infiltratcd Jesions. We have observed them in 61 per cent of our cases. Differential diagnosis: The most important diagnostic problem, as we see it, is the düferentiation between the hypochromic patches of this borderline group and those of the indeterminate group, sinee those seen in the tuberculoid type are easily distinguished by the immunologie reactions of the cases, and s ince sueh patches in the lepromatous type are rare. In dealing with this problem various possibilities must be borne in mind: l . Diagnostic errors in which hypochromic patches may be classified as indeterrninate when in reality they are borderline lesiona in the process of r egression. 2. Cases of the borderline kind evolving falsely from indeterminate. This possibility ex.ists in those hypochromie borderlines which in former stages showed active, erythematous infiltrations. If they were erroneously classified as "indeterminate to begin with, one would get the impression that they were borderline cases evolving from indeterminate, when in reality they were simply different stages of borderJine lesiona. S. Borderline cases may transform into leprornatous. When this occurs witb the hypochromic borderline stage as a transitory phase, one could certainly get the false impression that the lepromatous condition was evolving from the indeterminate one, and not from its true source, i. e., borderline. 4. Similar reasoning could be applied to eventual tr.ansitions of the hypochromic stage of borderline towards the tuberculoid type. Evolution : For several years we have had the opportunity to observe how the secondary hypoehromic patches of the borderline group follow different courses of development: (a) They may become repigmented. ( b) They m ay persist for a long time. (e) They may give origin to new erythematous infiltrations of their own borderline form. (d) They may be transformed into tubereuloid, although not very frequently. (e) They may be transformed more frequently into the lepromatous 378 lntern.a,tiona-l Journal of Lepro8&#39;1J 1956 (f) They may grow (&#39;.entrifugally. This process of growth individualizes the hypochromic stage of the borderline group, for one thing as a potentially active phase which can give origin to new reactive phenomena or change into either of the polar types (most frequently into lepromatous), and for another thing as a phase in which the patches may be active and progresa in the hypochromic phase itself. This concept is supported by the presence of the borderline histopathological structure in sorne of them. This finding, however, is not very frequent, and it may be stated almost as a rule that the hypochromic patches of borderline cases are productive, infiltrating, perivascular processes. When hypochromic patches with the borderline histopathology are found in patients who affirm that they have never had any different forro of lesion in the same spots, we are compelled to believe that the same patches have existed as initial lesions. A15 this may be of considerable interest in connection with the indeterminate group, it may be necessary to recognize a new form of borderline leprosy, naroely the hypochromic. The hypochromic patch of this group may thus not only be a lesion in procesa of regression, potentially active or active per s-e, but it rnay have existed as a borderline lesion frorn the beginning. Nerve disturbances: Our experience has sho\\&#39;11 that there are three possible eventualities as regards sensory changes and the result of the histamin t.est in these patches. l. The histamin reaction may be abnormal (i. e., with no reflex erythematous halo), this abnormality being accompanied by sensory disturbances. This is the classical finding. 2. The histamin reaction and sensitivity may, on the other hand, botb be normal. This integrity of the nerve elements within the patches is interesting, as it shows a divergence from the accepted rule that hypochromic skin lesiona in leprosy are accompanied by sensory disturbances and an abnormal histamin reaction, with the inference that tbe absence of these phenomena is a sign that the patches are not of leprous origin. The further absence of the Hansen bacillus would give stronger support to the possibility of error. S. There rnay be normal sensation, but an abnormal histamin reaction. It has long been an accepted notion that the abnorrnal histamin reaction is always accompanied by sensory disturbances, but we have found in sorne hypochromic patches of borderline caae.s a Iack of association of the two phenomena. In other words, the pathways of conduction of superficial sensation have remained intaet, while those that conduct the Lewis vascular reflex, which is concerned with normal histamin reaction, have been affected. The existence of this discordance in hypochromic patches of borderline cases stands in contrast with what is observed in similar patches of indeterminate cases, in which it is a rule that sensory disturbances and an abnormal histamin reaction S!"O toS!"ether. 24,4 Convit, Si8iruca and Lapenta Borderlin.e Leprosy 379 The situation that arises from the existence of hypochromic patches of cases of the borderline group in relation to similar pat~he-9 of the indeterminate group is very interesting from our point of view, in that the latter group loses importance. TESTS WITH METHYLENE BLUE IN BORDERI.INE LEPROSY In view of the interesting observation of Monte) (2) of the retention of methylene blue in parta of a Jesion of a borderline case, to which attention was called by Wade (8), we ha ve applied that test to 21 such cases. The methylene blue solution employed was of 1 per cent concentration, the injections intravenoUB. Starting with a dose of 3 ce. on the first day, 4 ce. on the second day, and 5 ce. on the third day, it was increased until by the 15th day it was 10 ce. In the cases that remained without colored lesions this dose was repeated daily until the 21st day. In-a few cases the injections were continued for as long as four months . . It was found that sorne tase-9 which show retention of the dye do so only in certain sites, such as the earlobes, the ciliary region, the alae nasi, and the cheeks, with no retention of the pigment in the rest of the lesions. From this observation it might be expected that lepromatous foci were present in the parts that retained the methylene blue, and that was proved to be a fact by histological examination. It was found that the failure of other lesions (borderline patches) to retain the pigment was dueto their lack of lepromatous elements. In sorne cases we have found, in ar eas contiguous to highly-retentive, histologically-proved lepromatous foci, certain Jesions that retained the blue pigment diffusely and in which a lepromatous component was found concomitantly with a borderline element. On the other hand, we have also found cases in which the methylene blue was not retained at all even after repeating the injections for fifteen days, or-in sorne casesas much as four months. On the basis of thi.s experience we are convinced that the pure borderline lesions do not retain methylene blue, and those cases which do hold the pigment do so in direct proportion to the amount of lepromatous granuloma they contain. These granulomas may sometimes be found concentrated in certain areas, and sometimes distributed within the borderline patches themselves. A noteworthy fa.ct is that there is a marked difference in the time that is needed to fi.x the methylene blue in lepromatous and borderline cases. In the former, the lesions become intensely blue in 1 or 2 days, whlle in the latter the blue color appears only after 4 to 7 days. We refer here to those cases in which the lepromatous granulomas are found distributed in the borderline patches. In our opinion, the test with methylene blue will not be useful in studying the cases of pure borderline leprosy, but it should serve to 880 lnt~ Journal. of Leprosy 1956 distinguish those cases of this class which have a lepromatous component. As the quantitative presence of that component is directly proportional to the intensity with which the pigment is retained, the test is prognos· tically usefu1. ELBCTROPHORETIC JNVESTIGATJON OF PLASMA PROTEIN We have subjected the sera of 30 of our cases to electrophoresis, and found that the albumin-globulin ratio wa.s normal in 60 per cent of tbem. These cases showed important regressive activity. In the remaining 40 per cent, the albumin-globulin quotient was below the normal value, ranging from 1.01 to 1.46. In this group the lesiona showed a tendency to persist and spread. SUMMARY From the various units of the leprosy service, data has. been eollected on 286 cases of the borderlíne form of leprosy, these constituting 3.2 per cent of the 8,872 known cases of the disease. The present report is based on personal study of 100 hospitalized cases. What is described as the "faciu di:nwrplw.!&#39; was seen in 63 of these cases. Ilypochromic halos around sorne lesion.s, usually a consequence oí their retrogression, was seen in 27. Hypochromic patches, secondary to regression of infiltrated lesions, seen in 61, are discussed in sorne detail. The problem of differentiation of these secondary pa~hes from lesiona of cases of the indeterminate group is considered first. Concerning their evolution there are severa! possibilities. including change to tuberculoid ( infrequent), or to lepromatous (more frequent), or centrifuga! progression as such. It is believed that such hypochromic lesions, with borderline histopathology, may exist as initial lesiona. Findings regarding sensory disturbance and the histamin test are variable. Intravenous injections of methylene blue daily for various pcriods, given to 21 cases, resulted in retention of the dye where there were histologically-proven lepromatous change.s. Sometimes this was only about the face, sometimes in parts of borderline patches which contained lepromatous etements, but sometimes there was no retention of· the dye even a!ter long courses of injections. It is concluded that pure borderline lesiona do not retain methylene blue. Brief mention is made of electrophoresis tests of the plasma of 80 cases. The albumin/ globulin ratio was normal in 60 per cent of them, these being regressive cases. RESUMEN De los varios departamentos del servicio de lepra, se han acopiado datos acerca de 286 caaoa de la forma limltrofe de lepra, constituyendo S.2 por ciento de loa 8,3&#39;72 casos conocidos de la enfermedad. La comunicación actual ~ basa en el estudio Jl(lraonal de 100 casos hospitaliudos. La llamada "facies dimorpha" fué obsenrada en 63 de estos casos. En 27, se notaron auréolas hipocrómicaa alrededor de algunas lesione!, por Jo general conaecuen24, 4 C&n&#39;Vit, Smruca a?Ul Lapenta: Borderlim Lepro81J 381 ci.a de la regreai6n do laa últimas. So discuten eon algún pol&#39;tDeJior las placas hipocrómicas, secundarias a regreai6n de leaiones infiltradas, observadas en 61 casos. Se considera primero el problema do la d1!ercnciaci6n do estas plaeaa secundarias de Jás lesiones de casos del grupo indeterminado. En cuanto a su evolución, caben vari.aa posibilidades, incluso cambio a la forma tttberculoidca (infrecuente) o lepromatosa (más frecuente) o progresión centrlfuga (como tal) . Parece que esas lesiones hipoc:rómieas, de histopatología limitrofo, pueden exi1tir eomo lesiones iniciales. Son variables loa hallazgos relativos al trastorno sensorial y a la prueba de la hlstamina. A 21 enfermos se les d.ieron diariamente durante varios periodos de tiempo inyecciones intravenosas de azul de meuteno, dando por resultado retención del colorante cua.ndo babia alteraciones lepromatosas comprobadas histológieamcnte. Algunas veces esto sucedió unic:amcnto alrededor do la cara, algunas veces en placas linútrofe.s que contenían elementos lepromatoso.9, pero a veces no hubo N!tenei6n del colorante, ni aun después de largas seriea de Inyecciones. Dedúcese que las leJJiones limShofea puras no retienen el azul de metileno. Se hace breve mención de las pruebas elect.ro!orétieos del plasma de 80 enfermos. La proporción de albúml.na/globulina fué normal en 60 por ciento de ellos, tratándose de casos regresivos. REFERENCES [MADRID CONGRESB] Technicol roaolutions. Claaeiíicationa of leprosy. Internat. J. Leprosy 11 (1958) 504-516; Mem. VI Congr. Intcrnac. Leprol., 1958, Madrid, 1954, pp. &#39;75-80. 2. MoNTE.L, M. L. R. La forme tuberculoi&#39;do de la l~pre (forme de debut) en France et en Cochinchine; lea clasa!Cicationa. Internat.. J. Leproay ZZ (1954) 408-408. S. W ADE, H. W. Hltherto unnoted !ea tu res of "borderlíne" cases. Interna t. J. Leprosy 2Z (1954) &#39; 69471 (editorial). 4. (WOJW) HEALTR 0RGANIZATION) Expert Committ~ on Leproay¡ Fint Report. World Hlth. Org. Ted\. Rep. Ser. No. 71, 1958, pp. 28.
  Ediciones > Año 1956 > Artículo No. 1 2
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