Plantar ulcer

Introduction Leprosy ulcers generally occur near the joints of the soles of the soles of the feet.

Cause

The pathogen is M. leprae. Under the optical microscope, the intact bacilli are straight rods or slightly curved, about 2 to 6 microns long, about 0.2 to 0.6 microns long, without flagella, spores or capsules. Incomplete ones can be seen in the shape of short rods, double spheres, beads, and granules. When the number is large, it has the characteristics of clustering, which can form a pellet or a bundle. The new structure of M. leprae can be observed under an electron microscope. The acid-fast staining of M. leprae was red and Gram staining was positive. The isolated M. leprae loses its fecundity after 2 to 3 hours of sunlight exposure in summer, and can lose its vitality after being treated at 60 ° C for one hour or ultraviolet irradiation for two hours. Generally, it can be killed by treatment such as boiling, high pressure steam, ultraviolet irradiation, and the like.

Leprosy patients are the natural host of M. leprae. The distribution of leprosy in patients (as an example of a tumor-type end) is more common, mainly found in certain cells of the reticuloendothelial system such as skin, mucous membranes, peripheral nerves, lymph nodes, liver and spleen. The skin is mainly distributed in nerve endings, macrophages, smooth muscles, hair bands and blood vessel walls. It is very common in the mucosa. In addition, bone marrow, testis, adrenal glands, and the front half of the eye are also areas where M. leprae is easily invaded and existing, and a small amount of leprosy is also found in the surrounding blood and striated muscle. M. leprae is mainly excreted by ruptured skin and mucous membranes (mainly nasal mucosa). Others in milk, tears, semen and vaginal secretions also have leprosy, but the amount of bacteria is small. The main mode of transmission of leprosy is direct contact with infection, followed by indirect contact with infection.

1. Direct contact with infection This method is a direct contact between a healthy person and a contagious leprosy patient. The infection is caused by contact between the skin or mucous membrane containing M. leprae and the damaged skin or mucous membrane of a healthy person. This infection is most common in family members who are in close contact with the patient. Although the closeness of exposure is related to the onset of infection, this does not rule out the possibility of occasional contact and infection.

2. Indirect contact with infection is a form in which healthy people and infectious leprosy patients are infected through certain media. For example, contact with clothes, bedding, hand towels, food utensils, etc. used by infected patients. The possibility of indirect contact with infection is less than the probability of direct contact with infection, but it cannot be ignored.

3, other methods of transmission In theory, leprosy can invade the human body through the skin, respiratory tract, digestive tract, etc., resulting in infection. Recently, some people have emphasized the way of respiratory infection. The nasal mucosa is the main route of discharge of leprosy. The leprosy in the nasal secretions can survive for a considerable period of time. The dust or droplets of bacteria can enter the respiratory tract of healthy people. Infection. It has also been pointed out that the use of blood worms as a medium may cause leprosy infection. However, there is still debate about these views. Moreover, the epidemiology of leprosy has not been confirmed.

It must be pointed out that although there is not enough evidence to confirm what is the main route of transmission, the resistance of the body is undoubtedly the leading factor in the infection process. Although the chances of infection of the surrounding population of an infectious patient are similar, it is a minority after the occurrence of leprosy. In the area around the leprosy hospital (village), the incidence of leprosy is not high, even for spouses of leprosy patients, the prevalence is generally not more than 5%. In addition, about two-thirds of leprosy patients can't ask for a history of leprosy exposure.

All of these indicate that most long-term close contacts are not ill. The pathogenesis and performance of M. leprae after entering the human body depends mainly on the resistance of the infected person, that is, the immune status of the body. In recent years, many people believe that leprosy, like many other infectious diseases, has subcllinical infections, which indicates that the infection rate of leprosy is much higher than the incidence rate. Most contacts are established after infection. The specific immunity against leprosy is terminated by subclinical infection.

an examination

Related inspection

Circulating immune complex (CIC) circulating immune complex spores agglutination test

Clinical manifestations:

After the leprosy invades the body, it is generally considered that the incubation period is 2 to 5 years on average, the short period is several months, and the elders are more than ten years. If the disease occurs, most of them are unconscious. Before the onset of typical symptoms, there are often systemic forequarters symptoms such as general malaise, muscle and joint pain and limb sensation. These performances are not specific. Those with stronger immunity develop to the end of tuberculosis-like leprosy, and those with low immunity or defects develop to the end of the tumor type. According to the five-level classification method, the characteristics of various types of leprosy symptoms are described as follows:

First, tuberculosis-like leprosy

This type of patient has a strong immunity, and the leprosy is confined to the skin and nerves. There are rashes and plaques on the skin. The number is often one or two. The edges are neat, clear, and often have obvious sensations (wet, pain, touch). The distribution of obstacles is asymmetrical, and the bristles are detached. This is an important feature. . Occurs in the vulnerable parts of the limbs, face, shoulders and arms. The color of the macules is light and reddish, and the surface is often free of scales. The color of the plaque is often dark red, with a clear outline, with the edges rising upwards and inward, moving to a flattened atrophy center, and some tending to a semi-annular, circular or arcuate shape with different edge thicknesses. The surface is mostly dry and scaly, and sometimes the damage caused by the accumulation of most small papules is visible. A large cutaneous nerve can be felt in the vicinity of the lesion. Sometimes the damage to the nearby lymph nodes also becomes larger. The eyebrows generally do not fall off.

After the peripheral nerve of this type is involved (such as auricular nerve, ulnar nerve, sacral nerve, etc.), the nerve rod becomes coarse and fusiform, nodular or beaded, hard and tender, mostly unilateral, severe Abscess or fistula can be formed due to delayed type hypersensitivity. Some patients have neurological symptoms without skin damage, called pure neuritis. Clinically, the nerves are coarse, and the skin lesions and muscle weakness in the corresponding parts. When the nerve is severely affected, neurological nutrition, exercise and other functions are impaired, and the large and small muscles and interosseous muscles atrophy occur, forming a "claw hand" (ulnar nerve involvement), "hand rubbing" (median nerve involvement), and "wrestling wrist" "( nerve involvement), "ulcer", "rabbit eye" (face nerve involvement), "finger (toe) bone absorption" and other manifestations. The deformity occurred earlier.

This type of bacteria is generally negative. The leprosy test was strongly positive. Bacterial immune function is normal or near normal. The histopathological changes were tuberculous granuloma, which was characterized by the fact that no "infiltration zone" was observed under the epidermis, and acid-fast bacilli were not detected by acid-fast staining. A small number of patients can heal without treatment, and if they are cured, they will resolve faster. The general prognosis is good, but the deformities that are formed are often difficult to recover.

Second, the boundary line of tuberculosis-like leprosy

This type of tuberculosis is similar to tuberculosis, with spotted plaques and plaques. The color is reddish, purple or brown, and the boundaries are neat and clear. Some areas have blank areas or drilling areas (also known as no holes). The infiltrating area and the immunizing area) form a ring-shaped lesion with clear inner and outer edges, and the skin inside the hole area seems normal. The damage surface is mostly smooth, and some have a little scale on it. The number of damages is multiple, the size is different, some are scattered, with the trunk, limbs, and face more, the distribution is wider, but asymmetrical. Although there are sensory disturbances, it is lighter and later than TT. The eyelashes generally do not fall off. The nerves are thick and asymmetrical, not as rigid and irregular as TT. Mucosa, lymph nodes, testicles, eyes and internal organs are less affected and lighter.

This type of bacteria is generally positive, cell density index (logarithmic classification, the same) 1 ~ 3 +. The leprosy test is weakly positive, suspicious or negative. Cellular immune function tests were lower than normal. Histopathological changes were similar to TT, but lymphocytes around epithelioid cells were less and loose. A narrow "no infiltration zone" was seen under the epidermis, and the sections were resistant to acid staining or had little leprosy. Prevention is generally better. The "upgrade reaction" is variable TT, and the "degraded reaction" can be changed to BB. Leprosy is easily deformed and disabled after the leprosy reaction.

Third, the middle line of leprosy

This type of skin lesion is characterized by polymorphism and pleochroism. The rash has rash, plaque, infiltration and the like. The colors are wine, yellow, brown, red, tan, etc. Sometimes two colors appear on a piece of skin lesions. The edges are clear and the parts are unclear. The form of damage is banded, serpentine or irregular. If it is strip-shaped, one side is clear and one side is infiltrated. In the case of plaque, there is a drilling zone in the center, and the inner ring is clearly raised, gradually slanting outward, and the outer edge is infiltrated and unclear, showing an inverted dish appearance. Some lesions are red or white ring-shaped or multi-ring, shaped like a target or a badge, called "target spot" and "badge spot".

Some patients have a bat-like facial skin lesion with a gray-brown color called a "bat-like face." It is common to have tumor-like and tuberculosis-like lesions on the skin of different parts of a patient. Sometimes "satellite" damage can be seen. Some patients have thick cushions on the elbows, knees, and hips that are composed of nodules. Damage to the surface is slippery and soft to the touch. The number of damages is large, the size is different, the distribution is wide, and the asymmetry is more. After nerve damage, it is mildly numb, lighter than tuberculosis, and heavier than tumor type. Eyebrows often do not fall off. Mucous membranes, lymph nodes, eyes, testicles and internal organs can be affected.

This type of bacteria is positive, and the bacterial density index is 2 to 4+. The leprosy test was negative. Cellular immune function tests are between the two polar types. Histopathological changes were histocytic granuloma, and most of the subcutaneous "non-invasive zone" existed. It was observed that the tissue cells differentiated into epithelial-like cells to varying degrees, which were generally small, and typical and atypical foam cells were observed in some sections. Lymphocytes are few and scattered. The sliced anti-hometown staining has more leprosy, and the prognosis is between the two poles. This type is the most unstable, "upgrade response" to BT development, "degraded reaction" to BL development.

Fourth, the boundary type of tumor-like leprosy

This type of skin damage has rashes, papules, nodules, plaques and diffuse infiltration. Most of the damage is tumor-like damage, the number is large, the shape is small, the boundary is unclear, the surface is bright, and the color is red or orange. It is widely distributed and has a tendency to be symmetrical. The sensory impairment within the lesion is lighter and appears later. Some of the damage is large, the center is a "drilling area", the inner edge is clear, and the outside is infiltrated. Eyebrows, eyelashes, hair can fall off, often asymmetrical. In the advanced stage, deep diffuse infiltration of the face can also form a "lion face." In the advanced stage, mucosal congestion, infiltration, swelling, lymph nodes and testicular swelling are tender. The nerve involvement tends to be bilateral, more uniform, softer, and the deformity appears later.

This type of bacteria is strongly positive, and the bacterial density index is 4 to 5+. The leprosy reaction was negative and the cellular immune function test showed a defect. Histopathological changes, granulomatous nature tends to foam cell granuloma, and some tissue cells develop into atypical epithelioid cells, and some develop into foam cells. Lymphocytes are often focal, present between foam cell infiltration, a pathological feature of this type. Slices of acid-fast staining have a large amount of leprosy. The prognosis is better than LL, worse than TT, but still unstable. The "upgrade response" can be changed to BB, and the "degraded reaction" can be changed to LL.

Five types of leprosy

This type of patient lacks immunity to M. leprae, and the leprosy spreads throughout the body through lymph and blood. Therefore, the scope of tissue and organ invasion is relatively wide. Skin damage is characterized by a large number, a wide distribution and symmetry, an unclear edge, a tendency to fuse, and a greasy surface. In addition to light spots, the color of the skin mostly develops from red to reddish yellow and brownish yellow. The sensory disorder is very light. In the early days, there was a thinning of the eyebrows, which first began to fall off from the outside of the eyebrows, and then the eyelashes were also sparse. This is a clinical feature of the tumor-type leprosy. M. leprae is strongly positive, and skin lesions include rash, infiltration, nodules, and diffuse damage. Early plaque lesions are distributed throughout the body. They are more common on the face, chest and back. The color is reddish or light, and the border is unclear. It must be carefully examined under good light to be recognized. Later, in addition to the continued increase in plaque loss, shallow, diffuse, and nodules were formed. In the face due to infiltration and thickening, the appearance is mildly swollen, and the eyebrows often fall off.

Later, the plaque was merged into a large infiltration, or nodules appeared on the plaque and diffuse infiltration, and the diffuse infiltration developed to the deep, which was more obvious and serious. It is often spread all over the body. The face is diffuse and thick, the skin is deepened, the nasolabial hypertrophy, the earlobe is enlarged, the eyelashes are stripped, the hair is thin or the large pieces fall off, the nodules and deep infiltration are mixed together, and the conjunctiva is congested to form a lion face. Exterior. There are many nodules of different sizes at the extremities, shoulders, back, buttocks, and scrotum. Later, due to diffuse damage, partial absorption, and significant sensory disturbances and sweating. In the calf, the skin is slightly hardened, smooth and shiny, and there are fish scales or snake skin-like damage. It will not be retired for a long time, and some hair will be almost stripped, showing that the residual hair is distributed along the blood vessels.

Although the nerve trunk is involved, the sensory disturbance is lighter and the performance is later. The nerve trunk is slightly thick, symmetrical and soft, and muscle atrophy, deformity and disability can also occur in the advanced stage.

Nasal mucosal damage occurs earlier, first congestion and swelling, and later, as the condition worsens, nodules, infiltration and ulcers occur. In severe cases, there may be a perforation of the nasal septum. When the bridge of the nose collapses, the saddle nose is seen. Lymph nodes are already affected at an early stage, mildly swollen, often not noticed by people, and swollen in the middle and late stages, and tender.

Testicular involvement, first atrophy and atrophy, and tenderness, breast enlargement. Eye involvement can occur with conjunctivitis, keratitis, iridocyclitis, etc. Visceral organs and organs are also affected at the same time, such as hepatosplenomegaly.

This type of bacteria is strongly positive, 4 ~ 6 +. The leprosy test was negative. Cellular immune function tests showed significant defects. The histopathological changes are characterized by foam cell granuloma structure, which is mainly composed of typical foam cells rich in cytoplasm. There is no "infiltration zone" under the epidermis. Slices of acid-fast staining have a large number of leprosy, which can be bundled or pelletized. Early treatment, good prognosis, less deformity, can lead to disability in the late stage. This type is relatively stable, and only a few can change to BL under certain conditions.

Sixth, undetermined leprosy

This class is the early manifestation of leprosy, is the original, is not included in the five-level classification, is unstable in nature, and can subside or change to other types. The type of evolution can be changed to other types depending on the strength of the patient's body immunity, most of which evolve to tuberculosis, and a few to boundary lines and tumor types. The clinical symptoms are mild and do not involve the internal organs. The skin lesions are simple, with light red spots or light spots on the surface, and the surface is flat without infiltration and does not shrink. The mane can fall off. Skin lesions are round, elliptical or irregular. The edges are clear or partially unclear, the distribution is asymmetrical, and the skin lesions may have mild sensory disturbances. The nerve trunk is less affected, although it is increased but the hardness is lower, and there are fewer dyskinesias and deformities. Most of the bacteria were negative. Most of the leprosy tests were positive. Some of the cellular immune function tests are normal or near normal, and some are obviously defective. Histopathological changes were non-specific inflammatory cell infiltration. The prognosis depends on the extent of cellular immune development in the body. The leprosy test was positive, and the normal cell immune function test had a good prognosis. Some of its development can be self-healing, and some evolve to other types.

diagnosis:

The diagnosis of leprosy must be meticulous and strive for early diagnosis, no missed diagnosis, and no misdiagnosis. Early treatment and early recovery will not increase the condition, cause deformity, disability, or enlarge the infection. The diagnosis is based on the results of medical history, clinical symptoms, bacterial examination and histopathology, and comprehensive analysis leads to conclusions. For cases that are difficult to be diagnosed at a time, you can return to the clinic regularly and follow up, or ask the relevant department for consultation and give exclusion or diagnosis.

First, the medical history inquiry must focus on the projects related to leprosy, such as whether there are patients from the epidemic areas, families, relatives and neighbors, whether there are patients with the same, and whether there is contact history.

Second, the physical examination should be comprehensive, check the whole body skin, nerves and lymph nodes under natural light.

When examining the nerve, pay attention to changes in the peripheral nerve trunk, and pay attention to changes in sensory and motor function.

Differential diagnosis

Peeling of the soles of the feet: When peeling off the skin of your feet, don't ignore this small problem. It is likely to be a sign of skin disease.

The palms and the soles of the feet are red: the sole of the feet is one of the collections of the meridians of the human body. The soles of the feet are also rich in acupuncture points, blood vessels and nerve endings. The internal organs of the human body have 64 corresponding reflex zones in the soles of the feet, and the palms are also The same is true. Redness in the palms and soles of the feet is generally caused by poor blood flow or local telangiectasia.

Feet burning on the soles of the feet: When the plantar fascia is acutely inflamed, there is a burning sensation in the soles of the feet, and there is redness and swelling. Plantar fasciitis is a painful symptom of the sole of the foot. It is located at the heel of the sole of the foot and is a common form of foot pain.

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