When I was working in Port Moresby I did not get to see much leprosy patients. There was a special leprosy clinic that was run by the dermatologist but the short exposure during medical school I think was not enough to diagnose and treat leprosy patients.
When I moved up to ILRH I heard there were some leprosy patients around but did not see them in our clinics. One old man did present to me but he had completed his treatment but we could do nothing to help correct his lower limp deformities. I only advised him to take care of his feet (he wears a pair of rubber gum boots everywhere) and come and see us as soon as he has a little sore. I also advised him to check his feet everyday before he goes to sleep and every morning he wakes up (in case rats had bites of his remaining toes or sole of his feet).
During one of our clinic days we had a lady who presented with a hand deformity which I thought was Dupuytren`s contracture as a result of ulnar nerve involvement by mycobacterium leprae. There was some degree of loss of sensation along the ulnar nerve distrubution and the ulnar nerve was also thickened. The deformity was unilateral.
The photos are shown below.
This may look like Dupuytren’s, but it is not. This similar pattern of contracture is due to intrinsic muscle paralysis, known to hand surgeons as “claw hand deformity”, and is due to muscle imbalance resulting in an inability to independently straighten the finger joints, a type of weakness, not from shrinking tissues beneath the skin of the palm, which is the hallmark of Dupuytren’s Disease.
If you look at the first photo there is wasting of the thenar and hypothena muscles. Would not this be the sign that tissues beneath the skin are shrinking?
I am a dermatologist from central India. The deformity is claw hand with involvement of both ulnar and median nerve, which makes it a total claw hand. There is also wasting of muscles in the hypothenar and thenar eminances with hollowing on the dorsum of the hand due to atrophy of the interosseous and lumbrical muscles. This kind of deformity is mostly caused by M. leprae, unless she had a history of trauma causing damage of both the nerves. But your location in a highly endemic area for leprosy points more towards a mycobacterial etiology. The tissue which is shrinking is actually the muscles due to disuse atrophy and also due to lack of the neurotrophic elements from the affected nerves. As such there wont be much involvement of the subcutaneous tissue and the dermis. The pictures are really good.
Thank you Dr Ajay for the wealth of information.
I know this is an old post, but yes, this is classic leprosy-related hand deformity. There are reconstructive surgical procedures available that will increase function and appearance, though at the cost of loss of some strength. If he has drop foot, a procedure is also available for that. If he was treated, he may still have contact with a leprosy organization. If not, The Leprosy Mission International has work in PNG and could give you any information you want and contacts for referrals. I don’t know how much surgery they perform in PNG. Your instructions about his feet were just right – find and treat an ulcer immediately. He could also soak his feet once daily in water (30 minutes), and follow that with scraping away any callouses with a stone or piece of brick, then oil the skin (with mustard oil if available) to help keep it soft to prevent cracks that become ulcers. The same can be done for hands. It looks like he needs to watch his hands as he has some tough callouses and old healed ulcers. He almost certainly has significant loss of sensation in that hand so needs to watch for burns and blisters. Even small cuts to the fingertips can lead to eventual shortening of affected fingers.
Oh, I am an occupational therapist who has worked with the Leprosy Mission International in Bangladesh for 10+ years.
I am not a doctor, but I wanted to add that my mother had syringomyelia and her left hand looked just like that. She also lost her sense of touch in that hand.
This is a classic ‘claw hand deformity’ because of ulnar nerve involvement – very common in leprosy. I am afraid this has no resemblance to Dupuytren’s disease at all.