Hansen’s Disease?

Thirty years ago, I was the medical officer of a leprosy camp. This was in addition to my role as Regional Medical Officer in Eastern Gambia. To be honest, the residents were all end-stage, “burned out” patients for whom I could do little apart from supportive care. I visited the camp every week or so to see how the dozen patients were getting along. When HRH Princess Anne (now HRH Princess Royal) came to visit The Gambia in 1984, I showed her around the camp, much to the consternation of her “minders”.

Nominally I was also in charge of the supervised leprosy treatment programme in Eastern Gambia, but the health workers rarely called for my help.

So I know a bit about leprosy. And when this thin, gaunt man staggered into the clinic at MKT, his feet bandaged with rags, the diagnosis flashed through my mind. He was leaning on a stout stick with one hand, while the other grasped his young son’s shoulder. As he entered the outpatients department, he shuffled out of his shoes. These were modified Wellington boots which he’d cut away to allow his bandaged feet to fit.

Image
Ulcer in tip of big toe
Deep ulcer in heel
Deep ulcer in heel

He had been suffering from a deep ulcer in his heel for six months, another in his great toe for two months, and now he had developed a third ulcer between the toes of his other foot. He told us he had not had a proper shower for six months because he was afraid that the water would adversely affect the ulcers on his feet. Not surprisingly, he was dirty and smelled rather ripe. But the filthy rags binding his feet stank to high heaven.

After he’d showered, we examined him, but I could find no thickened nerves, skin or eye problems, characteristic of leprosy. The blood supply to his feet was excellent. Blood and urine tests for diabetes were negative. The other routine blood tests were normal apart from an elevated C-reactive protein, which is a non specific indicator of inflammation. Given the state of his feet, I expected this.

When the medic cleaned out the biggest ulcer, he could insert the gauze swab half an inch deep into the heel pad. This should have been excruciatingly painful, but the patient didn’t bat an eyelid. The ulcer on the toe was so deep that the nurse could feel the bone of the terminal phalanx as he swabbed out the detritus. The odour was sickening. Again, the patient said he felt no pain.

Our TB specialist doctor thought we ought to admit him to a separate room, to be on the safe side. I felt that he needed antibiotics to deal with a deep anaerobic infection and possible osteomyelitis of his toe bone: metronidazole and clindamycin. He said he had lost 10 kilos in weight over the past year because he didn’t have the money to buy food. I prescribed him with extra folic acid, B1 and B12 vitamins and he could eat as much of the clinic food as he wanted. I ordered daily wound cleaning and dressing and we waited to see how he progressed.

Leprosy is only one of the dozens of diseases which can cause peripheral nerve damage (neuropathy). We had ruled out diabetes (one of the commonest causes in UK), poor blood supply, liver and kidney disease. Leprosy, tuberculosis, immune deficiency, syphilis and damage from alcohol were the next diseases to rule out. Quite often, we never find a cause.

The patient told us he’d sought advice from other doctors. No one seemed to know what was wrong. He had been treated unsuccessfully with acupuncture. He had refused to attend the local hospital because he was frightened that they would cut his legs off. He was pessimistic about being cured and thought that the best we could do for him was to fix him up with a set of crutches.

What a bonus we had our French infectious and tropical disease consultant visiting the clinic. He too thought that this was leprosy and he advised me carry out some special tests to confirm or refute this. He wanted to see the ulcers for himself so the nurses took down the dressings.

Three days later
Three days later
Heel
Heel

The nurse and I were both astonished by what we saw. The ulcer on the heel was half as deep as before and the ulcer on the toe was almost healed. This was after just three and a half days of antibiotics, food, vitamins, rest and cleaning. I showed the French consultant photographs of the lesions when we started treatment to prove how dramatic the improvement had been. Rather cheekily, he said that I was the only doctor he knew who could successfully treat leprosy with clindamycin.

When we got back to SMRU base later that day, the specialist started to poke fun at me. He told my colleagues about my “remarkable clinical skill” and jokingly bowed his head in my direction, a traditional Burmese mark of respect.

As Michael Myers (in the film “Wayne’s World”) would say, “I’m not worthy.”

I got lucky.

Correction: the patient and I both got lucky.

He’s not out of the woods yet. As his ulcers heal, the sensation is coming back and he is feeling more pain. We are still trying to find a cause for his symptoms#, but at least it looks like he isn’t going to need those crutches he was asking for.

# we know what germ we’re dealing with now, too.

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