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Images in Neurology
February 2002

Sural Nerve Without Nerve Fibers in Leprous Neuropathy

Arch Neurol. 2002;59(2):306. doi:10.1001/archneur.59.2.306

A 37-YEAR-OLD woman, a native of Cape Verde Islands who lived in Italy for 13 years, had an indolent perforating ulcer on her left big toe as her only complaint (Figure 1, A). Her deceased father had reportedly been affected by leprosy. On examination, muscle power and tendon reflexes were normal, but there was severe loss of pain and temperature sensation and moderate loss of light touch sensation in the 4 limbs (Figure 1, B). Electrophysiologic studies documented a distal polyneuropathy, with a severe involvement of sensory fibers and a moderate involvement of motor fibers. Autonomic dysfunction was represented by anhidrosis in the 4 limbs, where sudomotor skin responses were also absent. Radiographs of the left foot showed acute osteomyelitis in the first phalanx of the hallux, underlying the skin lesion. The presence of acid-fast bacilli was demonstrated in a skin biopsy processed by the Wade method. Sural nerve biopsy showed the absence of nerve fibers and Schwann cells in all fascicles, endoneurial fibrosis with typical foamy cells, and perineurial hypertrophy (Figure 1, C and D). No acid-fast bacilli could be detected in cryostat sections of the nerve by the specific auramine O fluorescent method. Altogether, these histopathological findings depict the rare "burnt-out" stage of lepromatous leprosy.1

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