INTERNAIlONA!. J OIRNAI. UI' LI[I'ROSY^

Volume 65, Number 3Printed in lhe U.S.A.

(ISSN 0145-916X)

Steroid Therapy for Paralytic Deformities in Leprosy'D. Samuel Thomson Sugumaran 2

Leprosy can cause damage to the cranialnerves (especially the zygomatic branch ofthe facial nerve) and to many peripheralnerve trunks in many patients. This nervedamage leais to visible paralytic deformi-ties (lagophthalmos in facial paralysis, clawhand in ulnar paralysis, ape thumb in me-diar paralysis and foot drop in commonperoneal paralysis). The nerve damage canoccur whether the patient is on dapsone mono-therapy or on multidrug therapy (MDT) andsometimes even after completion of chemo-therapy (3. ''). Timely intervention withsteroid therapy has been found to be effec-tive in reverting the disabilities to variousdegrees in a varying proportion of patients( 1 ". 19). We present here our experiente intreating paralytic deformities with long-termsteroid therapy over a period of 5 years.

PATIENTS ANI) METHODSPatients

All Leprosy patients (both sexes) attend-ing the Sacred Heart Leprosy Centre hospi-tal July 1989—June 1994 with paralysis ofthe hands and feet of a duration of 6 monthsor less were included in the study, totaling156 patients. Seven patients dropped outfrom follow up for various reasons: 1 fordisabilities and cellulitis, I for peptic ulcerperforation, and 5 defaulted after 1 monthand did not return. The details of the 149patients available for the study are given inTable 1.

Inclusion criteriainclusion criteria included: a) The muscle

power of the affected nerves should be less

' Received for publication on 24 October 1996. Ac-cepted for publicador in revised form on 25 March1997.

'D. S. T. Sugumaran, M.B.B.S., D.P.M., Depart-ment of Medicine, Sacred Heart Leprosy Centre,Sakkottai 612 401, Kumhakonam R.S., Thanjavur Dis-trict, Tamil Nadu, India.

Present address: Schieffelin Leprosy Research &Training Center, SLR Sanatorium P.O., N.A.A. Dis-trict 632 106, South India.

than the Medical Research Council (MRC,London, U.K.) grade 2 (0-2 or less thannormal range of movement). h) 1n case ofulnar nerve paralysis, there should be anobvious mobile claw hand (at least the littlefinger must show obvious claw deformityand difficulty in grasping function). c) Inmediar nerve paralysis, the ability to op-pose the thumb to the pulp of other fingersnnlst be lost at the time of inclusion roto thestudy. d) In common peroneal nerve paraly-sis, there should be an obvious foot dropwith loss of normal heel-toe gait.

Muscle assessmentMuscle power was graded as 0-5 based

on the MRC scale.Score. The 0-5 scoring is defined as:

O = paralysis; 1 = flicker; 2 = limite(' rangeof motion, visible movement; 3 = full rangeof motion, no resistance; 4 = full range ofmotion, reduced resistance; 5 = normalagainst resistance.

Ulnar nerve. The following muscleswere examined: abductor digiti minimi; 3rdand 4th lumbricales and the first dorsal in-terosseus.

Median nerve. The abductor pollicisbrevis and the opponens pollicis muscleswere examined.

Common peroneal. The tibialis anteriorand the peronei muscles were examined.

Sensory assessmentOnly the hands were included for this

sensory assessment study. The palms of thehands were assessed in detail usine gradednylon monotilaments.

Ulnar nerve. The hypothenar eminenceand the little finger base and pulp wereassessed.

Median nerve. The thenar eminenceand the pulp of the thumb, index and longfingers were assessed. Four rnonofilamentswere used. The force of the filaments andthe scoring system used in this study areshown in Table 2.

337

338^ International loura 1/ o/ Leprosy^ 1997

TAtu]. 1. Chame teristics o/ /49 patients betwecn lhe u,1.'e.v o/ 9 anel 65.

Sex No. patients^Leprosy class. No.Rcaction type

2

M^

128^

131' (P13)^

13^

129F^

21^

13L (M13)^

119^

20LL (MB)^

17

Other investigationsA urinalysis and a hemogram were done.

The renal and tiver functions, blood sugar,body weight and blood pressure were allexamined and recorded initially and re-ex-amined periodically thereafter.

Nerve palpationThe serves were palpated and thickening,

tenderness or pain was recorded.

TreatmentMost of the patients were admitted to the

hospital at the initiation of treatment for thefirst 2-4 wecks.

Prednisolone was the steroid used in ourstudy. In addition, all patients receivedM DT according to their paucibacillary/nutltibacillary (PB/MB) status. Prcdnisolonewas given as a single dose every day in themorning and in the dosages shown helow:

a) Patient body weight above 40 kg:60 mg/d for 2 wks.50 mg/d for 2 wks.40 mg/d for 2 wks.30 mg/d for 3 mos.^3 mos.daily dose reduced^5 mos.

by 5 mg/month

b) Patient body weight below 40 kg:40 mg/d for 2 wks.135 mg/d for 2 wks. J30 mg/d for 3 mos.^3 mos.daily dose reduced^5 mos.

by 5 mg/month

c) Children were treated as follows:1 mg/kg/d first 4 wks.^1 mo.

1/2 mg/kg/d for 3 mos.^3 mos.further reductions of 1

5 mg over a month^approx. 6-8thereafter^mos.

The regimens shown above were possibleonly in patients suffering from borderline

leprosy with a reversal reaction. Patientssuffering from an erythema nodosum Iepro-sum ( ENL) reaction required longer dura-tions of prednisolone lince their reactionskept recurring for longer periods. II therewas noticeable improvement in muscleparalysis within the tirst 3 months of initiat-ing steroid therapy, a tapering off of thesteroid dose was started from nwnth 4 on-ward. II there was neither deterioration norimprovement on reaching the dose of 10mg/d of prednisolone, then the patient wasmaintained on 10 mg/d for 3 months, 5mg/d for another 3 months, and 2.5 mg/dfor a final 3 months. All adverse effects dur-int' the steroid therapy were carefullywatched for and recorded promptly. Activeand passive exercises and splinting weredone as and when necessary.

Criteria for recoveryMotor recovery at end of steroid ther-

apy. The criteria for motor recovery in-cluded: a) There should be no visible defor-mity; no clawing of fingers, opposition ofthumb to fingers must be possible, and thefeet must regais normal heel-toe gait whilewalking [voluntary muscle testing (VMT)should have improved to >MRC grade 3].b) There should be no need for surgical cor-rection. c) The patient must feel satisfiedthat he/she lias regained good functional

TABLE 2. Sensorv testara,'.

Force exerted bynylon tilament (g)

Score

0.4 42.0 33.G 1

10.0 1No tilament felt 0

The perception of 3.6 g was considere(' by tis todenote intact protective sensation. This is hased on theexperience of Bell at Carville, Louisiana, U.S.A.(Be11, J. A. Deformity and neural status hand screen.The Star 44 11985] 1-4).

11/ mos.

Imo.

Nerves

UlnarMedianPeronealTotal

Paralyzed Recovered

53 40

26 1981 61

% Recovery^Paralyzed^Recovered^% Recovery

76%%^

98^

61^G2%

100%^

50^

43^

86%73%^

43^

35^

81%75%^

191^

139^

73%

Single paralysis (81 patients) Mu!tiple paralyses (68 patients)

65, 3^Sigumaran: Steroids for Paralrtic Deforntities^339

TABU; 3. Details of recoverv based on the tV/Ye of reaction.

Nerve

Paralysis (WHO grade 2 disability)

T'ype 1 reaction "1'ype 2 reaction Totalrecovery °7n

Paralyzed Recovered %Recovery Paralyzed Recovered `7r Recovery

Ulnar 125 $5 68% 26 16 61% 101 67%Median 48 41 85% 4 4 IOOc/c 45 86%Conunon

peroncal 60 45 75% 9 9 100% 54 78%Ali nerves 233 171 73% 39 29 74% 200 73%

Anesthesia (WHO grade 1 disahility)

Nerve Anesthetic Recovered (/ Recovery^Anesthetic^Recovered `7r Recovery Totalrecovery

Ulnar 125 59 47% 26 10 38% 69 46%Median 48 17 35% 4 4 100% 21 40%Ali nerves 173 76 44% 30 14 47% 90 44%

ability of the af7ected limb for personal caro,household work and gainful employment.

Sensory recovery. Only the palras ofthe hands were includcd in this recovery as-sessment. The arca of the palm correspond-ing to the particular verve supply shouldhave regained the perception of 3.6 g nylonmonofìlament as follows: a) ulnar nerve-in the hypothenar arca and little finger pulp;h) median nerve—in the thenar arca and thepulp of the thumb, index and long fingers.lmprovement was noticed after 3 months to1 year of initiating steroid therapy.

The study of sensory recovery over thesole of the foot was not taken up in thisstudy for the following reasons: a) At thetime of the initiation of the study, the nor-mal sensory threshold for the sole of thefoot had not been standardized (van Brakelreported in his 1994 Ph.D. thesis that a 2-gfilament force was the normal plantarthreshold in healthy Nepalese volunteers).b) Birke and Sims ( 5 ) and Hammond andKlenerman ( 10) have claimed a 10-g lila-ment force as the protective sensory thresh-old for the sole of the foot, and suggestedthat the inability to perceive 10 g over the

sole may indicate the risk of developingplantar ulcers.

However, we carried out a pilot study inthe years 1988 and 1989 on some healthyvolunteers in South Ilidia and found that be-cause of walking barefoot, which is so verycommon in our South Indian population,many had such thick callosity over theirsoles that they could not perceive a 10-g fil-ament force, especially over the heels. Cur-rie had also reported similar findings fromALERT in Ethiopia at the XIV InternationalLeprosy Congress in Orlando, Florida,U.S.A., in 1993.

RESULTSOf the 149 patients available for follow

up after completion of steroid therapy, 30patients (20%) could be followed up for 6months and 119 patients (80%) could hefollowed up for 1 to 5 years. The results aregiven in Table 3.

The overall recovery rate was similar intype 1 and type 2 reactions (Table 3), andalso similar whether the patient had a singleparalysis or multiple paralyses (Table 4) butin the patients with multiple paralyses, al-

TABLE 4. Recovery of/)aralvsis when patients had single paralvsis and when tiles /tadmultiple para!vses.

340^ International Jorrrnrrl of Lepros_v^ 1997

TABLE 5. Recovery of porolvses with relalion to the duration o/'hnrcrlvsis.

Duration of. paralysis

Nerveweek to 3 months

3 months to 6 months

(124 patients)

(25 patients)

Paralyr.ed^Recovered^

7 Recovery^Paralyied^Recovered^'G Recovery

Ulnar 128 89 69% 23 12 52`7rMedian 46 39 85'7 6 6 100%Peroneal 55 44 80% 14 Io 71%"rota' 229 172 75% 43 28 65%

though the duration of paralysis was thesame in each individual patient, somenerves recovered and others did not, whichis strange and frustrating (e.g., when a pa-tient with bilateral ninar paralysis which oc-curred simultaneously was treated, onehand recovered and the other hand did not).Similarly, a patient with ulnar median paral-ysis in one hand showed recovery of themediar nerve alone, leaving behind the ul-nar paralysis. Of course, some patients withbilateral ulnar, median and peroneal paraly-ses gained complete recovery of ali of thesenerves. Recovery was definitely betterwhen the duration of paralysis was <3months (Table 5). Two patients with ulnarparalysis who had persistent clawing of fin-gers at the time of cessation of steroid ther-apy presented after 1 year with remarkableimprovement with no visible deformity.

Initial improvement and recurrence ofparalysis

A total of 12 nerves (8 ulnar, 2 medianand 2 common peroneal) showed very goodimprovement in the beginning but the paral-ysis recurred at the time of tapering theprednisolone dosage and did not improvefurther in spite of increasing the dosage ofprednisolone. We could not explain the rea-son for this phenomenon. These nerves wereincluded under the "not improved" category.

Paralysis after stopping steroid therapySix patients developed a recurrence of

paralysis after stopping the steroid therapy.AII of the patients were borderline patientswith type 1 reaction 12 borderline tubercu-loid (BT) and 4 borderline lepromatous(BL) patients 1. resulting in 8 paralyses (3foot drop, 3 ninar paralysis with clawing offingers, 2 mediai] paralysis) (Table 6). Pa-tients 4, 5 and 6 with foot drop received an-other course of steroid therapy. Foot droprecovered well in two patients (4 and 6) anddid not improve in the other patient (no. 5).For the other 3 patients (3 ulnar paralysisand 2 median paralysis) surgical correctionhas been advised. Patient 3 (a 20-year-oldwoman) was apprehensive about the sideeffects of the steroids and opted voluntarilyto have surgical correction. Patients 1 and 2were advised to have surgical correction be-cause they had already received long-terrasteroid therapy (>1 year) and, hence, wewere apprehensive of the steroid side ef-fects and did not want to restart long-terrasteroid therapy.

Adverse effects of steroid therapyThe complications encountered while the

patients received steroid therapy are dis-cussed briefly below and in Table 7.

Moon face. "Moon face" was a univer-sal phenomenon, ranging from a mild de-

TABLE 6. Recurrence of paralysis after cessation of steroid therulr\'.

Patientno. Sex

Diseaseclassification

Paralysis Interval hetween steroidwithdrawal and paralysisRight Left

M BE Ulnar,median

Ulnar 3 mos.

F 13L Median 3 mos.3 F BT Ulnar 6 mos.4 M BI_ Peroneal 3 mos.5 M 131. Peroneal 3 mos.6 M BT Peroneal 1^yr.

65, 3^Sugnunaran: Steroids for Paralvtic Dcformities^341

TABLE 7. Adverse e lects of steroid ibera/)v in 149 patients.

No. patients ele Remarks

Moon face 149 100%Steroid acne 89 60%Gastritis 6 4%Peptic ulcer 1 0.7% Two wks. after 30 mg dosage perlorat1ou

occurred necessitating surgery. Steroidthcrapy not continued aftersvard.

Diabetes 4 2.67% 'l entporary.Steroid cataract 5 3.3% lteyond 12 aios. of steroid therapy;

no blindness.Tuberculosis 3 2r/r Less than 6 mos. of steroid therapy.Cutaneous funga)

infection34 23`Ic

gree to complete rounding up of the face. Itwas embarrassing and distressing as well asof great concern to ali patients and their rel-atives. Reassurance was given. Mooningstarted 2 weeks after initiation of the steroidtherapy and always subsided after stoppingthe steroids.

Steroid acne. Steroid acne was thenext common side effect noticed. Ac-neiform eruptions occurred 1 month afterinitiation of the steroid therapy. They weredistributed over the face, chest, arms andscapulae. Patients felt distressed due to cos-metic implication. The eruptions subsidedafter steroid withdrawal.

Cutaneous funga) infection. Cuta-neous fungai infection was the next com-mon phenomenon observed. Plaques offungus lesions occurred mainly over thethighs, abdomen, chest and intertriginousarcas, such as the axillae and groin. The in-fection occurred with 3 months of takingprednisolone, but was controlled well withtopical clotrimazole.

Gastritis. Gastritis occurred occasion-ally at any stage of the steroid therapy, andwas neither related to the dosage nor to theduration of steroid therapy. It was relievedby antacids and ranitidine given orally and,therefore, we could continue the steroidtherapy without interruption.

Peptic ulcer. A 35-year-old woman de-veloped severe abdominal pain 2 weeks af-ter taking prednisolone 30 mg daily. Shewas found to have a perforated peptic ulcerat laparotomy. Steroid therapy was discon-tinued in this patient.

Diabetes. Diabetes occurred within 1-2 months of steroid therapy, with postpran-dial blood glucose leveis ran g ing between230 mg/100 ml and 630 mg/-100 ml. Dia-

betes was easily controlled with oral gliben-clamide. Diabetes was always temporary,and blood sugar leveis returned to normalwhen the dose of prednisolone was reducedto <30 mg daily.

Cataract. Cataract occurred among pa-tients who received more than 12 months ofprednisolone therapy. There was no blind-ness but the patients suffered from "glaredisabilities," disturbing their vision whenthey were outdoors in bricht sunlight. Thevisual difficulty was described as "foggy""cloudy," and "smoky" and vision dramati-cally improved after dusk. The clarity oftheir vision also improved if they wore sun-glasses during bright daylight. Vision im-proved spontaneously in one patient 6months after the cessation of the steroidtherapy.

Tuberculosis. Three patients developedpulmonary tuberculosis within 6 months ofprednisolone therapy. They were managedwell with antituberculosis drugs withoutstopping the steroid therapy. Ali three pa-tients (1 BT, 2 BL) had a type 1 reaction.

DISCUSSIONThe restoration of nerve function when

treated with prednisolone in patients suffer-ing from leprosy reactions has been knownfor the past 25 years. Clinicai and electro-physiological improvement by steroids wasdemonstrated in ENL patients by Sheskin,et al. and Magora, et al. in 1969 and 1970,respectively Naafs and Dagne andNaafs, et al. demonstrated significant im-provement in the neurological status of bor-derline leprosy patients suffering from re-versai reaction in 1976 and 1977, respec-tively (" ' 5 ). Again, in 1979 Naafs, et al.highlighted the significantly better neuro-

342^ International.Ioarnal o/ - Lcpros_v^ 1997

logical recovery by long-term steroid ther-apy when compared to short-term steroidtherapy ('''). This has been repeatedly con-firmed by Sri ni vasan, et al. in índia ( 27 ),Touw-Langendijk, et al. in Ethiopia ( 2 h),and Kiran, et al. in índia ("). [Some of thestudies reporting poor outcome of steroidtherapy could be due to an inadequatedosage or duration of prednisolone ( 15 . 23 ).1

We deliberately concentrated on patientswith visible deformity and gross disabilityso that what is possible as the best outcomein this category of patients could be discov-ered. It was indeed gratifying to see such ahigh proportion of good recovery from thenerve damage (ninar claw recovered 67%,thumb paralysis recovered 86%, foot droprecovered 78%). This recovery has greatlyreduced the need for these patients to un-dergo surgical intervention. We feel that thenumber of nerves studied in this series isquite large and, hence, the significam favor-able outcome should encourage many otherleprosy projects to boldly introduce steroidtherapy with a sufficiently large dose/dura-tion of prednisolone. However, the' smallproportion of the nerves showing sensoryrecovery is both surprising and disappoint-ing (ulnar nerve 46%; median nerve 42%).Further analysis reveals that while 67% ofthe ulnar nerves improved from a WHOgrade 2 disability (101 out of a total of151), only 68% of these improved nervesalso regained protective sensation (69 outof 101), leaving 32 of these improved handswith a WHO grade 1 disability. Similarly,86% of the paralyzed thumbs regainedgood muscle power and function (45 out of52), but only 49% of these nerves regainedprotective sensation to the median arca ofthese hands (21 out of 45), leaving 24 handswith a WHO grade I disability. In otherwords, when the total number of ninar andmedian nerves included for treatment areconsidered, at the end of the steroid treat-ment the majority of the nerves persistedwith a WHO grade 1 disability (56%, 113out of 203), which is of great concern to us.

The adverse effects, although few, indi-cate the need for great vigilance on the partof the physician and other team memberstreating these patients. We strongly recom-mend the installation of the necessary skillsand Iaboratory facilities so that problems

can be spotted early for Rompi remedy.Since the World Health Organiration(WHO) published in 1993 a practical guidefor the prevention of leprosy deformitieswith the reconunendation to trcat ali earlydisabi1ities (<1 year duration) with ade-quate steroids, more physicians should en-thusiastically start treating patients withsteroids to preveni permanent disability/de-formity ("). In our present study, we in-cluded only paralysis of 6 months or less.Now we plan to include patients with paral-ysis of up to 1 year to lind out the possiblebenefit of steroid therapy in these patients.

Our dosage and duration of prednisolonemore or less resemble the experience of Ja-cobson ( 12 ) working in a referral center inthe "First World," and that of Pfaltzgraff(='). Most BT patients require 4-9 monthsof steroid treatment, B13 patients 6-12months, and BL patients 6-24 months ( 23 ).

Muscle assessment by VMT, grading thestrength 0-5, and sensory testing usinggraded nylon monofilaments were found tobe useful tools for monitoring nerve func-tion and treatment needs to recognize im-provement/deterioration 50 that the opti-nuini dosage/duration of prednisolone canbe determined for each patient individually(4 '"' 7 . 9 . 17 . ' 9 and Bell, J. A. Semmes-Wein-stein monofilament testing for determin1ngcutaneous light touch/deep sensation. TheStar 44 [198-4] 8-11. Bell, J. A. Deformityand neural status hand screen. The Star 44[1985] 1-4. Brandsma, J. W. Nerve func-tion testing and evaluation-Part I. The Star43 [1984] 2-3. Brandsma, J. W. Nervefunction testing and evaluation-Part II. TheStar 44 [ 1984] 8-10).

CONCLUSIONSTreatment of paralytic deformities with

careful follow up over the past 5 years hasenabled us to draw some conclusions.

1. Steroid therapy of paralytic deformi-ties (< 6 months' duration) is very effectivein correcting most of the deformities and inrestoring function to the affected limbs.

2. We could not discover a standard regi-men which could be effective in ali patients.Each patient had to be treated individually,tailoring the dosage/duration of the steroiddepending upon the response of each pa-tient.

65, 3^Sio,t u ,utran: Steroids for Paral tic Ucformities^343

3. Voluntary muscle testing and sensorytesting (using graded nylon monotilaments)are excellent parameters for monitoring pa-tients and for providing opt mum treatmentand, hence, very practical for making reli-able, rapid and repeated assessments.

4. Serious side effects of corticosteroids,although few, do occur and, therefore, ut-most vigilance is essential to spot complica-tions as and when they occur so that reme-dial steps can be taken promptly. We feelthat suitable laboratory support and extratraining regarding the recognition of steroidcomplications are necessary (").

5. There appears to be no short cut for theprevention of disability (POD) in leprosy.The chemotherapy of leprosy (MDT) andPOD efforts are inseparable for anyone un-dertaking leprosy control because reactionsand verve damage do occur during treat-ment and after (whether treatment is MDTor any other forte of therapy) ( 2 .This calls for "propor" allocation of re-sources, always keeping in mind the needsof the patient. It involves providing techni-cal knowledge, imparting suitable skill inPOD, laboratory back up, suitable medi-cines for treating early disability, tacklingtreatment- related complications, etc. Thearbitrary allocation of resources leads to im-proper planning and results in suboptimaltreatment or sometimes total neglect of PODaspects. So, in most of the leprosy projects(both governmental and nongovernmental)the ultimate outcome is "Leprosy cured butnerves died," hence permanent deformity/disability. (This is somewhat similar to thesaying, "Operation successful but patientdied.") Hence, the "patient" must be consid-ered as important instead of trying to treatthe "bacteria" or the "disease" or the "dis-ability" in isolation.

6. Only one case required surgical de-compression (of an ulnar nerve) becauseshe developed perforation of the stomachwithin a short period of beginning low-dosesteroid therapy (30 mg daily for 2 weeks).Hence, the need for surgical intervention inneuritis appears to be extremely rire.

7. Further research is needed to identifythe reasons for the failure of a proportion ofthe nerves to recover, especially the lowerincidence of sensory recovery. New ap-proaches to further improve nerve function

is warranted since we feel that our expe-riente, along with that of other workers inthe past, is just a beginning in the directionof POD.

SUMMARYOne-hundred-forty-nine patients with

272 nerve paralyses, with visible deformityand gross disability, were prospectively fol-lowed up with steroid therapy. Out of 151ulnar paralyses, 101 recovered (67%). Outof 52 median nerve paralyses, 45 recovered(86%); out of 69 foot drops, 54 recovered(78%) for ai] overall improvement of 73%.Serious side effects were few. Hence,steroid therapy should be widely encour-aged for the treatment of early verve dam-age to prevent permanent deformity/disabil-ity, and vigilance in spotting complicationsof steroid therapy is emphasized.

RESUMENCientocuarenta y nueve pacientes coe lepra con 272

parálisis de nervios, con visible deformidad y severaincapacidad, fueron tratados CO!) terapia esteroidal ysupervisados durante y después del tratamiento. De las151 parálisis atuares, 101 se recuperaron (67%). De las52 parálisis de los nervios medianos, 45 se recuperaron(86% ); de 69 pies caídos, 54 se recuperaron (78%). Lamejoría global rue del 73%. Los efectos colateralesgraves fueron pocos. Con base en estos resultados, re-comendamos ampliamente la terapia esteroidal para eltratamiento del dano nervioso temprano con el lin deprevenir las deformaciones y las discapacidades per-manentes de la lepra. Se enfatiza también la necesidadde vigilar las posibles complicaciones de la terapia es-teroidal.

RÉSUMÉCcnt quarante-neuf malades de la Ièpre présentant

272 paralysies nerveuses, aves des délormités visibleset d'importantes incapacites, ont été suivis prospec-tivement lors de teor traitement par stéroides. Des 151paralysies cubitales, 101 ont recupere (67%). Des 52paralysies du nerf médian, 45 ont recupere (86%); des69 pieds tombants, 54 ont recupere (78%), donnantune amélioration globale de 73%. Les effets sec-ondaires importants ont été peu nombreux. Le traite-ment par stéroides devrait donc être largemetu encour-agé pour le traitement des lesions nervveuses precocesafin de prevenir les incapacites irréversibles, et on in-siste sur la vigilance nécessaire pour détecter les com-plications du traitement par stéroides.

Acknowlcdgntent. 1 thank the Superintendent, Sa-cred 1leart Leprosy Centre, for allowing me to conductthis study. Sincere thanks also go to my fellow physi-

344^ /menu/tio/ia/ ,lo urna/ n/ Le/)ro.S_V^ 1997

cians and to the physiotherapy technicians for theirGlose collaboration and cooperation. My deep gratitudegoes to the staff of the Medical Records I)epartnment forsupplying the records and data as and when retinire(!repeatedly. Special thanks go to Mr. S. Seshadri fortyping the mantiscripts and for secretarial assistance. 1ani very grateful to 1). I). Palande. M.S., and G. Rainu,M.D., for their constant encouragement, criticai com-ments and helpful Suggestions while conducting thisstudy as well as while preparing Chis papei.

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