Book review
Differential Diagnosis of Leprosy; A guide book for histopathologists. Charles K. Job and Sushil M. Chandi, Sasakawa Memorial Health Foundation, Tokyo, Japan, 2001.
Some will undoubtedly ask, “Is another book on the histopathology of leprosy necessary?” The answer is definitely, “YES,” because, as these authors point out in their preface, pathologists in non-endemic countries are increasingly requested to evaluate biopsies in which Hansen’s Disease may be considered. Even though the prevalence of leprosy worldwide has declined markedly after the implementation of MDT and numerous changes in record-keeping, the number of new cases detected annually has not declined. Increasing international travel brings patients to see physicians in many developed countries. The success of treatment encourages patients to seek help sooner, and so the pathologist is confronted with earlier and more subtle lesions. For these reasons a good guide to the histopathologic diagnosis of leprosy, and differentiation from other diseases, is of increasing importance at a time when expertise in the histopathology of Hansen’s Disease is increasingly in short supply. In addition, “the pathologist must think about HD when examining not only skin biopsies, but tissues from the nose, eyes, or testes” and, as they discuss later, biopsies of lymph nodes, bone marrow and liver. The diagnosis must be considered in patients who have been immunosuppressed for cancer treatment or from organ transplantation, and must also be differentiated from ‘atypical’ mycobacterial infection in patients with AIDS.
Drs. Job and Chandi bring to this challenge a great wealth of expertise and experience. The diversity of organs and tissues described is a definite asset of this Handbook since, as noted, pathologists are now called upon to consider HD in a wider array of more complex medical settings. The chapters on fundamental leprosy lesions are concise and well written and will be valuable as teaching aids for almost any medical audience.
The organization of information concerning the differential diagnosis of leprosy is very useful; the chapters on indeterminate, tuberculoid, and lepromatous leprosy are each followed by chapters considering lesions of conditions resembling each of these entities, respectively. The section on indeterminate leprosy is good but should probably be supplemented by references to recent literature, since this is (as noted in the preface) an increasingly frequent presentation and a very difficult problem for the pathologist. It is also an area of increasing research activity.
In a similar fashion, after a concise but thorough discussion of neuritis in leprosy they present a chapter considering other types of neuritis that may resemble it. This chapter is unfortunately more brief than would be desirable, since the differential diagnosis of interstitial neuritis can be a very challenging problem when leprosy is suspected but is not yet confirmed. The discussion of systemic involvement in leprosy is also brief but is presented with several figures illustrating lesions of the eye, oropharynx, and reticulo-endothelial system, as well as several other organs. This is a particularly valuable presentation in the context of 21st century medicine, when visceral involvement in leprosy has nearly been forgotten by many, and when atypical mycobacterioses are now observed in immuno-compromised individuals.
An important question that these authors have not addressed is the distinction between reaction and relapse in leprosy. Admittedly this is a very difficult question, and one that is usually submitted to referral centers and not handled by a general pathologist. Since the authors themselves constitute a referral center, however, their thoughts on this matter would be a valuable addition to the book.
The photomicrographs in this text are adequate; although the color reproduction is often not of high quality, this is preferable to having black and white figures. In addition, although this text is self-sufficient, the absence of a good basic bibliography for each chapter is unfortunate but understandable since the authors have prepared this as handbook rather than a textbook.
This succinct guide is filled with useful information that is directly applicable to patient care in both developed and underdeveloped countries. It is highly recomamended and should find a permanent place on the bookshelf of all pathologists who are asked to consider biopsies in which leprosy is suspected.
- David Scollard