I’ve been back working in leprosy this week. Today, a bunch of patients were referred here from a nearby hospital as suspected leprosy cases. Now, as you recall from earlier blog posts, leprosy is a disease caused by a bacteria that ultimately results in decreased to lost nerve function in peripheral nerves (but you knew that already, of course). So to diagnose a patient with leprosy a few things go down:
1. The patient will have a “skin smear” taken. In a skin smear, a little clump of tissue is clipped off the patient’s ear lobe. Its heated, stained, and looked at under the microscope. If there is massive amounts of mycobacterim leprae then voila! You’ve got yourself a diagnosis.
Here’s the hangup: if someone doesn’t have a positive skin smear that doesn’t clear them as being leprosy-free. In fact, many leprosy patients test negative on the skin smear since you have to have a pretty heavy load of bacteria to get them to show up in your earlobe. So there needs to be another way to look for leprosy.
Lillykutty, better known as Lily to her friends, is certainly one-of-a-kind. She is the head nurse in the leprosy ward, and she is a tiny woman with cracked teeth and thick glasses who has no qualms whatsoever about bossing people around and showing everyone how its done. “How what’s done?” you might ask. Ah, poking.
So today, Dr. Thirapureddy told me to help Lilly. As soon as I appeared in her doorway, she grabbed me by the arm and half walked, half dragged me outside the office and out into the sun. “Here!” She thrust a ball point pen into my hand. I looked over at the blank chart sitting on the wall nearby, thinking that I might be taking notes? She called the first patient out here into the open air foyer, also directing him into the sunlight. “Off!” she said in Telugu and this young guy flipped off his shirt and dropped his trousers right on command. Standing there in his boxer shorts, Lilly looked at me and then cocked her head towards him. “Now, poke!” she said sharply. “Gently, of course” she added as an afterthought.
We asked the young man to close his eyes, and gently poked his skin with the tip of our pens. “Can you feel that?” I asked him. He nodded.
“Where?” Lilly jumped in.
The young man pointed to his arm, about 8 inches away from where I had touched him with the pen. Lilly clicked her tongue. And we poked some more.
We poked all over his arms, poked all over his legs. We even poked parts of his face. Lilly carefully sketched in the chart the areas where the patient had no feeling. She also pointed out to me some dry patches of dry, hairless skin in the same areas that had no feeling. “You see,” she said, “no nerve function means he cannot sweat in these places. And no sweat means dry skin. So if his skin is very dry in the same place he has no feeling, it is from nerve damage. And that nerve damage is probably leprosy.”
So there you go: Leprosy Screening Method: Poke with pen, scan for dryness.
She finished the chart and handed it to me. I walked with the young man into the office to see Dr. Thirapureddy.
“How was it?” he asked.
“Good.” I held up my pen to show him, and slid the chart to the doctor.
He nodded knowingly and opened the chart, scanning it quickly. “Ah Lilly” he sighed “she is the best.”