60, 1^ Correspondence^ 89

of a novel 2, 3-diacyl-trehalose-2'-sulfate (SL-IV)antigen for case finding and diagnosis of leprosyand tuberculosis. Res. Microbiol. 141 (1990) 679-694.

2. DAFFE, M., LACAVE, C., LANEELLE, M.-A. and

LANEELLE, G. Structure of the major triglycosylphenol phtiocerol of Mycobacternon tuberculosis(strain Canetti). Eur. J. Iliochem. 167 (1987) 155-160.

3. DAVID, H. L., LEVY-FREBAuLT, V. and MOREL,

M. F. Mt'thodes de Laboratoire pour Microbacte-riologiv Clinique. Comission des Laboratories deReference at d'Expertise de l'Institut Pasteur, eds.Paris: Institut Pasteur, 1989.

4. DAvip, H. L., MAROJA, NI. F. and CRUAUD, P.Quantitative relationship between anti-PGL-I-specific antibody levels and the lepromin reaction.Int. J. Lepr. 59 (1991) 332-334.

5. FANDINHO, F. C. 0., SALEM, J. I., GONTLIO-FIL110,

P. P., MAROJA, M. F. and DAVID, H. L. Nlyco-bacterial flora of the skin in Leprosy. Int. J. Lepr.59 (1991) 569-575.

6. GRANGE, J. M. Environmental mycobacteria and13CG vaccination. Tubercle 67 (1986) 1-4.

7. LEMASSU, A., LANEELLE, M.-A. and DAFFE, M.Revised structure of a trehalose-containing gly-colipid of Mycobacterium tuberculosis. FEMS Mi-crobiol. Lett. 78 (1991) 171-176.

8. PAPA, F., CRUAUD, P. and DAVID, H. L. Antige-nicity and specificity of selected glycolipid frac-tions from Mycobacterium tuberculosis. Res. Mi-crobiol. 140 (1989) 569-578.

9. SALEM, J. I., GONTIJO-FIL110, P., LEVY-FREBAULT,V. and DAVID, H. L. Isolation and characteriza-tion of mycobacteria colonizing the healthy skin.Acta Leprol. 7 Suppl. 1 (1989) 18-20.

10. SALEM, J. I., MAROJA, NI. F., CARVALI10, F. F.,Limn, NI. 0. and FEUILLET, A. Mycobacteria oth-er than tubercle bacilli in sputum specimens frompatients in Manaus (Amazonia, 13razil). ActaAmazonica 19 (1989) 349-354.

11. STANFORD, J. L., SHIELD, M. J. and ROOK, G. A.W. How environmental mycobacteria may pre-determine the protective efficiency of 13CG. Tu-bercle 62 (1981) 55-62.

Subcorneal Pustular Dermatosis inType 2 Lepra Reaction

To THE EDITOR:A 46-year-old male was diagnosed to have

lepromatous leprosy in July 1990, based onclinical and histopathological features andby demonstration of acid-fast bacilli in slit-skin and earlobe smears. There were mul-tiple, shiny, infiltrated macules, plaques andnodules distributed bilaterally and sym-metrically on the trunk, limbs and face. Thebacterial index (BI) was 6+ (Ridley-Joplingscale) and the morphological index (MI) was40%. Routine laboratory tests on blood,urine and stools were normal. He was treat-ed with dapsone, rifampin and clofazimineas recommended by the World Health Or-ganization (WHO) for multibacillary lep-rosy. While on treatment he developed fea-tures of type 2 lepra reaction characterizedby intermittent high fever, anorexia, neu-ralgia and multiple erythema nodosum lep-rosum (ENL) lesions on the front of his legs,face and forearms. Along with these, he alsodeveloped numerous pin-head to pea-sized,superficial, oval flaccid pustules on his limbs,buttocks and chest. On the buttocks they

were arranged in a serpiginous pattern, whileon the arms they remained discrete (Figs. 1and 2). These pustules were independent ofthe ENL lesions. Each pustule dried up anddesquamated in 5 to 7 days leaving fainthyperpigmentation, but fresh crops of pus-tules continued to erupt along with the fea-tures of systemic toxicity. Blood tests doneat this time revealed leukocytosis (12,000cells/cubic mm) with a predominance ofneutrophils (70%) in the differential leu-kocyte count. ESR was 80 mm first hour(Westergren). Blood VDRL and tests forrheumatoid factor and lupus erythematosus(LE) cells were negative. Gram staining ofthe pus taken from the pustules did not showany bacterium, and its culture was sterile.Histopathological study of an intact pustuleshowed a subcorneal pustule containing nu-merous neutrophils (Fig. 3) and diffuse mac-rophage granuloma in the dermis with a clearsubepidermal zone. There were no histo-pathological features of vasculitis.

The dose of clofazimine was increased to300 mg daily, and he was also given ibu-

90^

International .lournal of Leprosy^ 1992

FIG. 3. I listopathology showing a subcorneal pus-

tule containing neutrophils (x450).

FIG. I. SCPD in a patient with lepromatous lep-rosy. Note numerous, tiny pustules on the forearms

and upper arms and thickening of the earlobes.

FIG. 2. Close up view of the pustules which are

oval, superficial and discrete.

profen and cloxacillin orally. But the leprareaction could not be controlled and thepustules and ENL lesions continued to erupt.Further, he developed paralysis of the ulnarnerve on the right side as evidenced by dif-ficulty to adduct the medial two fingers ofthe right hand. He was then given oral pred-nisolone 40 mg daily along with antileprosydrugs. Within 48 hr of starting steroid ther-apy, his fever subsided and the pustules andENL lesions started to regress. There wasrelief of his neuritic pain and, hence, thedose of prednisolone was gradually reducedand finally withdrawn in September 1991.There has been no recurrence of subcornealpustules or ENL lesions, and the patient isnow on antileprosy drugs alone.

The morphology and evolution of thepustules and their histopathological featuressuggested a diagnosis of subcorneal pustulardermatosis (SCPD) in our patient. The exactcause of SCPD is unknown. Recently, im-munologic mechanisms have been impli-cated in its pathogenesis. Krogh and Tonder(4 ) could detect antistratum corneum anti-bodies in two cases. Rarely SCPD may co-exist with known autoimmune diseases suchas systemic lupus erythematosus and rheu-matoid arthritis ( 5 ' 6 ). Bomb, et al. ( 2 ) re-ported it in a patient with lepromatous lep-rosy and suggested that the autoantibodiesto stratum corneum probably led to the de-velopment of SCPD in their patient.

In our patient, the development of SCPDsimultaneously with the signs and symp-toms of type 2 lepra reaction appears to bemore than a chance occurrence. In additionto the clearly demonstrated mechanism of

60, 1^ Correspondence^ 91

the Arthus phenomenon, a possible auto-immune mechanism also has been suggest-ed in the induction of reactions in lepro-matous cases ( 3). Many serological findingsconfirm that the markers of autoimmunediseases are present in high titers during lep-ra reaction. These include rheumatoid fac-tor, thyroglobulin antibody, and cold pre-cipitable protein. The clinical features of type2 lepra reaction often resemble autoaggres-sive connective tissue diseases ('). Thus, au-toimmunity plays a major role in the de-velopment of SCPD as well as leprareactions. So, the coexistence of SCPD andtype 2 lepra reaction, as observed in ourpatient, appears to be more than fortuitous.Subsidence of both SCPD and ENL lesionsfollowing corticosteroid therapy furthersupports the view that both are induced bythe same immunologic mechanism.

—K. Pavithran, M.D., D.V.D.Associate ProfessorDepartment of Dermatology and

VenereologvMedical College hospitalKottayam 686 008, India

REFERENCES

I. AZULAY, R. D. Autoaggressive hanseniasis. J. Am.Acad. Dermatol. 17 (1987) 1042-1046.

2. BUMB, R. A., KHULLAR, R. and MATHUR, N. K.Coexistence of subcorncal pustular dermatosis andlepromatous leprosy. Indian J. Dermatol. Venereol.Leprol. 51 (1985) 48-49.

3. DHARMENDRA and DESIKAN, K. V. Mechanisms ofreactions. In: Leprosy. Vol. 2, Dharmendra, ed.Bombay: Samant and Company, 1985, pp. 984-998.

4. KROCH, H. K. and TONDER, O. Subcorncal pustulardermatosis: pathogenetic aspects. Br. J. Dermatol.83 (1970) 429-434.

5. OLSEN, T. G., WRIGHT, R. C. and LESTER, A. 1.Subcorneal pustular dermatosis and crippling ar-thritis. Arch. Dermatol. 115 (1979) 185-188.

6. SAULSBURY, P. T. and KESLER, R. W. Subcornealpustular dermatosis and systemic lupus erythema-tosus. Int. J. Dermatol. 23 (1984) 63-64.

The Leprosy Game; a Health Education Tool

To THE EDITOR:

Interaction, incentive, disincentive, andrepetition are four factors the interplay ofwhich influences the outcome of a learningexperience in experimental as well as reallife situations. All games have a scoring sys-tem which acts both as an incentive and adisincentive to the players. Repetitive play-ing sessions reinforce the rules and tricksthat one needs to use in a winning strategy.Health education is an important factor inthe control of leprosy ( 2). Cognizance musttherefore be taken of the above principlesof learning during the design and deliveryof health education (').

I have designed an indoor game suitablefor health education purposes in leprosy (TheFigure). The principles used can be manip-ulated to modify the game to suit other ed-ucational purposes as well the training ofparamedical workers springs to mind im-

mediately and, with intricate details, theteaching of medical students. The game at-tempts to make health education an enjoy-able process.

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