Pure Neuritic Leprosy: A Diagnostic Challenge To the Editor: The article “Leprosy: Forgotten in America?” by Drs Wu and Kim (November 2005) provides a great opportunity to recapitulate the essentials of a disease that is not common in the United States. The World Health Organization (WHO) and Ridley Jopling Classification are the 2 principal classification systems for leprosy.1 The WHO system is preferred by field workers for its simplicity. However, these 2 classifications fail to highlight pure neuritic leprosy as a clinical entity in the leprosy spectrum. The hallmark of leprosy lies in the demonstration of acid fast bacilli (AFB) in skin specimens. Pure neuritic leprosy manifests without any skin lesions, the patients having only signs and symptoms of peripheral nerve affection. The definitive diagnosis of pure neuritic leprosy can only be made by demonstration of AFB in nerve biopsy specimens or by a positive polymerase chain reaction test.2 It would thus be reasonable to consider leprosy in patients from endemic areas presenting with thickened nerves and peripheral nerve palsies, even without characteristic skin lesions.
—Prasanta Basak, MD Sound Shore Medical Center and NY Medical College New Rochelle, NY
2. Bezerra Da Cunha FM, Werneck MC, Scola RH, et al. Pure neural leprosy: diagnostic value of the polymerase chain reaction [Epub ahead of print]. Muscle Nerve. 2005;doi:10.1002/mus.20465.
C-Reactive Protein Not a Reliable Marker for CV Risk in the Elderly To the Editor: We read with interest the article “C-Reactive Protein: A New Tool for Cardiovascular Disease Risk Prediction,” by Dr Ansell (November 2005). A comment on the utility of C-reactive protein (CRP) as marker for cardiovascular (CV) disease in the elderly is appropriate.
In the past decade, several inflammatory markers have emerged as strong independent risk indicators for CV disease, and especially so CRP, because of the availability of standardized measurements of CRP and the large body of observational data available. Recent prospective observational information from the Framingham Heart Study, however, suggest that CRP provides no additional prognostic information beyond traditional risk factors.1 Furthermore, even if adults older than 65 years have a high rate of CV events, most epidemiologic data supporting the relationship between such events and CRP come from middle-aged patient cohorts.
Extrapolating data from middle-aged cohorts to the elderly is problematic for several reasons. First, aging by itself is associated with increased CRP levels because of many non–CV-related factors, including osteoporosis, sarcopenia, frailty syndrome, and functional decline.2 Second, as noted in the article, the American Heart Association and the Centers for Disease Control and Prevention recommend that CRP might be useful in those with a 10-year absolute risk of coronary heart disease (CHD) of 10% to 20%. The Framingham risk equation indicates that any person over the age of 65 has a 10-year CHD risk of at least 10%, so the guidelines would appear to apply to most older adults.
We acknowledge the relationship between inflammation and CV events. However, we consider that CRP is not a reliable prognostic tool for the prediction of CV events in the elderly. If such practice would become the standard of care, the financial cost and inherent risk of aggressive interventions would not be justified according to the data available today. Further studies are needed to find a more sensitive CV inflammatory marker with specific clinical utility in older adults.
—J. Roberto Duran, III, MD —Luis H. Eraso, MD Texas Tech University Health Science Center El Paso, Tex
1. Wilson PW, Nam BH, Pencina M, et al. C-reactive protein and risk of cardiovascular disease in men and women from the Framingham Heart Study. Arch Intern Med. 2005;165:2473-2478.
2. Kritchevsky SB, Cesari M, Pahor M. Inflammatory markers and cardiovascular health in older adults. Cardiovasc Res. 2005;66: 265-275.
Dr Ansell Replies: Many studies have documented the complexity of global risk assessment in the elderly, in whom the nature and weight of coronary heart disease (CHD) risk factors can differ from those of middle-aged and younger individuals. The prospective Cardiovascular Health Study of nearly 5000 patients older than 65 years without a history of myocardial infarction showed no relationship between either lipid levels or smoking to coronary risk.1 A single elevated C-reactive protein (CRP) measurement was associated with increased 10-year CHD risk, independent of other risk factors. CRP added to traditional cardiovascular (CV) risk assessment, especially in intermediate-Framingham-risk men and high-Framingham-risk women.
The supposition that non-CV conditions might limit the utility of CRP as a vascular risk factor is countered by multiple studies demonstrating significant increases in CHD risk in patients with rheumatoid arthritis2 and influenza,3 to cite 2 examples.
That said, the value of CRP in determining candidates for treatment who might be missed by traditional risk stratification does require validation by clinical trials. I agree that CRP should not be “standard of care” in CV risk assessment in the elderly or in any other group until such evidence is available. However, since 85% of CV events occur in the elderly—the group least likely to receive pharmacotherapies proven to reduce heart disease and stroke4—the real human and financial hazards for this population may lie in under-, not overestimation, of risk.
—Benjamin Ansell, MD, FACC David Geffen School of Medicine at UCLA Los Angeles, Calif
1. Psaty BM, Furberg CD, Kuller LH, et al. Traditional risk factors and subclinical disease measures as predictors of first myocardial infarction in older adults: the Cardiovascular Health Study. Arch Intern Med. 1999;159:1339-1347.
2. Solomon DH, Karlson EW, Rimm EB, et al. Cardiovascular morbidity and mortality in women diagnosed with rheumatoid arthritis. Circulation. 2003;107:1303-1307.
3. Smeeth L, Thomas SL, Hall AJ, et al. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med. 2004;351:2611-2618.
4. Fonarow GC, French WJ, Parsons LS, et al. Use of lipid-lowering medications at discharge in patients with acute myocardial infarction: data from the National Registry of Myocardial Infarction 3. Circulation. 2001;103:38-44.
Gluten-free Diet Worth the Expense for Patients with Celiac Disease To the Editor: We appreciate the timely and excellent case report, “Celiac Disease an Unrecognized Cause of Chronic Diarrhea” by Drs Borna and Glass (November 2005). Patients with celiac disease are constantly looking for ways to inform the medical community about the disease. Many doctors might be surprised at what we hear from newly diagnosed patients with celiac disease at our support group meetings. It is generally referred to as the “old run around with one test then another.” Or worse, patients are often being told, “It’s all in your head.”
As a celiac patient, I take exception to the comment in the article, “switching to a gluten-free diet is an expensive and often difficult life style” (page 23). Patients need to “know” for certain that they have celiac disease and not something else that could be worse, and that the disease has been confirmed by endoscopy. The sooner celiac disease can be confirmed, the sooner the patient can begin the healing process. I lost 40 pounds in 4 months before being diagnosed with the disease. The average is 11 years before an accurate diagnosis is made. It is now believed that 1 in 133 Americans is positive for the celiac disease antibody, making it the most prevalent autoimmune disease.
Maintaining a gluten-free diet is far better than continuing to have episodes and a host of health problems. Physicians should recommend to their patients to join a celiac support group to learn how to maintain a gluten-free diet. Patients will find that by joining a local chapter of the Celiac Sprue Association they can find help and excellent resources.
As for the cost of maintain a gluten-free diet—cost is not a consideration. It is far better to pay the fiddler and dance than to live in misery and be unhealthy.
—William E. Morris, CSA Region I Director Celiac Sprue Association Fox Valley Celiacs, Appleton, Wis celiacs@csaceliacs.org
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