Pathology and pathogenesis of predilective sites of nerve damage in leprous neuritis. Nerves in the arm and the face.

A very brief review of the literature on the clinicopathological aspects of leprosy is given; mainly through references. The salient features of the two main types of leprosy--tuberculoid and lepromatous--are presented in a Table. The surgical and pathological findings are briefly described and the pathogenesis of involvement of the facial nerve (a motor nerve) is discussed. On the basis of (i) the severe histopathologic changes (degeneration) of the most distal part of the zygomatic branch of the facial nerve (innervating the orbicularis oculi), with sparing of the roots of all branches and the trunk of the nerve; (ii) the concurrent loss of cutaneous sensations in the territory of the maxillary division of the trigeminal nerve (the region of the zygoma and the lower eyelid); and (iii) the close approximation or even anastomoses occurring between the ultimate branches of these two nerves, it is postulated that paralysis of orbicularis oculi occurs secondarily to the sensory nerve damage, i.e. due to spread of infection from the sensory branches of the trigeminal to the motor branches of the facial nerve. The surgical and pathological findings of the nerves in the arm, especially the ulnar and the median and their branches are described, in tuberculoid and lepromatous leprosy. The forms of nerve degeneration, the occasional axon regeneration, and the role of the Schwann cell in harbouring the bacilli, are illustrated. The lysosomal enzyme activity in the Schwann cells of nerve fibres, particularly of unmyelinated fibres which preferentially phagocytose the M. leprae, and their role, albeit not very successful, in degrading the bacilli and controlling the infection, are also stressed, through light and electronmicrographs. The constellation of secondary factors of the terrain operating to produce further damage to primarily diseased nerves, is discussed. These factors include indirect compression from unyielding fibroosseous tissues, minor traumata, stretching of the nerves, and their exposure to lower temperatures in subcutaneous tissues.