Tim - Leprosy

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Background Information

Tim, a 32 year old Canadian agricultural consultant, who has lived most of his life in Nigeria, presents to your clinic for travel immunization advice prior to undertaking a contract in Kenya. He has never taken antimalarial prophylaxis. His facial features were somewhat coarse, and there was obvious nasal crusting and bleeding. Nodules were present on his cheeks and ears, and both earlobes were quite large. Tim has a martial arts tattoo on the back of his right hand which was done as a teenager in Nigeria.

Upon questioning, he related that, two years previously, his hands began to swell and that weakness and wasting of his left hand followed. Several 'spots' appeared on his forearms and scaly skin on his left shin. He later developed a painless sore on the sole of his left foot.

Physical examination revealed keratitis present in both eyes. Nodules similar to those on the face were also present on his forearms and thighs, and scaly macules were distributed over the right tibia. The ulnar, popliteal and tibial nerves and the left radial nerve were clearly palpable. The patient’s left hand was in an unusual claw-like posture at rest. Stocking and glove anaeasthesia was present distal to the mid-forearms, and distal to the mid-thighs. An ulcer was present on the sole of the left foot.

The patient had recently sustained an injury to his right hand - he caught his fingers closing the drawer of a filing cabinet. Apparently the drawer closed completely over two fingers but, while no bones were broken, Tim appears almost nonchalant about the injury.

PCL Learning Issues

It is not possible to address all these objectives in detail! Each student should pick 3-5 from the list below.


Generate a differential diagnosis that is compatible with Tim's signs and symptoms

Discuss what 'fits' and what does not

Briefly review treatment/management

What are some common infectious diseases in Nigeria/Kenya?

What are the immunization / health recommendations for travellers to Africa?

Briefly discuss contagiousness and infectiousness in regard to infectious disease. What determines each?


Tim's symptoms began two years ago but he delayed seeing a physician. Why?

What are some reasons for not seeing or delaying to a visit to a physician?

What determines a patient's attitude toward injury / illness / disease / treatment (ie. psychological, other factors)?


Discuss vaccination from a public health perspective. Is there a choice regarding vaccinations? If so, which are mandatory?

Discuss nosocomial / occupational infections and prevention, especially as this relates to physician practice

What are some social repercussions/reactions to communicable infections/diseases, e.g. TB, HIV/Aids, SARS, etc.

Do particular social / cultural groups (in Canada? in London?) have higher incidences of infectious disease?


Discuss international travel as a risk for epidemics / pandemics. How effective is screening?

Has the SARS crisis changed Canada's approach to epidemic prevention?

Discuss vaccine cost and coverage (residents/immigrants). Who pays for 'travel immunizations'?

Discuss western initiatives to prevent infectious diseases in poor countries. Is this altruism or 'medical imperialism'?