LEPROSY. Leprosy I Leprosy I Introduction Introduction Epidemiology Epidemiology Bacteriology...

LEPROSLEPROSYY

Leprosy ILeprosy I IntroductionIntroduction EpidemiologyEpidemiology BacteriologyBacteriology ClassificationClassification Clinical featuresClinical features

Leprosy IILeprosy II ReactionsReactions DiagnosisDiagnosis TreatmentTreatment RehabilitationRehabilitation

IntroductionIntroduction

Chronic granulomatous diseaseChronic granulomatous disease Caused by Caused by Mycobacterium lepraeMycobacterium leprae Mainly involves the peripheral nerves Mainly involves the peripheral nerves

and skin and skin Other organs may involve: Other organs may involve:

Mucosa of mouthMucosa of mouthUpper respiratory tractUpper respiratory tractEyesEyesBonesBonesTestes etcTestes etc

Historical aspect of leprosyHistorical aspect of leprosy

Oldest disease known to mankindOldest disease known to mankind

Word Word leper leper comes from Greek word “scaling” comes from Greek word “scaling”

Earliest description from India in 600BCEarliest description from India in 600BC Kustha Roga & attributed punishment or curse of GodKustha Roga & attributed punishment or curse of God

M. leprae M. leprae discovered in 1873 by Armauer Hansen discovered in 1873 by Armauer Hansen

Referred as Hansen’s diseaseReferred as Hansen’s disease

EpidemioloEpidemiologygy

DistributionDistribution

PrevalencePrevalence

Wide distribution world-wide Wide distribution world-wide

Out of 122 countries, only 2 countries Out of 122 countries, only 2 countries

still have to reach the elimination goalstill have to reach the elimination goal

Brazil and East TimorBrazil and East Timor

Leprosy status in Leprosy status in districtsdistricts

March 2010March 2010

59 Districts with Prevalence rate less than 1 per 10,000

16 Districts with PR more than 1 per 10,000

Cases under treatment Cases under treatment at the end of the year at the end of the year

Year 2004-2010Year 2004-2010

BacterioloBacteriologygy

Lepra bacilliLepra bacilli Obligate intracellular Gram positive and acid fast Obligate intracellular Gram positive and acid fast

bacillibacilli

Short, thick, pink stained rodsShort, thick, pink stained rods

Size: 5Size: 5 X 0.5 X 0.5

Arrangement: Single or in cigar-shaped bundles or Arrangement: Single or in cigar-shaped bundles or

in “globi”in “globi”

Affinity for Schwan cells & cells of R-E systemAffinity for Schwan cells & cells of R-E system

Cannot grow Cannot grow in vitroin vitro but can grow in but can grow in

mice and mice and

nine banded armadillosnine banded armadillos

The Leprosy BacteriaThe Leprosy Bacteria

Reservoir of infectionReservoir of infection

Main reservoir: Human being Main reservoir: Human being Lepromatous case> Non lepromatous Lepromatous case> Non lepromatous

casescases

Animal reservoirsAnimal reservoirs 9-banded armadillos9-banded armadillos ChimpanzeesChimpanzees Mangabey monkeysMangabey monkeys

Portal of exitPortal of exit

Major portal of exit: NoseMajor portal of exit: Nose LL cases harbour millions of LL cases harbour millions of M. leprae M. leprae

in their nasal mucosain their nasal mucosa

Ulcerated or broken skin of Ulcerated or broken skin of bacteriologically positive casesbacteriologically positive cases

Mode of transmissionMode of transmission

Transmission by inhalationTransmission by inhalation Droplet infectionDroplet infection

Transmission by contactTransmission by contact Skin to skin contact with infectious casesSkin to skin contact with infectious cases

Skin contact with soil & fomitesSkin contact with soil & fomites

Incubation periodIncubation period

Long incubation periodLong incubation period

Ranged: 6 months-40 years or moreRanged: 6 months-40 years or more

Average: 2-5 yearsAverage: 2-5 years

Environmental factorsEnvironmental factors

Humidity favors survival of Humidity favors survival of M. lepraeM. leprae in in environmentenvironment

M. lepraeM. leprae remain viable in remain viable in Dried nasal secretions for 9 daysDried nasal secretions for 9 days Moist soil at room temperature for 46 daysMoist soil at room temperature for 46 days

Overcrowding & lack of ventilation within Overcrowding & lack of ventilation within householdshouseholds

Social factorsSocial factors

Often called a “social disease”Often called a “social disease”

Social factors:Social factors: PovertyPoverty Poverty related circumstancesPoverty related circumstances

OvercrowdingOvercrowding Poor housingPoor housing Lack of personal hygieneLack of personal hygiene

CLASSIFICATION CLASSIFICATION OF OF

LEPROSYLEPROSY

IMPORTANCE OF IMPORTANCE OF CLASSIFICATIONCLASSIFICATION

Identify the infectious cases – Identify the infectious cases – Epidemiological importance - Principal Epidemiological importance - Principal targets for treatmenttargets for treatment

Identify the patients likely to develop the Identify the patients likely to develop the deformities and determine the prognosisdeformities and determine the prognosis

Frame the line of treatmentFrame the line of treatment Helpful in planning and evaluation of Helpful in planning and evaluation of

leprosy control activities leprosy control activities

Ridley-Jopling 1966 Ridley-Jopling 1966 (Research purposes)(Research purposes)

Most widely acceptedMost widely accepted Based on clinical, bacteriological, Based on clinical, bacteriological,

immunological and histopathological immunological and histopathological parameters, which divide the leprosy parameters, which divide the leprosy into five recognizable groupsinto five recognizable groups

Exhibits a spectral disease with Exhibits a spectral disease with varied clinical characteristics due to varied clinical characteristics due to varied host immune response to varied host immune response to bacillibacilli

RIDLEY-JOPLING RIDLEY-JOPLING Tuberculoid (TT)Tuberculoid (TT)

Borderline Tuberculoid (BT)Borderline Tuberculoid (BT)

Borderline Borderline (BB)Borderline Borderline (BB)

Borderline Lepromatous (BL)Borderline Lepromatous (BL)

Lepromatous (LL)Lepromatous (LL)

Indeterminate leprosyIndeterminate leprosy

Immunity in leprosyImmunity in leprosy

(-)

(+)

LLHD BLHD BBHD BTHD TTHD

TT -TT -paucibacillary paucibacillary state, few state, few lesions due to lesions due to high immune high immune responseresponse

LL - multibacillary state with multiple lesions due to low immune response

Contd..Contd..

Borderline forms (BB, BT and BL) lie Borderline forms (BB, BT and BL) lie between these two poles and are between these two poles and are immunologically unstable, tending to immunologically unstable, tending to move towards one of the polar formsmove towards one of the polar forms

Immunology & Immunology & bacteriology in leprosy bacteriology in leprosy

(spectrum)(spectrum)

Bacilli

Bacilli

(-)

(+)

(++)

(+++)(+++)

(++)

(+)

(-)

Immunity

Immunity

LLHD BLHD BBHD BTHD TTHD

Clinical Clinical FeatureFeature

onon

Skin Lesion Skin Lesion

Pauci Pauci bacillarybacillary

Leprosy Leprosy

PBPB

Multi Bacillary Multi Bacillary LeprosyLeprosy

MBMB

Including Including macular flat macular flat lesion, papules & lesion, papules & nodules nodules

1 to 5 lesion1 to 5 lesionAsymmetrical Asymmetrical distributiondistributionDefinite loss Definite loss of sensationof sensation

More than 5 More than 5 lesionlesionSymmetrical Symmetrical distributiondistributionLoss of Loss of sensationsensationmay or may not may or may not be presentbe present

WHO ClassificationWHO Classification

W H O classificationW H O classification(For chemotherapy – M. (For chemotherapy – M.

leprae)leprae)PaucibacillaryPaucibacillary Indeterminate - IIndeterminate - I Tuberculoid – TTTuberculoid – TT Borderline Borderline

Tuberculoid – BTTuberculoid – BT If any of these have If any of these have

positive bacterial positive bacterial index they should be index they should be classified as classified as multibacillary for multibacillary for multidrug therapymultidrug therapy

MultibacillaryMultibacillary Mid borderline – BBMid borderline – BB Borderline Borderline

Lepromatous – BLLepromatous – BL Lepromatous – LLLepromatous – LL All smear positive All smear positive

casescases

Clinical FeatureClinical Feature

Indeterminate LeprosyIndeterminate Leprosy Earliest & transitory stageEarliest & transitory stage Hypopigmented macule with indistinct marginsHypopigmented macule with indistinct margins

Indeterminate LeprosyIndeterminate Leprosy

If untreated may progress towards If untreated may progress towards

tuberculoid, borderline or tuberculoid, borderline or

lepromatous leprosy lepromatous leprosy

Spontaneous regression may occurSpontaneous regression may occur

Usually negative for skin smear for Usually negative for skin smear for

AFBAFB

TUBERCULOID LEPROSYTUBERCULOID LEPROSY Single or a few lesionsSingle or a few lesions Asymmetrically distributed on trunk and limbsAsymmetrically distributed on trunk and limbs Sharply defined, dry, erythematous or Sharply defined, dry, erythematous or

hypopigmented, anesthetic macules or plaqueshypopigmented, anesthetic macules or plaques One or two nerves may be enlarged near the One or two nerves may be enlarged near the

skin lesionskin lesion SS for AFB: NegativeSS for AFB: Negative Lepromin test may be strongly positiveLepromin test may be strongly positive

Tuberculoid LeprosyTuberculoid Leprosy

Borderline TuberculoidBorderline Tuberculoid Single or multiple, asymmetrically Single or multiple, asymmetrically

distributeddistributed Macules or plaques of variable sizes with Macules or plaques of variable sizes with

well-defined margins & satellite lesionswell-defined margins & satellite lesions Peripheral nerves enlarged asymmetricallyPeripheral nerves enlarged asymmetrically Sensation: hyposthesiaSensation: hyposthesia SS for AFB: may be seenSS for AFB: may be seen Lepromin test may be weakly positiveLepromin test may be weakly positive

Borderline Borderline tuberculoidtuberculoid

Borderline BorderlineBorderline Borderline

Multiple erythematous macules & plaquesMultiple erythematous macules & plaques Various sizes and shapes with punched out Various sizes and shapes with punched out

centre and ill defined slopping outer margincentre and ill defined slopping outer margin Tend to be symmetricalTend to be symmetrical Nerves may be asymmetrically enlargedNerves may be asymmetrically enlarged Sensation:+/-Sensation:+/- SS for AFB: seen +/-SS for AFB: seen +/- Lepromin test-usually negative, may be Lepromin test-usually negative, may be

doubtfuldoubtful

Borderline BorderlineBorderline Borderline

Borderline Borderline LepromatousLepromatous

Numerous, symmetrically distributed Numerous, symmetrically distributed lesionslesions

Hypopigmented or erythematous irregularly Hypopigmented or erythematous irregularly shaped maculopapules, infiltrative nodules, shaped maculopapules, infiltrative nodules, or plaques, with smooth surfaces & ill or plaques, with smooth surfaces & ill defined borders, sloping outwardsdefined borders, sloping outwards

Nerves may be symmetrically or Nerves may be symmetrically or asymmetrically enlarged asymmetrically enlarged

Sensation:+/- Sensation:+/- SS for AFB: numerous seenSS for AFB: numerous seen Lepromin test -negativeLepromin test -negative

Borderline LepromatousBorderline Lepromatous

Lepromatous LeprosyLepromatous Leprosy Numerous macules, plaques, nodules or Numerous macules, plaques, nodules or

diffusely infiltrated lesions, symmetrically diffusely infiltrated lesions, symmetrically

distributed on face, trunk and extremities distributed on face, trunk and extremities

with ill-defined margin which may be with ill-defined margin which may be

slightly hypopigmented or erythematousslightly hypopigmented or erythematous Symmetrical nerve enlargement is seen Symmetrical nerve enlargement is seen Sensation: normal Sensation: normal SS for AFB: numerous seenSS for AFB: numerous seen Lepromin test - negativeLepromin test - negative

Lepromatous LeprosyLepromatous Leprosy

Ear lobes thickensEar lobes thickens

diffuse thickening of the skin, with loss of hair (eyebrows and eyelashes). .

saddle nose deformitysaddle nose deformity

leonine faciesleonine facies

General Findings

Eye The anterior chamber can be invaded in LL with resultant glaucoma and cataract formation. Iritis/Iridocyclitis

Testes May be involved in LL with resultant hypogonadism.

Systemic involvement – Respiratory, Bones, Kidneys, Lymph glands, etc.

Nerve Nerve involvement in involvement in

LeprosyLeprosy

M. Leprae M. Leprae : superficial nerve : superficial nerve involvementinvolvement

W Britton

Nerve InvolvementNerve Involvement

Neural involvement leads to muscle weakness, muscle atrophy, severe neuritic pain, and contractures of the hands and feet.

Ulnar nerve commonly involved

Examination for sensations of hot and cold , pain and fine touch

Nerve palpationNerve palpation

FaceFace

Facial NerveFacial Nerve

LagophthalmosLagophthalmos

Facial droopFacial droop

Trigeminal NerveTrigeminal Nerve

Corneal anaesthesiaCorneal anaesthesia

Nerve damage – Nerve damage – upper limbupper limb

UlnarUlnar SS Anaesthesia medial 1/3 Anaesthesia medial 1/3 palmpalm

MM Claw ring and little Claw ring and little fingersfingers

AA Dryness medial 1/3 Dryness medial 1/3 palmpalm

Median Median SS Anaesthesia lateral 2/3 Anaesthesia lateral 2/3 palmpalm

MM Claw mid + index + loss Claw mid + index + loss OppositionOpposition

AA Dryness lateral 2/3 palm Dryness lateral 2/3 palm

RadialRadial SS Anaesthesia dorsum Anaesthesia dorsum handhand

MM Wrist drop Wrist drop

Nerve damage – lower Nerve damage – lower limblimb

Lateral (common) PoplitealLateral (common) Popliteal

Foot dropFoot drop

Posterior TibialPosterior Tibial

SS Sole anaesthesia Sole anaesthesia

MM Claw Toes Claw Toes

AA Dryness in sole Dryness in sole

Classification of leprosyClassification of leprosy