KULIAH MORBUS HANSEN

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    LEPROSY( MORBUS HANSEN )

    Dr AMBAR RIALITA SpKK

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    DEFINITION :

    Chronic infection disease

    Mainly affects the skin,

    peripheral nerves, mucosaupper respiratory tract, reticuloendothelial system, eye, bone ,

    testis, except central nervoussystem.

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    AETIOLOGY :

    Mycobacterium leprae Curved rod shaped

    Acid Fast Bacilli

    Gram positive 1 8 long, 0,2 0,5

    Intracellular

    Prefer a growth temperature of less than37 C

    Can not be cultured

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    EPIDEMIOLOGY :

    Africa / Central Asia ---- World

    All ages ranging : early infancy to very

    old age 15 25 years old >>

    Both sex : Males : Females = 2 : 1

    Very long period : 3 5 years 1990 : 7 / 10,000 ----- 2000 : 1 / 10,000

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    TRANSMISSION:

    Contact person

    - Respiratory tract

    - Skin

    - Immunity

    - Virulence

    - Physical

    - Environment : - Biological

    - Social

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    The Microbiology of Leprosy :

    M. leprae can not be cultured

    Bacteriological examination :1. Diagnosis

    2. To get a cross spectrum

    3. Evaluations4. Prognosis

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    Material :

    Skin lession Ear lobe

    Nasal secretions / Nose blows

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    DIAGNOSIS of LEPROSY :

    If shown one or more of the following cardinal

    signs :

    1. Hipopigmented or reddish skin lession with

    definite loss of sensation2. Involvement of the peripheral nerves, as

    demonstrated by definite enlargement /thickening peripheral nerves with loss of

    sensation3. Skin smear positive for Acid Fast Bacilli

    Not Yet ----- Observation for 3 6 months

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    Measurement of the Bacterial Index :1. Diagnosis

    2. To get a cross the spectrum3. Therapy evaluation

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    Scoring the B I :

    Average Number ofAcid Fast Bacilli Bacterial Index( B I )

    1000 / field 6 +

    100 1000 / field 5 +

    10 100 / field 4 +

    1 10 / field 3 +

    1 10 / 10 fields 2 +

    1 10 / 100 fields 1 +

    0 / 100 fields 0

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    Morphological Index :

    The proportion or percentage ofregularly stained bacteria of the totalscored

    Ridley ( 1971 ) :

    - Regularly stained bacteria = Solidlybacteria

    - Irregularly stained bacteria =Fragmented + Granular bacteria

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    M I will be a guide in determining :

    1. Response to treatment

    2. Drug resistance

    3. Determining the infectiousness of apatient

    Treatment --- M I quickly

    B I slowly

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    If M I and then : possibility

    Irregularly

    Malabsorbtion

    Drug resistance

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    THE AIM OF CLASSIFICATION OFLEPROSY :

    1. Infectious / Non infectious

    2. Possible infectious3. Possible Disability

    4. Duration of treatment

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    CLASSIFICATION

    SPECTRUM

    Ridley &Jopling

    T T B T B B B L L L

    MADRID Indeter-minate

    Tuber-

    culoid

    Border-

    line

    Lepromatous

    WHO

    ( 1988 )

    Paucy Bacillar

    Leprosy

    Multi Bacillar

    Leprosy

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    CLINICAL LEPROSY

    Indeter-minate

    T T B T B B B L L L

    Infectious

    (-)

    Infectious

    (-)

    Infectious

    (-)

    Infectious Infectious Infectious

    Children 2 3lesion

    Satelit

    lesion

    Punch Out

    Hipopig-mented /

    pink : Face,back,buttock

    Macules hipopig-

    mented

    Macules :hipopig-

    mented /reddish

    Dimor-phous

    featuresand tendsymmetry

    Symetricalpapul,

    nodules

    Symetri-cal papul,

    nodules

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    CLINICAL LEPROSY

    Indeter-minate

    T T B T B B B L L L

    Loss ofsensation(-)

    (+) (+) (+) Sensoryloss,decreases

    sweating andhair growth

    Stockingand glovesanesthesia

    Nerveswollen (-)

    (+) (+) (+) Nervedamaged

    Nervedamaged

    Lepromin(-)

    (+) 4 (+) 3 (+) 1 -2 (-) (-)

    Acid FastBacilli (-)

    (-) (+) /

    (-)

    (+) 3 (+) 3 - 4 (+) 5 - 6

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    TREATMENT of LEPROSY :

    Multi Drug Therapy :

    - Prevention & treatment of resistance

    - As short a period of time fortreatment

    - To interrupt the transmission of the

    infection

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    W H O ( 1997 ) :

    Paucibacillary Single Lesion Leprosy

    (one lesion) Paucibacillary Leprosy (2-5 skin lesion)

    Multibacillary Leprosy (More than 5 skin

    lesion)

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    I. P B SINGLE LESION

    CHILD ADULT

    Rifampicin 300 mg Rifampicin 600 mg

    Ofloxacin 200 mg Ofloxacin 400 mg

    Minocycline 50 mg Minocycline 100 mg

    Dosage: Single Dose R O M

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    II. P B 2 5 SKIN LESION

    CHILD ADULT

    Monthly Treatment :

    Day 1 :

    Rifampicin 450 mg

    Dapsone 50 mg

    Daily :

    Day 2 28

    Dapsone 50 mg/daily

    Monthly Treatment :

    Day 1 :

    Rifampicin 600 mg

    Dapsone 100 mg

    Daily :

    Day 2 28

    Dapsone 100 mg/daily

    Duration of treatment : 6 - 9 Months

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    III. M B :

    CHILD ADULTMonthly treatment

    Day 1 :

    Rifampicin 450 mg

    Clofazimine 150 mg

    Dapsone 50 mg

    Daily 2 28 :Clofazimine 50 mg / daily

    Dapsone 50 mg / daily

    Monthly treatment

    Day 1 :

    Rifampicin 600 mg

    Clofazimine 300 mg

    Dapsone 100 mg

    Daily 2 28 :Clofazimine 50 mg / daily

    Dapsone 100 mg / daily

    Duration of treatment : 12 18 months

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    LEPROSY REACTIONS :

    Type 1 reaction : Reversal reaction

    Type 2 reaction : Erythema Nodosum

    Leprosum

    ( E N L reactions )

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    Manifestation of : 1. Reversal reaction

    Mild Severe

    Skin - Lesion become reddish& swollen

    - Same & rarely new skin lesion

    - Fever, malaise

    Nerve - Enlarge, painfull (-)- Nerve damage (-)

    - < 6 weeks

    - Enlarge, painfull (+)- Nerve damage, loss sensation

    - > 6 weeks

    Skin &

    Nerve

    - Lesion become reddish

    - Painful on peripheralnerves

    - < 6 weeks

    - Same

    - Ulceration- Swollen on hand & foot

    - Nerve enlarge

    -- > 6 weeks

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    2. E N L reaction

    MILD SEVERE

    Skin Skin nodules :- Tender reddish

    - Ulceration

    Skin nodules >>- Painful

    - Ulceration

    - Fever & malaise

    Nerve EnlargePainful (-)

    Nerve damage (-)

    EnlargePainful & swollen

    Nerve damage

    Eye Not involvement Painful

    Visual impairment

    Testis Swollen, Painful (-) Painful, Enlarge

    Skin, nerve,eye, testis

    Same - Same

    - Very painful

    - Fever

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    TREATMENT of REACTION :

    Prednisone : 30 80 mg / daily and thentappering off

    Continued M D T without interruption

    MILD REACTION :

    - Immobilization

    - Rest

    SEVERE REACTION :

    Reffered to the nearest hospital

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    MH tipe BB

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    MH tipe BL

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    MH tipe BT

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    MH indeterminate

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    MH tipe TT

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    MH tipe LL

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    MH tipe LL

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    Eritema Nodusum Leprosum(ENL)

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    Lepromatous leprosy. Note the diffuse infiltration of the face withleonine facies and madarosis.

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    Sequele of leprosy. The patient has madurosis, a saddle nose andblindness in the left eye. Courtesy of Evangeline Handog, M.D.

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