Investigations for M. LepraeBacteriological examinationSkin smears:Made by slit and scrape method from the most active looking edge of skin lesion and stained with Ziehl-Neelsen method.

Reading of smears:Bacteriological index- Indicates density of leprosy bacilli (live & dead) in the smears and ranges from 0 to 6+Morphological index- It is the percentage of presumably living bacilli in relation to total number of bacilli in the smear

InvestigationsHistopathological examinationNerve biopsySweat function test Lepromin testAnimal Models: Armadillo, Thymectomised,

irradiated nude mice, Korean chipmunk etc.

Newer InvestigationsSerological assays: FLA-ABS, RIA, ELISAPGL, PCROther techniques: Chemical, Immunological,

Molecular biological, Bioluminescent techniques, Strain specific probes

Indications:- To confirm diagnosis in c/o inconclusive

histopathological/smear reports.- To distinguish between reaction and relapse - To demonstrate M. leprae or its components - To elicit strain differentiation for molecular

epidemiology - To detect drug susceptibility or resistance

MDT-WHOPaucibacillary leprosy (6 months)- Cap. Rifampicin (600 mg) monthly, supervised- Tab. Dapsone (100 mg) dailyMultibacillary leprosy (1 year) - Cap. Rifampicin (600mg) monthly, supervised - Cap. Clofazimine (300mg) monthly, supervised- Tab. Dapsone (100mg) daily- Cap. Clofazimine (50mg) daily

Blister packets for MDTEasy to use, handy and of convenient sizeProvide complete treatmentImprove clinical attendanceDrugs are better protected against moisture,heat

and accidental damageEnsures quicker dispensing of the drugsCan be dispensed by non medical person

Other RegimensROMComprises Rifampicin - 600 mgs, Ofloxacin - 400 mgs, Minocycline - 100mgSingle dose – single patch (WHO accepted)ROM -6 (Monthly for 6 months) - PaucibacillaryROM -12 (Monthly for 12 months) – Multibacillary

Newer Drugs / RegimensRO - 28Fluoroquinlones - Nalidixic acidMacrolides (Clarithromycin)Ansamycin-Rifabutin, RifapentineDihydrofolate reductase inhibitors-Brodimoprim, K-

130Fusidic acid Beta-lactam antibioticsCephalosporinsQuinolones (Pefloxacin and Sparfloxacin

Immunomodulatory DrugsDrugs- Levamisole, ZincAntigenically related mycobacteria- B.C.G vaccine,

M.leprae +B.C.G vaccine, Mycobacterium welchii vaccine, ICRC vaccine.

Other immunomodulators-Gamma interferons,interleukin

Lepra ReactionsAcute episodes or bouts of exacerbations occurring

in course of chronic disease Sudden increase in activity of existing lesions,

appearance of fresh lesions with or without constitutional symptoms

Type I reaction - all borderline cases (BT, BB,BL)Type II reaction - BL & LL cases

Precipitating factorsPhysiological conditions like pregnancyDrugs: anti-leprosy drugs, iodides Severe physical or mental stressInfections

Type I ReactionSub-types - Upgrading (Reversal) - DowngradingType IV hypersensitivity reaction.Existing lesions worsen/New lesions may appearNeuritis / Nerve abscessesSystemic disturbances: Unusual

Type I reaction - complicationsNeuritisDactylitis, edema of hands & feet, inflammation of

small joints of fingersCorneal anesthesia, ConjunctivitisSudden occurrence of claw hand, foot-drop, facial

palsy

Type II ReactionOccurs in BL and LL cases Type III hypersensitivity reactionErythema Nodosum Leprosum-crops of painful,

recurrent, erythematous, papulonodular lesions.Fever and malaiseIridocyclitis, episcleritis, epididymo-orchitis,

arthritis, neuritis, lymphadenitis

Type II Reaction - complicationsFrozen handLaryngitisNon-paralytic deformityPolyarthritis/ RA-like syndromeMultiple dactylitisLeucocytosis, Anaemia, raised ESRAlbuminuria/ nephrotic syndromeLiver/spleen enlargement Epididimytis/ orchitis, Testicular atrophy/sterilityGynaecomastia Adrenal gland hypofunction Eye involvement

Treatment of Lepra reactions

Principles of treatment Early initiation of treatment for reaction

Continuation / initiation of MDT

Removal of precipitating factor

Rest, physical and mental

Treatment modalitiesAnalgesicsCorticosteroidsAntimalarials ClofazimineThalidomideMiscellaneous – colchicine, zinc, cetrizine,

antimonialsSupportive management – for eye complications,

splints etc.

Deformities in leprosyPrimary: Are caused by the tissue reaction to infection with

M.Lepra e.g. leonine facies, flat-nose, claw hand.

Secondary: Occur as a result of damage to the anesthetic parts

of the body e.g. planter ulcers, corneal ulcers.

Grading of Deformities/Disabilities: WHO Classification

Grade 0No anaesthesia, no visible deformity or damage in hands and feet, or no problems in eye or no visual loss

Grade 1Anaesthesia present, but no visible deformity or damage, eye problems present but vision 6/60 or better.

Grade 2Visible deformity or damage present in hands or feet , and vision worse than 6/60

Primary deformities

Leonine FaciesLoss of eyebrows and eyelashes Depressed noseGynaecomastiaPalatal Perforation

Secondary deformities

Corneal ulcers and opacitiesPlantar ulcersPalmar ulcers and ulcers on tips of fingersResorptionCharcot joints

Deformities: Nerve damage

Claw hand (ulnar, median)Clawing of the toes (posterior tibial)Wrist-drop (radial)Foot-drop (lateral popliteal) Lagophthalmos, facial palsy (facial)

Trophic ulcer: stages

Threatened ulcer- slight puffiness and warmth in region of metatarsal head with associated tenderness

Concealed ulcer - Necrosis, blisters at the site of damage.

Open ulceration - Frank ulcerTypes of ulcers - Acute ulcer

Chronic ulcer Complicated ulcer

Prevention of deformities

Early detection of nerve damage

Adequate treatment of leprosy patient

Use of protective footwear

Adequate hydration of skin

Physiotherapy

Management of deformities

Education of patient regarding prevention of injuriesDaily examination of hands and feet and prompt

treatment for minor injuriesUsing adapted tools and appliances after training Reconstructive surgeryRehabilitation

Physiotherapy

Oil massage/Wax Therapy-Uses To make the skin soft and supple and loosen stiff

jointsAs a preliminary to exercisesTo strengthen muscles and keep joints mobileTo reduce pain in acute neuritis To stimulate innervated sweat glands to increase

blood flow

Physiotherapy

Splints-Indication Acute neuritisMobile deformities(to prevent fixed deformities),Fixed deformities(to correct the deformities). Splints usedFor radial neuritis-Static or dynamic wrist drop splintFor mobile deformity- Static or dynamic splintFor fixed deformity-Gutter splints,finger loops etc.

Physiotherapy

Electric stimulation - Uses To maintain the tone of denervated muscle Helpful in breaking post operative adhesions After tendon surgery could be used as a means of

documenting nerve damage and the progress of the nerve recovery with treatment.

Prevention and Control of leprosy

Prevention of leprosyEarly detection through survey and initiation treatmentFamilies of patients to be kept under surveillanceImmunoprophylaxis -Use of leprosy vaccinesImprovement in socio-economic conditions

Control of leprosyThree activities of a leprosy control unit Case detectionCase holding, including treatmentHealth education of public and patients

Prevention and Control of leprosy

Leprosy Organizations UNICEF LEPRA , DANIDA, SIDA ,CIDA ,Leprosy mission,

American leprosy mission, German leprosy relief association

Leprosy control ProgrammesNational leprosy control programme (NLCP)1954Triad of survey, education and treatment (S.E.T).National leprosy eradication programme (NLEP)1982

Prevention and Control of leprosy

National Leprosy Eradication Programme (NLEP),1982 Eradicate leprosy from the country by 2000 ‘Vertical’ health programme- In areas where

prevalence of leprosy is more than 5 per 1000.‘Horizontal’ programme- In areas where the

prevalence rate is less than 5 per 1000

NLEP

Three main units for programme operation:Basic tier- Survey, education and treatment unit,

leprosy control unit and urban leprosy control unit.

Second tier-District/zonal leprosy office

Third tier-Leprosy division of the state directorate of the health services.

Rehabilitation in leprosy

Rehabilitation: Physical and mental restoration of patients to normal

activities, so that they are able to assume their place in the home, society and industry.

Treatment of physical disabilityEducation of patient, family and publicRehabilitation in special homes or institutional

rehabilitationCommunity based rehabilitation

Thank you