LEPROSY Leprosy I Introduction Epidemiology Bacteriology Classification Clinical features Leprosy II Reactions Diagnosis Treatment Rehabilitation Introduction Chronic granulomatous disease Caused by Mycobacterium leprae Mainly involves the peripheral nerves and skin Other organs may involve: Mucosa of mouth Upper respiratory tract Eyes Bones Testes etc Historical aspect of leprosy Oldest disease known to mankind Word leper comes from Greek word “scaling” Earliest description from India in 600BC Kustha Roga & attributed punishment or curse of God M. leprae discovered in 1873 by Armauer Hansen Referred as Hansen’s disease Epidemiology Distribution Prevalence Wide distribution world-wide Out of 122 countries, only 2 countries still have to reach the elimination goal Brazil and East Timor Leprosy status in districts March 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 at the end of the year Year 2004-2010 Bacteriology Lepra bacilli Obligate intracellular Gram positive and acid fast bacilli Short, thick, pink stained rods Size: 5 X 0.5 Arrangement: Single or in cigar-shaped bundles or in “globi” Affinity for Schwan cells & cells of R-E system Cannot grow in vitro but can grow in mice and nine banded armadillos The Leprosy Bacteria Reservoir of infection Main reservoir: Human being Lepromatous case> Non lepromatous cases Animal reservoirs 9-banded armadillos Chimpanzees Mangabey monkeys Portal of exit Major portal of exit: Nose LL cases harbour millions of M. leprae in their nasal mucosa Ulcerated or broken skin of bacteriologically positive cases Mode of transmission Transmission by inhalation Droplet infection Transmission by contact Skin to skin contact with infectious cases Skin contact with soil & fomites Incubation period Long incubation period Ranged: 6 months-40 years or more Average: 2-5 years Environmental factors Humidity favors survival of M. leprae in environment M. leprae remain viable in Dried nasal secretions for 9 days Moist soil at room temperature for 46 days Overcrowding & lack of ventilation within households Social factors Often called a “social disease” Social factors: Poverty Poverty related circumstances Overcrowding Poor housing Lack of personal hygiene CLASSIFICATION OF LEPROSY IMPORTANCE OF CLASSIFICATION Identify the infectious cases – Epidemiological importance - Principal targets for treatment Identify the patients likely to develop the deformities and determine the prognosis Frame the line of treatment Helpful in planning and evaluation of leprosy control activities Ridley-Jopling 1966 (Research purposes) Most widely accepted Based on clinical, bacteriological, immunological and histopathological parameters, which divide the leprosy into five recognizable groups Exhibits a spectral disease with varied clinical characteristics due to varied host immune response to bacilli RIDLEY-JOPLING Tuberculoid (TT) Borderline Tuberculoid (BT) Borderline Borderline (BB) Borderline Lepromatous (BL) Lepromatous (LL) Indeterminate leprosy Immunity in leprosy LL - multibacillary state with multiple lesions due to low immune response (+) TT -paucibacillary state, few lesions due to high immune response (-) LLHD BLHD BBHD BTHD TTHD Contd.. Borderline forms (BB, BT and BL) lie between these two poles and are immunologically unstable, tending to move towards one of the polar forms (+++) Immunology & bacteriology in leprosy (spectrum) (+++) Bacilli (++) Bacilli Immunity (++) Immunity (+) (+) (-) (-) LLHD WHO Classification Clinical Feature on Skin Lesion Pauci bacillary Leprosy PB Including macular flat 1 to 5 lesion lesion, papules & nodules Asymmetrical distribution Definite sensation loss of Multi Bacillary Leprosy MB More than 5 lesion Symmetrical distribution Loss of sensation may or may not be present W H O classification (For chemotherapy – M. leprae) Paucibacillary Indeterminate - I Tuberculoid – TT Borderline Tuberculoid – BT If any of these have positive bacterial index they should be classified as multibacillary for multidrug therapy Multibacillary Mid borderline – BB Borderline Lepromatous – BL Lepromatous – LL All smear positive cases Clinical Feature Indeterminate Leprosy Earliest & transitory stage Hypopigmented macule with indistinct margins Indeterminate Leprosy If untreated may progress towards tuberculoid, borderline or lepromatous leprosy Spontaneous regression may occur Usually negative for skin smear for AFB TUBERCULOID LEPROSY Single or a few lesions Asymmetrically distributed on trunk and limbs Sharply defined, dry, erythematous or hypopigmented, anesthetic macules or plaques One or two nerves may be enlarged near the skin lesion SS for AFB: Negative Lepromin test may be strongly positive Tuberculoid Leprosy Borderline Tuberculoid Single or multiple, asymmetrically distributed Macules or plaques of variable sizes with welldefined margins & satellite lesions Peripheral nerves enlarged asymmetrically Sensation: hyposthesia SS for AFB: may be seen Lepromin test may be weakly positive Borderline tuberculoid Borderline Borderline Multiple erythematous macules & plaques Various sizes and shapes with punched out centre and ill defined slopping outer margin Tend to be symmetrical Nerves may be asymmetrically enlarged Sensation:+/- SS for AFB: seen +/- Lepromin test-usually negative, may be doubtful Borderline Borderline Borderline Lepromatous Numerous, symmetrically distributed lesions Hypopigmented or erythematous irregularly shaped maculopapules, infiltrative nodules, or plaques, with smooth surfaces & ill defined borders, sloping outwards Nerves may be symmetrically or asymmetrically enlarged Sensation:+/SS for AFB: numerous seen Lepromin test -negative Borderline Lepromatous Lepromatous Leprosy Numerous macules, plaques, nodules or diffusely infiltrated lesions, symmetrically distributed on face, trunk and extremities with ill-defined margin which may be slightly hypopigmented or erythematous Symmetrical nerve enlargement is seen Sensation: normal SS for AFB: numerous seen Lepromin test - negative Lepromatous Leprosy Ear lobes thickens diffuse thickening of the skin, with loss of hair (eyebrows and eyelashes). saddle nose deformity leonine 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 involvement in Leprosy M. Leprae : superficial nerve involvement W Britton Nerve 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 palpation Face Facial Nerve Lagophthalmos Facial droop Trigeminal Nerve Corneal anaesthesia Nerve damage – upper limb Ulnar S Anaesthesia medial 1/3 palm M Claw ring and little fingers A Dryness medial 1/3 palm Median S Anaesthesia lateral 2/3 palm M Claw mid + index + loss Opposition A Dryness lateral 2/3 palm Radial S Anaesthesia dorsum hand M Wrist drop Nerve damage – lower limb Lateral (common) Popliteal Foot drop Posterior Tibial S Sole anaesthesia M Claw Toes A Dryness in sole Classification of leprosy