Upload
deborah-short
View
254
Download
0
Tags:
Embed Size (px)
Citation preview
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