LEPROSY

Ali M. GargoomAli M. GargoomMB,ChB. MSc. MD

Assistant Professor Assistant Professor

Department of DermatologyDepartment of Dermatology

Faculty of Medicine.Faculty of Medicine.

Benghazi University Benghazi University

An ancient, chronic infectious An ancient, chronic infectious disease caused by disease caused by Mycobacterium leprae Mycobacterium leprae . . It principally affects the skin It principally affects the skin

andand peripheral nerves.peripheral nerves.

Leprosy (Leprosy (Hansen’s Hansen’s diseasedisease))

M. leprae is discovered by Hansen from Norway in 1873

BACTERILOGYBACTERILOGYThey are straight or slightly curved rod-like bacilli. They are straight or slightly curved rod-like bacilli. It measure about (It measure about (3 x 0.5 micrometer)3 x 0.5 micrometer)..

Weakly Gram +ve & stained by Ziehl-Neelsen method.Weakly Gram +ve & stained by Ziehl-Neelsen method.

M. leprae is an obligate intracellular acid-fast bacillus.M. leprae is an obligate intracellular acid-fast bacillus.

Has never been grown in artificial media.Has never been grown in artificial media.

It grow in nine - banded armadillo.It grow in nine - banded armadillo.

The nine - banded armadillo

BACTERILOGY BACTERILOGY (cont.)(cont.)

Replicate very slow (every 12 days once).Replicate very slow (every 12 days once). Has an affinity for macrophages & Schwann Has an affinity for macrophages & Schwann

cell.cell.

It grows best at 27-30 C, hence its predilection It grows best at 27-30 C, hence its predilection for cooler areas of the body. for cooler areas of the body.

Skin, peripheral nerves, anterior chamber of Skin, peripheral nerves, anterior chamber of the eye, upper respiratory tract & testes. the eye, upper respiratory tract & testes.

Mode of Mode of transmissiontransmission The exact rout of transmission is not fully knownThe exact rout of transmission is not fully known. .

The spread of leprosy is believed to be via nasal discharge (Droplets (Droplets infection).infection).

Every 1 cc of nasal secretion contains 1- 2millions lepra bacilli

Other modes of Other modes of transmissionstransmissions

1. Contact through the skin (rare). 2. Arthropod-born infection (rare).3. Through placenta and milk.

Leprosy is not STD or directly inherited. Leprosy is not STD or directly inherited.

EpidemiologyEpidemiology Leprosy is a disease of developing countries but affects

all races.

Registered cases of leprosy have fallen from 5.4 millions worldwide in 1985 to below one million in 1998.

80% of the worldwide cases are found in five countries, namely India, Mynamar, Indonesia, Brazil and Nigeria.

Epidemiology Epidemiology (cont.)(cont.)

The incubation period range from 2 -5 years.The incubation period range from 2 -5 years. Males appear to be twice common than Males appear to be twice common than

females.females.

Bimodal age (10-14years & 35-44 years).Bimodal age (10-14years & 35-44 years).

Children are more susceptible to disease.Children are more susceptible to disease.

Genetic factors, e.g. HLA markers may Genetic factors, e.g. HLA markers may determine the type of leprosy which the patient determine the type of leprosy which the patient develops .develops .

0

1000000

2000000

3000000

4000000

5000000

6000000

Global Trend in Registered CasesGlobal Trend in Registered Cases

Predisposing or risk factorsPredisposing or risk factors

1.1. Residence in an endemic area.Residence in an endemic area.

2.2. Having a blood relative with leprosy.Having a blood relative with leprosy.

3.3. Poverty (malnutrition).Poverty (malnutrition).

4.4. Contact with affected armadillo.Contact with affected armadillo.

Classification & Clinical Classification & Clinical PresentationPresentation

Jopling Classification

Based on Host Immunity

TT BL LL

BT BB BL

Classification & Clinical Classification & Clinical PresentationPresentation

WHO Classification

Based on Bacterial Load

Paucibacillary Multibacillary

Slit Skin Smear

Positive Negative

LEPROSY

Paucibacillary (PB) Multibacillary (MB)

Indeterminate Leprosy (IL)

Tuberculoid Leprosy (TL)

Borderline Tuberculoid (BT)

Borderline Borderline (BB)

Borderline Lepromatous(BL)

Lepromatous Leprosy (LL)

CLINICAL PICTURECLINICAL PICTURE

Indeterminate Leprosy

Tuberculoid Leprosy

Borderline Leprosy

BT BB BL

Lepromatous Leprosy

TT BT BB BL LL

Skin Lesions

No. of Bacilli

Slit skin test

Immunity

Clinical spectrum of leprosy

Indeterminate Leprosy Indeterminate Leprosy (IL)(IL)

Usually single (multiple) macule / patche.Usually single (multiple) macule / patche. Hypopigmented or faintly erythematous.Hypopigmented or faintly erythematous. Sensation normal but sometimes imparied.Sensation normal but sometimes imparied. The peripheral nerves normal.The peripheral nerves normal. Slit skin smear negative. Slit skin smear negative.

Indeterminate leprosy :Hypopigmented patch, sensation normal, no palpable peripheral nerve and slit skin smear negative.

Tuberculoid Leprosy Tuberculoid Leprosy (TL)(TL)

Usually single but may be few (Usually single but may be few (<<5).5). Hypopigmented / erythematous plaque.Hypopigmented / erythematous plaque. Varying in size from few Varying in size from few MMMM to several to several CMCM.. Well defined borders.Well defined borders. Sensation markedly imparied.Sensation markedly imparied. Enlarged peripheral nerve.Enlarged peripheral nerve. Slit skin smear negativeSlit skin smear negative

Tuberculoid leprosy: Two hypopigmented patches, hypoastheticwell defined borders, palpable peripheral nerve and SSS negative.

Tuberculoid Leprosy: Annular, erythematous, anasthetic patch with well defined and raised borders and SSS Negative.

Borderline Leprosy Borderline Leprosy (BL)(BL)(BT,BB,BL)(BT,BB,BL)

Few / many asymmetrical patches. Partly well-defined borders. Sensory impairments range from slight

to marked. Slit skin smear usually positive. P. nerves asymmetrically enlarged.

BTBT BBBB BLBL

Lesion noLesion no . . FewFew(<5)(<5) Some Some Many Many

Lesions bordersLesions borders WellWell LessLess RoughlyRoughly

Sensory Sensory impairmentimpairment

MarkedMarked ModerateModerate SlightSlight

Distribution of Distribution of skin lesionsskin lesions

Asymmetrical Asymmetrical Asymmetrical Asymmetrical Roughly Roughly symmetricalsymmetrical

Peripheral Peripheral nervesnerves

Asymmetrical Asymmetrical Asymmetrical Asymmetrical Less Less asymmetrical asymmetrical

Type of leprosyType of leprosy PaucibacillaryPaucibacillary MultibacillaryMultibacillary MultibacillaryMultibacillary

Slit skin smearSlit skin smear - - / 1+/ 1+ 22 / + / +33++ 4+4+

Note: Sometimes patients may have BT/BB or BB/BL or BL/LL

Borderline Tuberculoid Leprosy: Well-defined large anaesthetic patcheswith satellite lesions. SSS Negative.

Borderline Borderline Leprosy: Less defined, asymmetrically distributed hypoaesthetic patches. SSS positive.

Borderline Lepromatous Leprosy: Numerous, hypoaesthetic almost symmetrically distributed patches . SSS positive.

Lepromatous Leprosy (LL)Lepromatous Leprosy (LL)

Very numerous ill defined lesions.Very numerous ill defined lesions. (macules, patches, papules,and nodules).(macules, patches, papules,and nodules). Symmetrically distributed allover the bodySymmetrically distributed allover the body Loss of eyebrows and eyelashes.Loss of eyebrows and eyelashes. Leonina facies.Leonina facies. No sensory impairments in lesions .No sensory impairments in lesions . Peripheral nerves symmetrically enlarged.Peripheral nerves symmetrically enlarged. Slit skin smear always positive.Slit skin smear always positive.

Lepromatous Leprosy: Leonine Face

Diagnosis of Diagnosis of LeprosyLeprosy

1. Clinical Examination.2. Slit Skin Smear.3. Skin Biopsy.

11..Clinical Clinical examinationexamination::

What are the cardinal skin signs of leprosyWhat are the cardinal skin signs of leprosy? ?

1. Hypopigmented or erythematus patch / plaque

2. Complete / partial loss of sensation.3. Thickening of peripheral nerves.

22..Slit Skin SmearSlit Skin Smear

Simple and valuable test.Simple and valuable test. It is needed for diagnosis.It is needed for diagnosis. Monitor the progress of the Monitor the progress of the

treatment.treatment.

Slit Skin Smear (method). Pinch the site tight.Pinch the site tight. Incise.Incise. Scrape & collect Scrape & collect

materialmaterial Smear on a slide.Smear on a slide. Air dry & fix.Air dry & fix. Stain (Z-N method)Stain (Z-N method)

Slit Skin Smear Slit Skin Smear (site)(site).. Ear lobe. Forehead. Gluteal region. Active edge of patch.

Slit Skin Smear (Reporting the smear).

Bacteriological indexBacteriological index00 – – no bacilli in 100 fieldsno bacilli in 100 fields

11 :+ :+1-101-10 bacilli in 100 fieldsbacilli in 100 fields22 :+ :+1-101-10 bacilli in 10 fieldsbacilli in 10 fields

33 :+ :+1-101-10 bacilli in 1 fieldbacilli in 1 field44 :+ :+10-10010-100 bacilli in 1 fieldbacilli in 1 field

55 :+ :+100-1000100-1000 in 1 fieldin 1 field66< :+< :+10001000 bacilli field (globi)bacilli field (globi)..

Morphological indexMorphological indexThe percentage of living bacilli to the total number of bacilli in the smear.

Skin Biopsy

Tuberculoid Leprosy (TT).

Histologically TT resemble tuberculosis.

Characterized by tuberculoid granuloma, made up of epitheloid cell in the center surrounded by abundant

Langhans giant cells, lymphocytes and foci of caseating necrosis.

No acid-fast bacilli

Lepromatous Leprosy (LL) Characterized by diffuse infiltration of Characterized by diffuse infiltration of

foamy macrophages in the dermis.foamy macrophages in the dermis. Acid-fast bacill are present inside these Acid-fast bacill are present inside these

foamy cells eighter singly or in globi.foamy cells eighter singly or in globi. There is free subepidermal zone (grenz There is free subepidermal zone (grenz

zone).zone). Lymphocytes are scanty and giant cells Lymphocytes are scanty and giant cells

typically absent.typically absent.

TREATMENT

LEPROSY IS A CURABLE DISEASELEPROSY IS A CURABLE DISEASE

Leprosy treatment is simple, available Leprosy treatment is simple, available free & the drugs are supplied in backs free & the drugs are supplied in backs that contain correct dose for 4 weeks.that contain correct dose for 4 weeks.

All you have to do is decide which course All you have to do is decide which course of treatment the patient needs and make of treatment the patient needs and make

sure that he take it regularlysure that he take it regularly. .

Drugs used in Leprosy treatmentWhat are the three commonly used What are the three commonly used

drugs?drugs?

1.1. Dapson.Dapson.2.2. Rifampicine.Rifampicine.3.3. ClofazimineClofazimine..

The combination of these three drugs isThe combination of these three drugs is known as Multi Drug Therapy (MDT)known as Multi Drug Therapy (MDT)

Rifampicin is highly bactericidal Rifampicin is highly bactericidal 99.999% of bacilli will be killed within 3 99.999% of bacilli will be killed within 3 monthly doses.monthly doses.

Dapsone & clofazimine are weekly Dapsone & clofazimine are weekly bactericidal, but in combination will bactericidal, but in combination will

kill 99.999% of bacilli within 3 months.kill 99.999% of bacilli within 3 months.

MDT (Chemotherapy) renders Leprosy patients non-infectious.

MDT for PB leprosy6 months

Monthly dose Rifampicin 600mgDapsone 100 mg

Daily doseDapsone 100 mg

Multidrug Therapy (MDT) for Paucibacillary Leprosy (PB)

MDT for MB leprosy

24 months

Monthly doseRifampicin 600mgClofazimine 300 mgDapsone 100 mg

Daily doseDapsone 100mg Clofazimine 50 mg

Multidrug Therapy (MDT) for Multibacillary Leprosy (MB)

Multi Drug Multi Drug TherapyTherapy

24 months

6 months

COMLICATIONS COMLICATIONS OFOF LEPROSY LEPROSY

COMLICATIONS OF LEPROSY

1. Reactions.2. Complications of peripheral nerves.3. Complications of eyes4. Complication of bones

It’s a sudden change in the clinical picture of the disease It’s a sudden change in the clinical picture of the disease because because of conflict between the bacilli and the immune system of the of conflict between the bacilli and the immune system of the hosthost..

What are the precipitating factors ?

1.1. Effective treatment.Effective treatment.

2.2. Intercurrent infection.Intercurrent infection.

3.3. Physical stress.Physical stress.

4.4. Surgical operation.Surgical operation.

5.5. Pregnancy.Pregnancy.

6.6. Sometimes Sometimes spontaneously.spontaneously.

LEPROSY REACTIONLEPROSY REACTION

TYPES OF LEPRA TYPES OF LEPRA REACTIONSREACTIONS

Type I•Change in host CMI •Seen in borderlines•Skin and nerve lesions

Type II•Antigen antibody•Seen in LL & BL leprosy•Skin, nerve & systemic involvement

Type I Lepra ReactionType I Lepra Reaction(Reversal Reaction)(Reversal Reaction)

Seen in BT, BB & BL.Seen in BT, BB & BL. Sudden onset.Sudden onset. Eythematous & odematous changes in old Eythematous & odematous changes in old

lesions.lesions. Appearing of new lesions.Appearing of new lesions. Tenderness & swelling of peripheral nerves.Tenderness & swelling of peripheral nerves.

Treatment of type I Reaction:Treatment of type I Reaction:1.1. Continue MDT.Continue MDT.2.2. NSAID.NSAID.3.3. Systemic corticosteroid.Systemic corticosteroid.

Type II Lepra Reaction Type II Lepra Reaction (ENL)(ENL)

Acute onset of constitutional symptoms.Acute onset of constitutional symptoms. Appearance of ENL-like skin lesions.Appearance of ENL-like skin lesions. Visceral manifestations includes :- Visceral manifestations includes :- Iridocyclitis, hepato-splenomegaly, Iridocyclitis, hepato-splenomegaly,

epididmo-orchitis, nephritis, pleuritis, epididmo-orchitis, nephritis, pleuritis, lymphadenitis & neuritis.lymphadenitis & neuritis.

Treatment of type II Reaction:Treatment of type II Reaction:1.1. Continue MDT.Continue MDT.2.2. NSAIDNSAID3.3. Thalidoamide Thalidoamide ( clofazimine, corticosteroid )( clofazimine, corticosteroid )

Erythema Nodosum Leprosum Erythema Nodosum Leprosum (ENL)(ENL)

Erythematous.Erythematous. Tender .Tender . Subcutaneous.Subcutaneous. Resolve in 7 to 10 days.Resolve in 7 to 10 days. Appear in crops.Appear in crops. Occur any whereOccur any where Associated with fever & joint pains.Associated with fever & joint pains. May be vesicular, pustular & may May be vesicular, pustular & may

ulcerateulcerate

COMPLICATIONSCOMPLICATIONS OF OF PERIPHERAL NERVESPERIPHERAL NERVES

Peripheral nerves

Sensory Motor Autonomic

Hypoaestesia / anaestesia Muscle paralysis Lack of sweating & sebum

Ulcers Ulnar nerve Claw handRadial nerve Wrist dropLt. popliteal Foot dropPost. tibial Claw toesFacial lagophthalmous

Dry skinCracked skin

Ulcers

COMPLICATIONS COMPLICATIONS OFOF

EYEEYE

Involvment of the ophthalmic division of the (5th.) trigeminal nerve

Corneal sensation imparment

Patients ignore injuries

keratitis, conjunctivitis and ulcers

Involvment of zygomatic & temporal braches of the (7th.) facial nerve .

Lagophthalmos

Unable to close the eye (unbliking stare)

Complications Of Complications Of BonesBones

Bone damage in Leprosy is confined to bones of hand , feet & skull.

In the skull two pathognomonic changes occurs

1 -Atrophy of anterior nasal spine.

Nasal collapse

2 -Atrophy of maxillary alveolar process.

Loss of upper central incisors

These two skull changes known as “facies leprosa ”

Thank you.Thank you.