3. INTRODUCTIONINTRODUCTION
Chronic granulomatous infectious disease.Chronic granulomatous infectious disease.
Caused byCaused by Mycobacterium lepraeMycobacterium leprae
Mainly involves the peripheral nerves and skinMainly involves the peripheral nerves and skin
Other organs may involve:Other organs may involve:
Mucosa of mouthMucosa of mouth
Upper respiratory tractUpper respiratory tract
EyesEyes
Bones & Muscles.Bones & Muscles.
Testes etc.Testes etc.
Commonly involves every organ except :Commonly involves every organ except :
CNS, Ovary and Lungs.CNS, Ovary and Lungs.
4. HistoricalHistorical aspect of leprosyaspect of leprosy
One of the Oldest and most dreaded disease known to Mankind.One of the Oldest and most dreaded disease known to Mankind.
Earliest description from India in 600BCEarliest description from India in 600BC
Kustha Roga & attributed to punishment or curse of GodKustha Roga & attributed to punishment or curse of God
Al-Bukhari’s Muslim Hadith (volume 1, 2.443) documentedAl-Bukhari’s Muslim Hadith (volume 1, 2.443) documented
Prophet Mohammed’s apparent dread of leprosy in hisProphet Mohammed’s apparent dread of leprosy in his
statement: “statement: “Escape from the leprous the way you escape from a lion”Escape from the leprous the way you escape from a lion”
WordWord leperleper comes from Greek word “scaling”comes from Greek word “scaling”
M. leprae wasM. leprae was discovered bydiscovered by Gerhard Henrik Armauer HansenGerhard Henrik Armauer Hansen
in 1873 in Norway. Hence referred to asin 1873 in Norway. Hence referred to as HansenHansen’’s disease.s disease.
Leprosy control started with the use of chaulmoogra oil and forLeprosy control started with the use of chaulmoogra oil and for
the last three decades, MDT has been the main tool againstthe last three decades, MDT has been the main tool against
leprosyleprosy..
6. DistributionDistribution
PrevalencePrevalence
Worldwide distribution but essentially a disease of developingWorldwide distribution but essentially a disease of developing
countries.countries.
The prevalence rate has dropped by 90 percent fromThe prevalence rate has dropped by 90 percent from
21.1cases/10000 in 1985 to <1/10000 in 2000.21.1cases/10000 in 1985 to <1/10000 in 2000.
Out of 122 countries, only 2 countries still have to reach theOut of 122 countries, only 2 countries still have to reach the
elimination goal :elimination goal :
Brazil and East TimorBrazil and East Timor
To date there has been no resistance to antileprosy medicinesTo date there has been no resistance to antileprosy medicines
when used as MDT.when used as MDT.
8. Leprosy Situation in IndiaLeprosy Situation in India
The goal of leprosy elimination at National level (i.e. PR of <1 case/10,000The goal of leprosy elimination at National level (i.e. PR of <1 case/10,000
population) as set by National Health Policy 2002 had been achieved in the monthpopulation) as set by National Health Policy 2002 had been achieved in the month
of December 2005.of December 2005.
9. Leprosy Situation in India 2012-13Leprosy Situation in India 2012-13
A total ofA total of 1.35 lac1.35 lac new cases were detected duringnew cases were detected during
2012-13 i.e, ANCDR of 10.78/lac population2012-13 i.e, ANCDR of 10.78/lac population
Prevalence wasPrevalence was 0.92 lac0.92 lac cases as on 1cases as on 1stst
Apr’13 i.e, PR ofApr’13 i.e, PR of
73/10000 population.73/10000 population.
Multibacillary cases were 49.92 percentMultibacillary cases were 49.92 percent
Female cases were 37.72 percent, children 9.93 percentFemale cases were 37.72 percent, children 9.93 percent
3.45 percent cases were with visible deformity3.45 percent cases were with visible deformity
33 states/UTs have already achieved the PR of <133 states/UTs have already achieved the PR of <1
case/10000.case/10000.
Chhattisgarh(1.69), Dadra & Nagar Haveli(2.93) are yetChhattisgarh(1.69), Dadra & Nagar Haveli(2.93) are yet
to achieve the goal.to achieve the goal.
10. LeprosyLeprosy Situation in India 2012-13Situation in India 2012-13
Three States viz. Bihar, Maharashtra and West BengalThree States viz. Bihar, Maharashtra and West Bengal
which have achieved elimination earlier have shownwhich have achieved elimination earlier have shown
slight increase in P.R. (1-1.2) in the current year due toslight increase in P.R. (1-1.2) in the current year due to
the effect of SAP-2012.the effect of SAP-2012.
This brings the total number of persons affected byThis brings the total number of persons affected by
Leprosy cured of the disease in the country with MDTLeprosy cured of the disease in the country with MDT
from the beginning till date tofrom the beginning till date to 12.80 million.12.80 million.
14. Lepra bacilliLepra bacilli
Gram positive Obligate intracellular bacillus - due to its largeGram positive Obligate intracellular bacillus - due to its large
pool of non functional genes.pool of non functional genes.
Acid fast stained with modified Fite stain or ZN stainAcid fast stained with modified Fite stain or ZN stain
Short, thick, pink stained rods of Size: (5Short, thick, pink stained rods of Size: (5µµ X 0.5X 0.5 µµ ))
Occurs characteristically in clumps or bundles(Occurs characteristically in clumps or bundles( ““globiglobi”)”)
Affinity for Schwann cells & cells of R-E system .Affinity for Schwann cells & cells of R-E system .
M. leprae grows best in cooler tissues (the skin, peripheral
nerves, anterior chamber of the eye, upper respiratory tract,
and testes), sparing warmer areas of the skin (the axilla, groin,
scalp, and midline of the back).
Optimal temp. for growth is 30-33 centigradeOptimal temp. for growth is 30-33 centigrade
15. M. leprae remains one of the few bacterial species
that still has not been cultivated on artificial
medium or tissue culture and produces no known
toxins, but can grow in
Nude mouse
Nine banded armadillos(best)
17. Reservoir of infectionReservoir of infection
Main reservoir :Main reservoir : Human beingHuman being
Lepromatous case> Non lepromatous casesLepromatous case> Non lepromatous cases
Animal reservoirsAnimal reservoirs
9-banded armadillos9-banded armadillos
ChimpanzeesChimpanzees
Mangabey monkeysMangabey monkeys
Sphagnum mossSphagnum moss
18. Portal of exitPortal of exit
Major portal of exitMajor portal of exit :: Nasal MucosaNasal Mucosa
LL cases harbour millions ofLL cases harbour millions of M. lepraeM. leprae in their nasalin their nasal
mucosa discharged when they sneeze or blow nose.mucosa discharged when they sneeze or blow nose.
Ulcerated or broken skin of bacteriologicallyUlcerated or broken skin of bacteriologically
positive casespositive cases
19. Mode of transmissionMode of transmission
Transmission by inhalationTransmission by inhalation
Droplet infection(most common)Droplet infection(most common)
Transmission by contactTransmission by contact
Skin to skin contact with infectious casesSkin to skin contact with infectious cases
Contact with soil or fomitesContact with soil or fomites
Other RoutesOther Routes
Insect Vectors e.g.. Mosquito, BedbugsInsect Vectors e.g.. Mosquito, Bedbugs
Tattooing needlesTattooing needles
NB : Breast feeding and Transplacental infection do notNB : Breast feeding and Transplacental infection do not
occuroccur..
20. Incubation periodIncubation period
Long incubation periodLong incubation period
Ranged: 2 to 40 years or moreRanged: 2 to 40 years or more
Average: 3-5 yearsAverage: 3-5 years
Generation timeGeneration time : 12 days.: 12 days.
InfectivityInfectivity :: Leprosy is a highly infectious disease with lowLeprosy is a highly infectious disease with low
pathogenicity. Among household contacts of lepromatouspathogenicity. Among household contacts of lepromatous
cases about 5 to 12 percent is expected to show signs ofcases about 5 to 12 percent is expected to show signs of
leprosy within 5 yrs.leprosy within 5 yrs.
21. VIRULENCE FACTORVIRULENCE FACTOR
The bacterium's complex cell wall contains large amounts
of an M. leprae–specific phenolic glycolipid (PGL-1),
which is detected in serologic tests. The unique
trisaccharide of M. leprae binds to the basal lamina of
Schwann cells; this interaction is probably relevant to the
fact that M. leprae is the only bacterium to invade
peripheral nerves.
22. Host FactorsHost Factors
Leprosy affects all age groups but incidence generallyLeprosy affects all age groups but incidence generally
rises to a peak between 10 to 20 years of age and thenrises to a peak between 10 to 20 years of age and then
fall.fall.
Higher incidence is seen in males, more marked amongHigher incidence is seen in males, more marked among
adults, more marked among lepromatous cases.adults, more marked among lepromatous cases.
Cell Mediated Immunity is responsible for resistance toCell Mediated Immunity is responsible for resistance to
infection with M.infection with M.leprae.leprae. In lepromatous leprosy there isIn lepromatous leprosy there is
complete breakdown of CMI.complete breakdown of CMI.
23. Environmental factorsEnvironmental factors
Humidity favors survival ofHumidity favors survival of M. lepraeM. leprae in environmentin environment
M. lepraeM. leprae remain viable inremain 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 householdsOvercrowding & lack of ventilation within households
24. Social factorsSocial factors
Often called a “social disease”Often called a “social disease”
In addition to the physical effects of the disease,In addition to the physical effects of the disease,
patients have also suffered severe social stigma andpatients have also suffered severe social stigma and
ostracism from their families, communities, and evenostracism from their families, communities, and even
health professionals to such an extent that leprosy hashealth professionals to such an extent that leprosy has
been known since ancient times as “the death beforebeen known since ancient times as “the death before
death”.death”.
Social factors:Social factors:
PovertyPoverty
Poverty related circumstancesPoverty related circumstances
OvercrowdingOvercrowding
Poor housingPoor housing
Lack of personal hygieneLack of personal hygiene
26. IMPORTANCE OF CLASSIFICATIONIMPORTANCE OF CLASSIFICATION
Identify the infectious casesIdentify the infectious cases –– EpidemiologicalEpidemiological
importance - Principal targets for treatmentimportance - Principal targets for treatment
Identify the patients likely to develop the deformitiesIdentify the patients likely to develop the deformities
and determine the prognosisand determine the prognosis
Frame the line of treatmentFrame the line of treatment
Helpful in planning and evaluation of leprosy controlHelpful in planning and evaluation of leprosy control
activitiesactivities
27. Various ClassificationsVarious Classifications
Indian ClassificationIndian Classification : clinicobacteriological: clinicobacteriological
Madrid ClassificationMadrid Classification : clinicobacteriological: clinicobacteriological
Ridley Jopling classificationRidley Jopling classification : immunohistological: immunohistological
Classification by WHO Study GroupClassification by WHO Study Group on Chemotherapyon Chemotherapy
of Leprosy : clinicobacteriological.of Leprosy : clinicobacteriological.
28. Ridley- Jopling 1966Ridley- Jopling 1966
(Research purposes)(Research purposes)
Most widely acceptedMost widely accepted
Divides Leprosy cases into five groups accordingDivides Leprosy cases into five groups according
to their position on an immunohistological scale.to their position on an immunohistological scale.
It can be used only when full research facilitiesIt can be used only when full research facilities
are available :are available :
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)
29. Indian classificationIndian classification
Indeterminate typeIndeterminate type
Tuberculoid typeTuberculoid type
Borderline typeBorderline type
Lepromatous typeLepromatous type
Pure neuritic typePure neuritic type
30. Immunity in leprosyImmunity in leprosy
(-)
(+)
LLHD BLHD BBHD BTHD TTHD
TT -paucibacillaryTT -paucibacillary
state, few lesions duestate, few lesions due
to high immuneto high immune
responseresponse
LL - multibacillary state with
multiple lesions due to low
immune response
31. Contd..Contd..
Borderline forms (BB, BT and BL) lie between theseBorderline forms (BB, BT and BL) lie between these
two poles and are immunologically unstable, tendingtwo poles and are immunologically unstable, tending
to move towards one of the polar formsto move towards one of the polar forms
33. Clinical Feature onClinical Feature on
Skin LesionSkin Lesion
PaucibacillaryPaucibacillary
LeprosyLeprosy
PBPB
Multi BacillaryMulti Bacillary
LeprosyLeprosy
MBMB
Including macular flatIncluding macular flat
lesion, papules & noduleslesion, papules & nodules
1 to 5 lesion1 to 5 lesion
AsymmetricalAsymmetrical
distributiondistribution
Definite loss ofDefinite loss of
sensationsensation
BI <2 at all sites in theBI <2 at all sites in the
initial skin smearinitial skin smear
More than 5 lesionMore than 5 lesion
Symmetrical distributionSymmetrical distribution
Loss of sensationLoss of sensation
may or may not be presentmay or may not be present
BI >= 2 at any site in theBI >= 2 at any site in the
initial skin smearinitial skin smear
WHOWHO
Classification(1981,87,93)Classification(1981,87,93)
34. W H O classificationW H O classification
(For chemotherapy – M. leprae)(For chemotherapy – M. leprae)
PaucibacillaryPaucibacillary
Indeterminate - IIndeterminate - I
Tuberculoid – TTTuberculoid – TT
Borderline Tuberculoid – BTBorderline Tuberculoid – BT
If any of these have positiveIf any of these have positive
bacterial index they should bebacterial index they should be
classified as multibacillaryclassified as multibacillary
for multidrug therapyfor multidrug therapy
MultibacillaryMultibacillary
Mid borderline – BBMid borderline – BB
Borderline Lepromatous –Borderline Lepromatous –
BLBL
Lepromatous – LLLepromatous – LL
All smear positive casesAll smear positive cases
36. Indeterminate LeprosyIndeterminate Leprosy
Earliest & transitory stageEarliest & transitory stage
One or two vague hypopigmented macule with definiteOne or two vague hypopigmented macule with definite
sensory impairment.sensory impairment.
37. Indeterminate LeprosyIndeterminate Leprosy
If untreated may progress towards tuberculoid,If untreated may progress towards tuberculoid,
borderline or lepromatous leprosyborderline or lepromatous leprosy
Spontaneous regression may occurSpontaneous regression may occur
Bacteriologically NegativeBacteriologically Negative
38. 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, flat or raised, erythematous orSharply defined, dry, flat or raised, erythematous or
hypopigmented, and are anesthetic.hypopigmented, and are anesthetic.
One or two nerves may be enlarged near the skinOne or two nerves may be enlarged near the skin
lesionlesion
SS for AFB: NegativeSS for AFB: Negative
Lepromin test may be strongly positiveLepromin test may be strongly positive
40. Borderline TuberculoidBorderline Tuberculoid
Four or more lesions, asymmetrically distributedFour or more lesions, asymmetrically distributed
Macules or plaques of variable sizes with well or ill-Macules or plaques of variable sizes with well or ill-
defined margins & satellite lesionsdefined margins & satellite lesions
Peripheral nerves enlarged asymmetricallyPeripheral nerves enlarged asymmetrically
Sensation: hypoesthesiaSensation: hypoesthesia
SS for AFB: may or may not be positive.SS for AFB: may or may not be positive.
Lepromin test may be weakly positiveLepromin test may be weakly positive
42. Borderline BorderlineBorderline Borderline
Multiple erythematous macules & plaquesMultiple erythematous macules & plaques
Various sizes and shapes with punched out center andVarious sizes and shapes with punched out center and
ill defined slopping outer marginill 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 doubtfulLepromin test-usually negative, may be doubtful
44. Borderline LepromatousBorderline Lepromatous
Numerous, symmetrically distributed lesionsNumerous, symmetrically distributed lesions
Hypopigmented or erythematous irregularly shapedHypopigmented or erythematous irregularly shaped
maculopapular, infiltrative nodules, or plaques, withmaculopapular, infiltrative nodules, or plaques, with
smooth surfaces & ill defined borders, sloping outwardssmooth surfaces & ill defined borders, sloping outwards
Nerves may be symmetrically or asymmetrically enlargedNerves may be symmetrically or asymmetrically enlarged
Sensation:+/-Sensation:+/-
SS for AFB: numerous seenSS for AFB: numerous seen
Lepromin test -negativeLepromin test -negative
46. Lepromatous LeprosyLepromatous Leprosy
Numerous macules, plaques, nodules or diffuselyNumerous macules, plaques, nodules or diffusely
infiltrated lesions, shiny, smooth, symmetricallyinfiltrated lesions, shiny, smooth, symmetrically
distributed on face, trunk and extremities with ill-distributed on face, trunk and extremities with ill-
defined margin which may be slightly hypopigmenteddefined margin which may be slightly hypopigmented
or erythematousor erythematous
Symmetrical nerve enlargement is seenSymmetrical nerve enlargement is seen
Sensation: normalSensation: normal
SS for AFB: numerous seenSS for AFB: numerous seen
Lepromin test - negativeLepromin test - negative
49. Diffuse thickening of the skin, with loss of hair
(eyebrows and eyelashes) : madarosis.
Saddle nose deformitySaddle nose deformity
Leonine faciesLeonine facies
50. Clinical, Bacteriologic, Pathologic, and Immunologic
Spectrum of Leprosy
Feature Tuberculoid (TT, BT) Leprosy Borderline (BB, BL) Leprosy Lepromatous (LL) Leprosy
Skin lesion One or a few sharply defined
annular asymmetric macules or
plaques with a tendency toward
central clearing, elevated borders
Intermediate between BT- and
LL-type lesions; ill-defined
plaques with an occasional sharp
margin; few or many in number
Symmetric, poorly marginated,
multiple infiltrated nodules and
plaques or diffuse infiltration;
xanthoma-like or dermatofibroma
papules; leonine facies and
eyebrow alopecia
Nerve lesion Skin lesions anesthetic early; nerve
near lesions sometimes enlarged;
nerve abscesses most common in
BT
Hypoesthetic or anesthetic skin
lesions; nerve trunk palsies, at
times symmetric
Hypoesthesia a late sign; nerve
palsies variable; acral, distal,
symmetric anesthesia common
BI(Bacteriological index) 0-1+ 3-5+ 4-6+
lymphocytes 2+ 1+ 0-1+
Macrophage differentiation Epitheloid Epitheloid in BB,usually undiff
but may have foamy changes in
BL
Foamy change is the rule,may be
undifferentiated in early lesions
Langhans giant cells 1-3+ - -
Lepromin skin test +++ - -
Lymphocyte transformation test Generally positive 1 to 10 1 to 2
CD4 : CD8 ratio 1.2 BB(NT),BL:0.48 0.50
PGL1 antibodies 60 85 95
51.
52. Other Variants of LeprosyOther Variants of Leprosy
HISTOID LEPROSYHISTOID LEPROSY : variant of LL with better: variant of LL with better
CMI. Usually seen in patients with incompleteCMI. Usually seen in patients with incomplete
chemotherapy or acquired drug resistance.chemotherapy or acquired drug resistance.
Characterized by presence of spindle shaped histiocytesCharacterized by presence of spindle shaped histiocytes
in tissue section.in tissue section.
LUCIO LEPROSYLUCIO LEPROSY : mimics myxedema, diffuse non-: mimics myxedema, diffuse non-
nodular type of leprosy ch. by melancholy look, thicknodular type of leprosy ch. by melancholy look, thick
shiny skin, widespread sensory loss, hoarseness of voiceshiny skin, widespread sensory loss, hoarseness of voice
and ulceration of nasal mucosa.and ulceration of nasal mucosa.
LAZARINE LEPROSYLAZARINE LEPROSY : seen in association with: seen in association with
HIV.HIV.
53. 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.
56. M. LepraeM. Leprae :: superficialsuperficial nerve involvementnerve involvement
W Britton
57. Nerve InvolvementNerve Involvement
Neural involvement leads to muscle weakness, muscle
atrophy, severe neuritic pain, and contractures of the
hands and feet.
Ulnar nerve is most commonly involved , least common
is radial.
Most common cranial nerve involved is Trigeminal.
>30 percent neural loss required for loss of sensation.
First sensation to go is thermal (cold>fine touch).
Proprioception is usually preserved.
60. UlnarUlnar SS Anesthesia medial 1/3 palmAnesthesia medial 1/3 palm
MM Claw ring and little fingersClaw ring and little fingers
AA Dryness medial 1/3 palmDryness medial 1/3 palm
61. MedianMedian SS Anesthesia lateral 2/3 palmAnesthesia lateral 2/3 palm
MM Claw mid + index + loss OppositionClaw mid + index + loss Opposition
AA Dryness lateral 2/3 palmDryness lateral 2/3 palm
66. CASE DEFINITIONCASE DEFINITION
Leprosy is clinically defined by one or more of theLeprosy is clinically defined by one or more of the
following cardinal features :following cardinal features :
I.I. Hypopigmented patchesHypopigmented patches
II.II. Partial or total loss of cutaneous sensation in affected area.Partial or total loss of cutaneous sensation in affected area.
III.III. Presence of thickened nerves andPresence of thickened nerves and
IV.IV. Presence of AFB in the skin or nasal smearsPresence of AFB in the skin or nasal smears
It also includes : patients who started MDT but did notIt also includes : patients who started MDT but did not
receive for 12 consecutive months and subsequentlyreceive for 12 consecutive months and subsequently
presents with signs of active disease as well as patientpresents with signs of active disease as well as patient
who relapse after completing a full course of treatment.who relapse after completing a full course of treatment.
68. DIAGNOSISDIAGNOSIS
HISTORYHISTORY
History should include the following points :History should include the following points :
Patients Bio data : name, age, sex, addressPatients Bio data : name, age, sex, address
Presenting complaintsPresenting complaints
Family history of leprosyFamily history of leprosy
Contact with leprosy casesContact with leprosy cases
Previous history of treatment for leprosy, if anyPrevious history of treatment for leprosy, if any
69. DIAGNOSISDIAGNOSIS
CLINICAL EXAMINATIONCLINICAL EXAMINATION
Physical examination should include :Physical examination should include :
A thorough inspection of the body surface(skin).A thorough inspection of the body surface(skin).
Palpation of commonly involved superficial nerves:Palpation of commonly involved superficial nerves:
1.1.Ulnar N. near the medial epicondyle.Ulnar N. near the medial epicondyle.
2.2.Greater Auricular N as it turns over SCM muscle.Greater Auricular N as it turns over SCM muscle.
3.3.Lateral Popliteal N.Lateral Popliteal N.
4.4.Dorsal branch of Radial N.Dorsal branch of Radial N.
Testing for :Testing for :
1.1.Loss of sensation : heat, cold, pain, touch .Loss of sensation : heat, cold, pain, touch .
2.2.Paresis or paralysis of muscles of hands and feet.Paresis or paralysis of muscles of hands and feet.
73. DIAGNOSISDIAGNOSIS
BACTERIAL INDEXBACTERIAL INDEX
Bacterial index is the only objective way of monitoringBacterial index is the only objective way of monitoring
benefit of treatment.benefit of treatment.
According ToAccording To Ridley’ Logarithmic ScaleRidley’ Logarithmic Scale It RangesIt Ranges
From 0 To 6+ and is based on the no. of bacilli seen inFrom 0 To 6+ and is based on the no. of bacilli seen in
an average microscopic field.an average microscopic field.
B 0 stands for no bacilli in any of 100 oil immersionB 0 stands for no bacilli in any of 100 oil immersion
field.field.
77. DIAGNOSISDIAGNOSIS
MORPHOLOGICAL INDEXMORPHOLOGICAL INDEX
The MI is calculated after examining 200 pink-stainedThe MI is calculated after examining 200 pink-stained
free standing bacilli.free standing bacilli.
The percentage of solid staining bacilli in a stainedThe percentage of solid staining bacilli in a stained
smear is referred to as MI.smear is referred to as MI.
It is a valuable indicator of the patient’s response toIt is a valuable indicator of the patient’s response to
treatment during the first few months and helps totreatment during the first few months and helps to
signal drug resistance.signal drug resistance.
SOLID FRAGMENTED GRANULAR(SFG)SOLID FRAGMENTED GRANULAR(SFG)
PERCENTAGEPERCENTAGE : similar to MI but a more sensitive: similar to MI but a more sensitive
indicator of the patient’s response to treatment.indicator of the patient’s response to treatment.
78. DIAGNOSISDIAGNOSIS
FOOT-PAD CULTUREFOOT-PAD CULTURE
Only certain way of identifying M.Only certain way of identifying M. Leprae.Leprae.
10 times more sensitive at detecting the bacilli than slit10 times more sensitive at detecting the bacilli than slit
skin smear.skin smear.
Time consuming : requires 6 to 9 months.Time consuming : requires 6 to 9 months.
Used for :Used for :
1.1. Detecting drug resistance.Detecting drug resistance.
2.2. Evaluating the potency of anti-leprosy drugs.Evaluating the potency of anti-leprosy drugs.
3.3. Detecting the viability of bacilli during treatment.Detecting the viability of bacilli during treatment.
NewerNewer in vitroin vitro macrophage culture which takes only 3 –macrophage culture which takes only 3 –
4 weeks.4 weeks.
79. DIAGNOSISDIAGNOSIS
HISTAMINE TESTHISTAMINE TEST
Reliable test for detecting at an early stage peripheral
nerve damage due to leprosy.
Method : carried out by injecting 0.1ml of a 1:1000
solution of histamine phosphate into hypopigmented
patches or in areas of anesthesia.
Result : in normal person it gives rise to a wheal
surrounded by erythematous flare(Lewis triple
response). In case of leprosy where the nerve supply is
destroyed, flare response is lost.
Particularly useful in cases of indeterminate leprosy.
80. DIAGNOSISDIAGNOSIS
BIOPSYBIOPSY
Usually resorted to when there is high clinicalUsually resorted to when there is high clinical
suspicion but the other test are unyielding. It alsosuspicion but the other test are unyielding. It also
gives information about the bacterial content ofgives information about the bacterial content of
skin.skin.
81. DIAGNOSISDIAGNOSIS
IMMUNOLOGICAL TESTSIMMUNOLOGICAL TESTS
Tests for cell mediated immunity(CMI)Tests for cell mediated immunity(CMI)
LEPROMIN TESTLEPROMIN TEST
Tests for humoral antibodies(serological tests)Tests for humoral antibodies(serological tests)
FLA-ABS testFLA-ABS test :: used for detecting subclinical infections. 92.3
percent sensitive and 100 percent specific in detecting specific
antibodies in all types leprosy irrespective of type and duration of
disease.
Monoclonal antibodiesMonoclonal antibodies
Others : RIA, ELISAOthers : RIA, ELISA..
82. DIAGNOSISDIAGNOSIS
LEPROMIN TESTLEPROMIN TEST
Method :Method : it is performed by injecting 0.1ml of leprominit is performed by injecting 0.1ml of lepromin
into inner aspect of the forearm. The reaction is read at 48into inner aspect of the forearm. The reaction is read at 48
hours and 21 days. Two types of reaction have beenhours and 21 days. Two types of reaction have been
described :described :
EARLY REACTION(FERNANDEZ REACTION) :EARLY REACTION(FERNANDEZ REACTION) :
an inflammatory reaction develops within 24 to 48 hours and thisan inflammatory reaction develops within 24 to 48 hours and this
tends to disappear in 3 to 4 days. If the diameter of the red area istends to disappear in 3 to 4 days. If the diameter of the red area is
more than 10mm the test is considered positive. It is a delayed typemore than 10mm the test is considered positive. It is a delayed type
hypersensitivity reaction to soluble constituents of lepra bacilli andhypersensitivity reaction to soluble constituents of lepra bacilli and
indicates whether or not a person has been sensitized by exposureindicates whether or not a person has been sensitized by exposure
to and infection by lepra bacilli.to and infection by lepra bacilli.
83. DIAGNOSISDIAGNOSIS
LEPROMIN TESTLEPROMIN TEST
LATE REACTION(MITSUDA REACTION) :LATE REACTION(MITSUDA REACTION) : It is
characterized by the appearance of a nodule which
becomes apparent in 7 to 10 days and reaches its
maximum in 3 to 4 weeks. The test is read at 21 days. If
the nodule is more than 5 mm it is considered positive. It
is induced by the bacillary component and indicates cell
mediated immunity.
In the first six months of life most children are lepromin
negative
BCG vaccination is capable of converting lepra reaction
from negative to positive.
84. DIAGNOSISDIAGNOSIS
LEPROMIN TESTLEPROMIN TEST
VALUE OF LEPROMIN TEST :VALUE OF LEPROMIN TEST :
Useful tool for evaluating the immune status of leprosy patients.
Aid to classify the type of disease.
Estimating the prognosis
Strongly positive in a typical tuberculoid case and getting weaker
towards the lepromatous end, the typical lepromatous case being
lepromin negative indicating failure of CMI.
The greatest drawback being high false positive and false negative
cases hence not used as a diagnostic test.
OTHER TESTS FOR CMI :OTHER TESTS FOR CMI :
Lymphocyte transformation test(LTT)
Leucocyte migration inhibition test(LMIT)
85. TREATMENTTREATMENT
MULTIDRUG CHEMOTHERAPYMULTIDRUG CHEMOTHERAPY
In the absence of effective of primary prevention by aIn the absence of effective of primary prevention by a
leprosy vaccine leprosy control is based on effectiveleprosy vaccine leprosy control is based on effective
multidrug chemotherapy(secondary prevention).multidrug chemotherapy(secondary prevention).
OBJECTIVES :OBJECTIVES :
To interrupt transmission of infection
Early detection and treatment of cases to prevent deformities
To prevent drug resistance
86. TREATMENTTREATMENT
MULTIDRUG CHEMOTHERAPYMULTIDRUG CHEMOTHERAPY
In multidrug regimens only bactericidal drugs areIn multidrug regimens only bactericidal drugs are
used :used :
First line drugsFirst line drugs : rifampicin, dapsone, clofazimine,: rifampicin, dapsone, clofazimine,
ethionamide and prothionamide.ethionamide and prothionamide.
Second line drugsSecond line drugs : quinolones, minocycline,: quinolones, minocycline,
clarithromycin.clarithromycin.
87. TREATMENTTREATMENT
MULTIDRUG CHEMOTHERAPYMULTIDRUG CHEMOTHERAPY
WHO RECOMMENDED REGIMENS OFWHO RECOMMENDED REGIMENS OF
CHEMOTHERAPY :CHEMOTHERAPY :
MULTIBACILLARY LEPROSYMULTIBACILLARY LEPROSY
Rifampicin : 600mg once monthly under supervision
Dapsone : 100mg daily self administered
clofazimine : 300mg once monthly under supervision
50mg daily self-administered
Where clofazimine is unacceptable due skin coloration it may
be substituted by 250 to 375mg daily dose of ethionamide or
prothionamide.
The above regimen needs to taken for 12 months within 18
months
88. TREATMENTTREATMENT
MULTIDRUG CHEMOTHERAPYMULTIDRUG CHEMOTHERAPY
WHO RECOMMENDED REGIMENS OFWHO RECOMMENDED REGIMENS OF
CHEMOTHERAPY :CHEMOTHERAPY :
PAUCIBACILLARY LEPROSYPAUCIBACILLARY LEPROSY ::
The above regimen needs to be taken for 6months within 9The above regimen needs to be taken for 6months within 9
monthsmonths
89. TREATMENTTREATMENT
MULTIDRUG CHEMOTHERAPYMULTIDRUG CHEMOTHERAPY
Treatment regimen for children 10-14 years :Treatment regimen for children 10-14 years :
MULTIBACILLARY LEPROSY
Rifampicin : 450mg once monthly under supervision
Dapsone : 50mg daily self administered
clofazimine : 150mg once monthly under supervision
50mg every other day self-administered
PAUCIBACILLARY LEPROSYPAUCIBACILLARY LEPROSY
Rifampicin : 450mg once a month under supervision
Dapsone : 50mg daily self administered.
91. TREATMENTTREATMENT
MULTIDRUG CHEMOTHERAPYMULTIDRUG CHEMOTHERAPY
Important points :Important points :
MDT is not contraindicated in patients with HIVMDT is not contraindicated in patients with HIV
infection.infection.
MDT is safe during pregnancy.MDT is safe during pregnancy.
Drugs are excreted in breast milk but no reports ofDrugs are excreted in breast milk but no reports of
adverse reaction except for mild discoloration of infantsadverse reaction except for mild discoloration of infants
skin by clofazimineskin by clofazimine
Leprosy is exacerbated during pregnancy, it is importantLeprosy is exacerbated during pregnancy, it is important
that MDT is continuedthat MDT is continued
92. TREATMENTTREATMENT
MULTIDRUG CHEMOTHERAPYMULTIDRUG CHEMOTHERAPY
DrugsDrugs
Rifampicin :Rifampicin : highly bactericidal, a single 1500mg dose
kills 99 percent of viable organisms
Toxic effects includes anorexia, nausea, vomiting,
abdominal discomfort and orange discoloration of body
secretions. It is hepatotoxic
Dapsone :Dapsone : weakly bactericidal.
Adverse effects include hemolytic anemia,
methemoglobinemia, agranulocytosis, hepatitis,
neuropathy, psychosis and rarely…
93. TREATMENTTREATMENT
MULTIDRUG CHEMOTHERAPYMULTIDRUG CHEMOTHERAPY
DDS syndrome ch. by fever, maculopapular rash, enlarged
lymph nodes, hepatitis and exfoliative dermatitis.
Clofazimine :Clofazimine : was originally synthesized for TB. Less
effective than dapsone but has added advantage of
preventing lepra reaction. More expensive but less toxic
which includes dark red discoloration of skin, mucus
membranes, sweat and urine.
95. LEPRA REACTIONSLEPRA REACTIONS
During the course of leprosy, immunological mediatedDuring the course of leprosy, immunological mediated
episodes of acute or subacute inflammation known asepisodes of acute or subacute inflammation known as
reaction may occur.reaction may occur.
There are two types of reactions :There are two types of reactions :
Type 1 or Reversal reactionType 1 or Reversal reaction
Type 2 or erythema nodosum leprosumType 2 or erythema nodosum leprosum
Both types can occur before the start of MDT, duringBoth types can occur before the start of MDT, during
treatment or after completion of treatment.treatment or after completion of treatment.
96. LEPRA REACTIONSLEPRA REACTIONS
REVERSAL REACTIONREVERSAL REACTION
In reversal reaction the leprosy skin lesions themselvesIn reversal reaction the leprosy skin lesions themselves
become inflamed red, swollen and painful.become inflamed red, swollen and painful.
It is type of delayed type of hypersensitivity.It is type of delayed type of hypersensitivity.
Occurs in both PB and MBOccurs in both PB and MB
Nerves may be enlarged, tender and painful with loss ofNerves may be enlarged, tender and painful with loss of
function.function.
General symptoms are uncommonGeneral symptoms are uncommon
Do not affect other organs.Do not affect other organs.
97. LEPRA REACTIONSLEPRA REACTIONS
ERYTHEMA NODOSUM LEPROSUMERYTHEMA NODOSUM LEPROSUM
In ENL new inflamed, red nodules appear under theIn ENL new inflamed, red nodules appear under the
skin, while the original lesions remain same. Commonlyskin, while the original lesions remain same. Commonly
on face, arm and legs & bilaterally symmetrical. Theyon face, arm and legs & bilaterally symmetrical. They
appear in crops and subside within few days evenappear in crops and subside within few days even
without treatmentwithout treatment
It is antigen antibody reaction.It is antigen antibody reaction.
Seen in MB cases only.Seen in MB cases only.
Nerves may be affected but is uncommonNerves may be affected but is uncommon
Other organs like testis, eye, kidney may be affectedOther organs like testis, eye, kidney may be affected
General symptoms of fever, joint pain, red eyes andGeneral symptoms of fever, joint pain, red eyes and
watering may be associated.watering may be associated.
98. LEPRA REACTIONSLEPRA REACTIONS
TREATMENTTREATMENT
Because of high risk of permanent nerve damageBecause of high risk of permanent nerve damage
reversal reaction needs to be promptly diagnosed andreversal reaction needs to be promptly diagnosed and
treated adequatelytreated adequately
Standard 12 wk. regimen of prednisolone is theStandard 12 wk. regimen of prednisolone is the
treatment of choice.treatment of choice.
ENL varies in severity, duration and organENL varies in severity, duration and organ
involvement, and can be treated with prednisolone asinvolvement, and can be treated with prednisolone as
reversal reaction.reversal reaction.
Treatment includes bed rest, splinting of affectedTreatment includes bed rest, splinting of affected
nerves, analgesics and prednisolone.nerves, analgesics and prednisolone.
99. LEPRA REACTIONSLEPRA REACTIONS
TREATMENTTREATMENT
Prednisolone regimen Add clofazimine in ENL
40mg daily for first 2 weeks
30mg daily or week 3 and 4
100mg tds x 4 weeks
20mg daily for week 5 and 6
15mg daily for week 7 and 8
100mg bd x 4weeks
10mg daily for week 9 and 10
5mg daily for week 11 and 12
100mg od x 4 weeks
For neuritis, treatment with prednisolone
20mg onwards
Should be prolonged to four weeks from
100. LEPRA REACTIONSLEPRA REACTIONS
TREATMENTTREATMENT
For pregnant women prednisolone should be started atFor pregnant women prednisolone should be started at
30mg dose instead of 40mg and limit the course for30mg dose instead of 40mg and limit the course for
10weeks in PB cases and 20 weeks for MB cases.10weeks in PB cases and 20 weeks for MB cases.
For children dose should be started at 1mg/kg of bodyFor children dose should be started at 1mg/kg of body
wt. per day.wt. per day.
Thalidomide :Thalidomide : was reintroduced for the treatment of ENL,
mainly because of its antipyretic action. WHO does not
recommend the use of thalidomide in leprosy. Prednisolone is
more effective in controlling ENL and associated neuritis,
clofazimine is the drug of choice for the management of
chronic, recurrent ENL reactions. Another drug claimed to be
useful in ENL is pentoxyfylline.
101. IMMUNOPROPHYLAXISIMMUNOPROPHYLAXIS
Till date there is no effective vaccine against leprosyTill date there is no effective vaccine against leprosy
The vaccine undergoing trials are :The vaccine undergoing trials are :
BCG –34.1% PROTECTIONBCG –34.1% PROTECTION
BCG+KILLED M.LEPRAE – 64.0%BCG+KILLED M.LEPRAE – 64.0%
M.W – 25.7%M.W – 25.7%
ICRC – 65.5%ICRC – 65.5%
102. CHEMOPROPHYLAXISCHEMOPROPHYLAXIS
Chemoprophylaxis as a public health measure is notChemoprophylaxis as a public health measure is not
recommended on account of lack of consistent resultsrecommended on account of lack of consistent results
from various studies.from various studies.
103. DEFORMITIESDEFORMITIES
As a single disease entity leprosy is the foremost causeAs a single disease entity leprosy is the foremost cause
of deformities and crippling.of deformities and crippling.
Approx. 25 percent of cases who are not properlyApprox. 25 percent of cases who are not properly
treated at an early stage develop deformities of handstreated at an early stage develop deformities of hands
and feet.and feet.
Deformities may results from the disease process, orDeformities may results from the disease process, or
from muscle paralysis due nerve damage, or due tofrom muscle paralysis due nerve damage, or due to
injuries or infections.injuries or infections.
104. DEFORMITIESDEFORMITIES
Face Masked face, facies leonina, sagging face, lagopthalmos,
madarosis(eyebrows, cilliary) corneal ulcers and opacities,
perforated nose, depressed nose, nodules on ears and
elongated lobules
Hands Claw hand, wrist drop, ulcers, absorption of digits, thumb web
contracture, hollowing of interosseus space, swollen hand
Feet Plantar ulcers, foot drop, inversion of foot, clawing of toes,
absorption of toes, collapsed foot, swollen foot and callosities
Others Gynaecomastia and perforation of palate.
105. DEFORMITIESDEFORMITIES
PREVENTIONPREVENTION
Measures include care of dry and denervated skin ofMeasures include care of dry and denervated skin of
palms and soles.palms and soles.
Treating wounds, ulcers, and cracks in palms & solesTreating wounds, ulcers, and cracks in palms & soles
Use of protective gloves and footwearUse of protective gloves and footwear
Prevent joint stiffness in case of paralysisPrevent joint stiffness in case of paralysis
Protection of eyesProtection of eyes
Periodic check up for progression of disease.Periodic check up for progression of disease.
106. DEFORMITIESDEFORMITIES
IMPROVEMENTIMPROVEMENT
Improvement of disabilities is achieved through the useImprovement of disabilities is achieved through the use
of prostheses and orthopaedic devices, includingof prostheses and orthopaedic devices, including
corrective splints as well as by corrective surgery.corrective splints as well as by corrective surgery.
107. REHABILITATIONREHABILITATION
Rehabilitation includesRehabilitation includes all the measures used forall the measures used for
reducing the impact of disability for an individual,reducing the impact of disability for an individual,
enabling him/her to achieve independence, socialenabling him/her to achieve independence, social
integration, a better quality of life and self actualization.integration, a better quality of life and self actualization.
Community Based Rehabilitation (CBR) is a strategyCommunity Based Rehabilitation (CBR) is a strategy
within community development for the rehabilitation,within community development for the rehabilitation,
equalization of opportunities, poverty alleviation andequalization of opportunities, poverty alleviation and
social inclusion of all the people with disabilities. It issocial inclusion of all the people with disabilities. It is
implemented with combined efforts of people withimplemented with combined efforts of people with
disability, their families, community, social anddisability, their families, community, social and
government organisation..government organisation..
108. REHABILITATIONREHABILITATION
Basic principles of CBR includesBasic principles of CBR includes ::
ParticipationParticipation
EmpowermentEmpowerment
Raising awarenessRaising awareness
Self–advocacySelf–advocacy
Gender sensitivity and special needsGender sensitivity and special needs
PartnershipsPartnerships
SustainabilitySustainability
109. NATIONAL LEPROSYNATIONAL LEPROSY
ERADICATION PROGRAMMEERADICATION PROGRAMME
The history of anti leprosy work in India goes back to 1874The history of anti leprosy work in India goes back to 1874
when the mission to lepers(leprosy mission) was founded bywhen the mission to lepers(leprosy mission) was founded by
Bailey at Chamba, HPBailey at Chamba, HP
The NLCP was launched in 1954 later converted to NLEP inThe NLCP was launched in 1954 later converted to NLEP in
19831983
The prevalence rate was 57cases/10000 population in 1981The prevalence rate was 57cases/10000 population in 1981
which declined to 5.7/10000 in 2000which declined to 5.7/10000 in 2000
In Dec 2005 India achieved the target of leprosy eliminationIn Dec 2005 India achieved the target of leprosy elimination
envisaged in NHP 2002, when PR was brought down toenvisaged in NHP 2002, when PR was brought down to
<1/10000.<1/10000.
Chhattisgarh and Dadra & Nagar haveli are yet to reach theChhattisgarh and Dadra & Nagar haveli are yet to reach the
target.target.
