Lep-R

Leprosy: 

Leprosy Dr Rajesh Kumar Singh Asst Prof Dept of Community Medicine ACMS

HISTORY OF LEPROSY : 

HISTORY OF LEPROSY Leprosy is the oldest disease known to mankind LEPRA from Greek means Scaly. For long time confused with Psoriasis, Elephantiasis, Pellagra. In India known since ancient times as kustharoga Has maximum social stigma attached to it (such as attributed to curse from God).

Introduction: 

Introduction Nonfatal, chronic granulomatous infectious disease Caused by Mycobacterium leprae , Clinical manifestations are largely confined to the skin, peripheral nervous system, upper respiratory tract, eyes, and testes.

Slide 5: 

Leprosy is characterized by one or more of following, a) hypopigmented patches b)partial or total loss of cutaneous sensation c)presence of thickened nerves d)AFB bacilli in skin or nasal smear.

Slide 6: 

The signs of advanced disease are — presence of nodules or lumps esp. in skin of face and ears, plantar ulcers, loss of fingers or toes, nasal depression, foot drop, claw toes

PROBLEM STATEMENT : 

PROBLEM STATEMENT Leprosy is almost exclusively a disease of the developing world, affecting areas of Asia, Africa and the Latin America. More than 80% of the world's cases occur in a few countries: India, China, Myanmar, Indonesia, Brazil, Nigeria, Madagascar, and Nepal.

Leprosy Situation in States of India as on 31.03.2010 : 

Leprosy Situation in States of India as on 31.03.2010 States/UTs with PR > 1 ( 3 States ) S.No Name of State ANCDR/100000 population PR/ 10000 population 1 D & N Haveli 47.01 2.62 2 Chhattisgarh 31.68 2.20 3 Bihar 20.71 1.08 States/UTs with PR < 1 ( 32 States ) 1. West Bengal 12.33 0.98 India 10.93 0.71 Total no. of 133717 new cases were detected at national level during the year 2009-10

Epidemiological triad : 

Epidemiological triad

Agent factor : 

Agent factor Caused by Mycobacterium leprae . Slightly curved rod. Gram + ve and acid fast. Occur in characteristic clumps or bundles called GLOBI’. Parallel rows of bacilli in globi present a’Cigar bundle’ appearance. Occur in human host both intracellularly and extracellularly

Source of infection: 

Source of infection Multibacillary cases are the most important source of infection. All patients with active leprosy must be considered infectious. Portal of Exit Nose is a major portal of exit Ulcerated or broken skin of bacteriologically positive cases of leprosy

Host factors : 

Host factors Age --- Infection can occur at any age depending upon the opportunities for exposure. Sex --- Males show higher prevalence. Immunity ---high degree of innate immunity seems to exist, so only a few persons exposed to infection develop the disease. CMI is responsible for resistance to infection with bacilli. Type of leprosy determined by status of CMI .

Slide 13: 

When CMI is adequate ---- tuberculoid type . Show delayed hypersensitivity to bacillus. lepromin test + ve . When CMI is deficient---- Lepromatous . delayed hypersensitivity absent. Lepromin test – ve .

Environmental factors : 

Environmental factors Leprosy is called ‘Social disease’--- Poverty , Overcrowding, Poor housing, lack of education, and personal hygiene play a major role.

Mode of transmission: 

Mode of transmission Droplet infection Contact transmission Direct Indirect (e.g. contact with soil and fomites such as contaminated clothes and linen) Other routes Insect vectors Tattooing needles

Incubation period: 

Incubation period Average of 3-5yrs

Classification : 

Classification

Madrid classification: 

Madrid classification

Indian classification: 

Indian classification

Ridley and Jopling classification: 

Ridley and Jopling classification

Slide 21: 

Tuberculoid and lepromatous are called POLAR FORMS ,since they are at two poles of immune system.

Indeterminate type: 

Indeterminate type One or two vague hypopigmented macules Definite sensory impairment Bacteriologically negative

Tuberculoid type: 

Tuberculoid type Seen where CMI adequate. One or two well defined lesions, which may be flat or raised, hypopigmented or erythematous Sensory loss Bacteriologically negative Lepromin + ve .

Borderline type: 

Borderline type Four or more lesions, well or ill defined, flat or raised, hypopigmented or erythematous Sensory impairment or loss Bacteriologically positivity is variable

LEPROMATOUS LEPROSY : 

LEPROMATOUS LEPROSY Seen where CMI low. Numerous flat or raised ,poorly defined, smooth shiny, symmetrical lesions. Nodular lesion->ulceration->deformity &mutilation. Bacteriologically positive Lepromin test – ve

Pure neuritic type: 

Pure neuritic type nerve involvement without skin lesion. bacteriologically negative

Clinical classification for control programme: 

Clinical classification for control programme Paucibacillary leprosy 1-5 skin lesions &/or Only one nerve involvement Multibacillary leprosy 6 or more skin lesions &/or More than one nerve involvement

Diagnosing a case of leprosy: 

Diagnosing a case of leprosy

How to diagnose leprosy: 

How to diagnose leprosy Examine skin Check for patches Test for sensation Count the number of patches Look for damage to nerves

Signs of leprosy: 

Signs of leprosy Pale or slightly reddish patch Definite loss of sensation in the patch Signs of damage to nerves definite loss of sensation in hands/feet weakness of muscles of hands/feet/face visible deformity of hands/feet/face

What is not leprosy : 

What is not leprosy Skin patches which have normal feeling are present from birth cause itching are white, black, dark red or silver coloured show scaling appear and disappear periodically spread quickly

How to examine for leprosy?: 

How to examine for leprosy? Examine in a well-lit room Examine the whole body Ask since when the patch was noticed Ask what treatments have been tried Test for sensation Look for any visible deformities

OTHER METHODS OF DIAGNOSIS: 

OTHER METHODS OF DIAGNOSIS Bacteriological examination Foot-pad culture Histamine test Biopsy Immunological tests Tests for detecting CMI( lepromin test) Test for Humoral responses to M. Leprae (FLA-ABS test)

BACTERIOLOGICAL INDEX : 

BACTERIOLOGICAL INDEX BI=total plus/total smear sites Multibacillary ----BI>2 Paucibacillary ----BI<2 0 - no bacilli in 100 fields 1+ - 1-10 bacilli, on average, in 100 fields 2+ - 1-10 bacilli, on average, in 10 fields 3+ - 1-10 bacilli, on average, in each fields 4+ - 10-100 bacilli, on average, in each fields 5+ - 100-1000 bacilli, on average, in each fields 6+ - >1000 bacilli, on average, in each fields

HISTAMINE TEST : 

HISTAMINE TEST Reliable method for detecting at an early stage peripheral nerve damage. Injecting intradermally 0.1ml of 1:1000 solution of histamine phosphate into hypopigmented patch or in areas of anaesthesia . In normal case give triple response(a wheel surrounded by an erythematous flare). In cases of leprosy flare response is lost.

LEPROMIN TEST : 

LEPROMIN TEST Test for delayed hypersensitivity. Intradermal injection of 0.1ml of lepromin into the inner aspect of forearm and reaction read at 48hrs and 21 days. Early (Fernandez reaction) & late( Mitsuda )reaction.

Leprosy control : 

Leprosy control • Estimation of problem • Early case detection • MDT • Immunoprophylaxis • Chemoprophylaxis • Rehabilitation • Health education • Social support

Leprosy - one of the few diseases which can be eliminated: 

Leprosy - one of the few diseases which can be eliminated Leprosy meets the demanding criteria for elimination practical and simple diagnostic tools: can be diagnosed on clinical signs alone; the availability of an effective intervention to interrupt its transmission: multidrug therapy a single significant reservoir of infection: humans.

Standard WHO-MDT for the treatment of leprosy : 

Standard WHO-MDT for the treatment of leprosy

Steps to start MDT: 

Steps to start MDT Classify as PB or MB leprosy Inform the patient about the disease Explain the MDT blister pack - show drugs to be taken once a month and every day Explain possible side effects (e.g. darkening of skin) and possible complications and when they must return to the health centre Fill out the patient treatment card

Treatment regimens: 

Treatment regimens PB Adult (6 blister packs) Rifampicin 600 mg once a month Dapsone 100 mg every day MB Adult (12 blister packs) Rifampicin 600 mg once a month Clofazimine 300 mg once a month Clofazimine 50 mg and dapsone 100 mg every day

Multi Drug Therapy: 

Multi Drug Therapy

Information to patients About the disease: 

Information to patients About the disease Caused by a bacteria Affects skin and sometimes nerves Progresses slowly Easy to diagnose and cure Lead normal life, do not change life style

Information to patients About the treatment: 

Information to patients About the treatment MDT will cure you completely MDT is free of cost MDT is available in all health centres MDT should be taken as advised (regular, full course) If you have problem or questions contact your health centre

Information to patients About possible problems: 

Information to patients About possible problems Skin discoloration due to clofazimine Urine discoloration due to rifampicin In case of fever, pain in the nerves, muscle weakness, joint pains they must return immediately to the health centre

What is Accompanied MDT (A-MDT): 

What is Accompanied MDT (A-MDT) A patient receives a full course of MDT at the outset receives information (verbal and printed materials) about the disease, its treatment and when and where to come for follow up, and someone close to or important to the patient assumes the responsibility of ensuring that the patient completes a full course of treatment. Note: In some areas (difficult to access, poor security etc) or for some patients ( students,workers etc), this will ensure that all patients have adequate supply of MDT at home.

How to manage complications : 

How to manage complications

Some patients may develop complications: 

Some patients may develop complications Leprosy reactions Side-effects Disabilities

Lepra reaction : 

Lepra reaction Immunologically mediated episodes of acute or subacute inflammation during the course of leprosy Type 1/reversal reaction--- May occur throughout the whole spectrum of leprosy but more frequent in borderline type. occur spontaneously or following chemotherapy. Swelling and redness of skin lesions. Type 2/ Erythema nodosum leprosum — In LL & BL., a few months after chemotherapy. Crops of tender, inflammed subcutaneous nodules with fever and arthralgia

Leprosy reactions: 

Leprosy reactions 1 or 2 patients in 10 may develop reactions Reactions are not a side effect of MDT. They are the body’s response to leprosy More commonly seen in MB cases (more than 5 lesions) Signs and symptoms include Skin : patch/s becomes reddish and/or swollen; sometimes painful reddish nodules appear Nerves : pain in the nerve and/or joint; loss of sensation and weakness of muscles (commonly of hands, feet and around eyes) General : fever, malaise, swelling of hands/feet

Managing reactions (1) : 

Managing reactions (1) Early diagnosis and prompt treatment of reactions Every patient should be informed about the signs and symptoms of reactions Inform them to go as soon as possible to the health centre Reassure patients that: reactions can be treated they are not a side-effect to MDT does not mean that MDT is not working

Managing reactions (2): 

Managing reactions (2) Rest is very important: Help to get leave from work or school for a few days (e.g. medical certificate) Control of pain and fever Aspirin or paracetamol Continue MDT regularly

Managing reactions (3): 

Managing reactions (3) Reactions which only involve the skin : rest and pain-killers are usually sufficient. If there is no improvement within few days or worsening, then specific treatment is needed Reactions which involves the nerves start treatment with a course of corticosteroids (e.g. prednisolone) as soon as possible will control all signs/symptoms of reaction

Before starting treatment with prednisolone: 

Before starting treatment with prednisolone Make sure that you have adequate stock One course will require 336 tablets of 5 mg each The course lasts for 12 weeks It is better to examine the patient once every 14 days and reduce the dose Advise to take the total daily dose every morning If you do not have adequate stock, then start treatment and refer to another centre/hospital Always send a written note with the patient, when you refer

Suggested course of prednisolone: 

Suggested course of prednisolone 40 mg (8 tablets) every morning for 14 days 30 mg (6 tablets) every morning for 14 days 20 mg (4 tablets) every morning for 14 days 15 mg (3 tablets) every morning for 14 days 10 mg (2 tablets) every morning for 14 days 5 mg (1 tablets) every morning for 14 days Note: Continue rest and aspirin or paracetamol as required Examine the patient every 14 days before reducing the dose If there is no improvement or worsening, refer to hospital Continue MDT regularly

MDT side-effects: 

MDT side-effects Red coloured urine Darkening of skin Severe itching of skin This is due to rifampicin . Lasts only for few hours Reassure the patient that this is harmless This is due to clofazimine . Reassure the patient that this will disappear after treatment is completed This is due to allergy to one of the drugs (commonly to dapsone ). Stop all medicines and refer to hospital

Why do disabilities occur?: 

Why do disabilities occur? Disabilities such as loss of sensation and deformities of hands/feet/eyes occur because: Late diagnosis and late treatment with MDT Advanced disease (MB leprosy) Leprosy reactions which involve nerves Lack of information on how to protect insensitive parts

Disabilities can be prevented: 

Disabilities can be prevented The best way to prevent disabilities is: early diagnosis and prompt treatment with MDT Inform patients (specially MB) about common signs/symptoms of reactions Ask them to come to the centre ASAP Start treatment for reaction ASAP Inform them how to protect insensitive hands/ feet /eyes Involve family members in helping patients

When treatment is completed: 

When treatment is completed Congratulate the patient Thank family/friends for their support Reassure that MDT completely cures leprosy Any residual lesions will fade away slowly Show them how to protect anaesthetic areas and/or disabilities Encourage to come back in case of any problem Tell that they are welcome to bring other members of family or friends for consultation Remove the patient’s name from the treatment register