Cutaneous Leprosy

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Cutaneous Leprosy : 

1 M.Yousry TB&leprosy Cutaneous Leprosy BY Professor M.Yousry M.Abdel-Mawla Zagazig Faculty of Medicine

Cutaneous leprosy : 

M.Yousry TB&leprosy 2 Cutaneous leprosy Leprosy is a chronic granulomatous disease, caused by Mycobacterium leprae, which affects principally the skin and peripheral nervous system Animal reservoirs of leprosy : 9-banded armadillos & chimpanzees

Pathophysiology: : 

M.Yousry TB&leprosy 3 Pathophysiology: The areas most commonly affected by leprosy are the superficial peripheral nerves, skin, mucous membranes of the upper respiratory tract, anterior chamber of the eyes, and testes. These areas tend to be cooler parts of the body. Tissue damage is caused by the degree to which cell-mediated immunity is expressed, the extent of bacillary spread and multiplication, the immunologic complications (ie, lepra reactions), and the nerve damage and its sequelae

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M.Yousry TB&leprosy 4 M leprae is an obligate intracellular acid-fast bacillus with a unique ability to enter nerves. The incubation period ranges from 6 months to 40 years or longer. The average incubation period is 2-3 years.

Medical Diagnosis of Leprosy : 

M.Yousry TB&leprosy 5 Medical Diagnosis of Leprosy The disease is usually diagnosed on the basis of : anesthesia of a skin lesion, thickened nerves, and typical skin lesions. Prodromal symptoms are generally so slight that the disease is not recognized until a cutaneous eruption is present. Temperature is the first sensation that is lost The next sensation lost is light touch, then pain, and finally deep pressure. A hypopigmented macule :the first cutaneous lesion. From this stage, most lesions evolve into the lepromatous, tuberculoid or borderline types.

Indeterminate leprosy (IL) : 

M.Yousry TB&leprosy 6 Indeterminate leprosy (IL) This early form causes one to a few hypopigmented, or sometimes erythematous, macules. Sensory loss is unusual. Most cases evolve from this state into one of the other forms, depending on the patient's immunity to the disease. Those with strong immunity may become cured of disease. May persist in this indeterminate form. In those with weaker immunity, the disease progresses to one of the other forms.

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Tuberculoid leprosy (TT) : 

M.Yousry TB&leprosy 11 Tuberculoid leprosy (TT) Skin lesions :few in number. Usually, one erythematous large plaque is present, with well-defined borders that are elevated and slope down into an atrophic center. Another presentation involves a large asymmetric hypopigmented macule. Neural involvement is common in TT; it leads to tender, thickened nerves

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Borderline tuberculoid leprosy (BT) : 

M.Yousry TB&leprosy 13 Borderline tuberculoid leprosy (BT) Lesions in this form are similar to those in the tuberculoid form, but they are smaller and more numerous. The nerves are less enlarged, Disease can remain in this stage, convert back to the tuberculoid form, or progress.

Borderline borderline leprosy (BB) : 

M.Yousry TB&leprosy 14 Borderline borderline leprosy (BB) Cutaneous : numerous, red, irregularly shaped plaques that are less well defined. Their distribution may mimic those of the lepromatous type, but they are more asymmetric. Anesthesia : moderate. Regional adenopathy may be present. Disease may remain in this stage, improve or worsen.

Borderline lepromatous leprosy (BL) : 

M.Yousry TB&leprosy 15 Borderline lepromatous leprosy (BL) Lesions : numerous and consist of macules, papules, plaques, and nodules. . Anesthesia : often absent. As with the other forms of borderline leprosy, the disease may remain in this stage, improve, or regress.

Lepromatous leprosy (LL) : 

M.Yousry TB&leprosy 16 Lepromatous leprosy (LL) Early cutaneous lesions :pale macules. Later, infiltrations are present, with numerous bacilli. Macular lesions : small, diffuse, and symmetric. The lateral eyebrows are affected by alopecia Lepromatous infiltrations : diffuse, nodules (called lepromas), or plaques. The diffuse type results in the appearance of a leonine facies. Lymphadenopathy ,hepatomegaly Stridor ,hoarseness ,osteomyelitis &Brawny edema .

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Skin Biopsy : 

M.Yousry TB&leprosy 18 Skin Biopsy Epidermis Collections of Foamy macrophages in the upper dermis. Around adnexa

Case:Clinical details : 

M.Yousry TB&leprosy 19 Case:Clinical details An 8 year old boy presented to clinic with a right Bell’s palsy. In addition it was noted that he had multiple hypo-aesthetic pale patches on the skin.

Mouth : 

M.Yousry TB&leprosy 20 Mouth Drooping corner of mouth Reduced nasolabial fold

Right arm : 

M.Yousry TB&leprosy 21 Right arm Slightly nodular hypopigmented rash

Left leg : 

M.Yousry TB&leprosy 22 Left leg Slightly nodular hypopigmented rash

Case : 

M.Yousry TB&leprosy 23 Case A 29 year old man was screened for skin lesions after his father was found to have leprosy

Left cheek : 

M.Yousry TB&leprosy 24 Left cheek Raised erythematous plaque over left cheek

Lab. Studies: : 

M.Yousry TB&leprosy 25 Lab. Studies: Tissue smear test:An incision is made in the skin, to obtain fluid from a lesion. The fluid is placed on a glass slide and stained by using the Ziehl-Neelson acid-fast method to look for organisms.The bacterial index (BI) is then determined Skin biopsy: for morphologic features and the presence of acid-fast bacilli. Sensory testing :Tactile and temperature sensations should be tested.

Lab. Studies: : 

M.Yousry TB&leprosy 26 Lab. Studies: Lepromin testing It indicates host resistance to M leprae. and does not not confirm the diagnosis, but they are useful in determining the type of leprosy. A positive finding indicates cell-mediated immunity,. A negative finding suggests a lack of resistance to disease. To perform this test, bacillary suspension is injected into the forearm. When the reaction is assessed at 48 hours, it is called the Fernandez reaction When the reaction is read at 3-4 weeks, it is called the Mitsuda reaction.

Reactions in Leprosy : 

M.Yousry TB&leprosy 27 Reactions in Leprosy

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Medical Classification of leprosy : 

M.Yousry TB&leprosy 32 Medical Classification of leprosy Paucibacillary or PB leprosy.: patients can be cured by treating the patient with two drugs for six months. Multibacillary or MB leprosy :patients can be cured by treating the patient with three drugs for twelve months. How to tell if someone has PB or MB leprosy? Count the skin patches • If you find five patches or less, classify the patient as PB. • If you find more than five patches, classify the patient as MB. When a skin smear is taken • If the skin smear is negative and the patient has five patches or less, classify the patient as PB. • If the skin smear is positive, classify the patient as MB, whatever the number of skin patches.

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Therapy of LeprosyMultiple Drug Therapy (MDT) : 

M.Yousry TB&leprosy 34 Therapy of LeprosyMultiple Drug Therapy (MDT)

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Therapy for lepra reactions : 

M.Yousry TB&leprosy 37 Therapy for lepra reactions Early diagnosis and the timely initiation of anti-inflammatory measures. The possible precipitating factor should be removed MDT should be continued in full dosage without interruption. The principles of treatment : Rest, both physical and mental, with appropriate sedation. Analgesics and anti-inflammatory drugs: Aspirin (acetylsalicylic acid) and corticosteroids

Therapy with corticosteroids : 

M.Yousry TB&leprosy 38 Therapy with corticosteroids Type 1 lepra reaction: Prednisolone should be started with a single daily dose of 40–60 mg (maximum 1mg/kg body weight) according to severity. In severe Type 2 lepra reaction: prednisolone should be started at a dose of 20–40 mg/day. Clofazimine :given in doses up to 300 mg daily for one month, and then gradually reduced.

THANK YOU : 

M.Yousry TB&leprosy 39 THANK YOU

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