complications of leprosy

Complications of Leprosy

Amarendra B Singh090201263

1) LEPROSY REACTION

2) ADVERSE EFFECT OF ANTI-LEPROTIC DRUGS

3) DISABILITIES & DEFORMITIES

4) PSYCHO-SOCIAL PROBLEMS

COMPLICATION CAN BE CATEGORISED AS:

DISABILITIES & DEFORMITIES

TERMINOLOGY• `Impairments' are defined as `problems in body function

or body structure such as a significant deviation or loss'.

• A `deformity' is a structural, usually visible, impairment.

• A `defect' could be either a functional or structural impairment.

• `Disability' is used as an umbrella term for impairments, activity limitations and participation restrictions.

Risk factors and Types Of Deformities

• Risk factors are:- 1) Type of Leprosy- more extensive and highly

bacilliferous types carry a high risk if not treated early.

2) No. of nerve trunk involved- more than three nerve trunk involvement increases the risk manifold.

3) Attack of reaction and neuritis increases the risk.4) Duration of active diseases- longer the disease

remains untreated, greater the risk of disability.

Types of Deformities

1. Specific Deformities:- loss of eyebrows, nasal deformities.

2. Paralytic Deformities:- claw finger, foot drop, facial palsy.

3. Anesthetic deformities:- ulceration, mutilation

GRADE HAND & FEET EYES

0 No loss of sensationNo visible deformity or damage(Muscle power normal)

No eye problem due to leprosy;No evidence of visual loss

1 LOSS OF SENSATION is thereNo visible deformity or damage

Eye problem due to leprosy present, but vision not severly affected as a result of these (can count fingers at 6m)

2 VISIBLE DAMAGE [loss of sensation and muscle power weak/paralysed](wounds, ulcer, deformity due to muscle weakness, loss of tissue such as foot drop, claw hand, loss or partial resorption of fingers/toes)

Severe vsual impairmentVision – cannot count fingers at 6mAlso includes lagophthalmos, iridocyclitis and corneal opacities.

WHO GRADING OF DISABILITIES IN LEPROSY

Nerve Involvement• Nerve damage occurs in two settings- in skin lesion– small dermal sensory and autonomic nerve fibres supplying dermal and subcutaneous structures are damaged.

involving Peripheral nerve trunks– usually those which are superficial or are in fibrocasseous tunnels leading to dermato sensory loss and dysfunction of muscles.

Posterior tibial nerve is the most frequently affected nerve followed by ulnar, median, lateral popliteal and facial.

Stages Charecteristics

1 Parasitization A few leprae found in nerve

2 Tissue response Host tissue response(TT to LL)+, bacilli+

3 Clinical involvement Clinically thickened w or w/o pain. No NFD

4 Nerve damage NFD+, recovery possible

5 Nerve destruction Irreversible NFD, severe wasting +

Nerve Care Practice• AIM- to prevent permanent damage to nerve trunks• It involves- Recognizing acute or subacute “clinical neuritis” and treating it using steroid or other measures.

Recognizing Nerve function deficit and instituting appropriate treatment without delay.

‘Clinical neuritis’ is diagnosed when a nerve trunk shows moderate to severe nerve pain. It may or may not be associated with NFD and similarly NFD may or may not be associated with clinical neuritis(Quiet Nerve Paralysis)

NERVE TENDERNESS SCALE

GRADE Clinical features

0 No tenderness Palpation not painful

1 Mild tenderness Palpation hurts only when asked about it

2 Moderate tenderness Palpation hurts even w/o asking

3 Severe tenderness Palpation is very painful

4 Very severe tenderness Pt. is apprehensive of palpation

Nerve Function Deficit Clinical Neuritis Absent Present

Absent A B

Present C D

• Category A patients- pt is taught how to look for signs and symptoms of neuritis.

• Category B patients-(Neuritis +, no NFD) Start Prednisolone 40-80 mg daily 4 wks taper dose 5mg/wk upto 30mg 2-3 wks and then taper it.

• In BT leprosy cases (neuritis due to RR), if there is no significant improvement in the clinical condition within 48-72 hrs then immediate surgical decompression is required so that haemoperfusion to nerve can occur.

• In BL and LL cases(neuritis due to ENL), one can wait for six weeks or even longer.

• Category C patients- ( No neuritis, NFD+) Clinically, one may assume that the nerve trunk has the potential to recover if NFD is :-– of recent onset - < 6 months involvement– incomplete- some sensibility is there– and if no severe muscle wasting present

If NFD considered reversible:- prednisolone 30mg 4 wks then tapered off over 30 days. If NFD not recent:- prevent secondary impairment.

• Category D patients:-(NFD +, neuritis+) Prednisolone 40-80 mg daily 2-3 wks reduce to maintenance dose in 3-4wks

Maintenance dose 30mg daily 8-10 wks

If there is no improvement in neuritis within 3-7days then surgical decompression is required.To accelerate resolution of inflammation:- 1- splint affected nerve in slightly stretched position 2-supportive therapy like analgesics 3- short wave or microwave diathermy

Nerve abscess

• Nerve abscess is cold abscess occurring in a damaged fascicle usually in Tuberculoid Leprosy

• Occasionally, ‘hot’ abscess occurs in ENL related neuritis

Management :--• if nerve shows no NFD: wait and watch, drain

abscess only if risk of sinus formation is there.• if nerve is considered irrecoverably damaged:

same as above.• if NFD is considered likely to recover: evacuate

and excise the abscess.

Hand Problems in Leprosy Patients

Hand Problems in Leprosy Patients

• Hands are affected because of damage to nerves supplying them or directly affected by reaction process(especially in BL, LL).

• Ulnar nerve is affected most often than others. (Claw hand)

• In BL,LL cases usually Glove type extensive acral anesthesia occurs without significant motor involvement.

Impairment Direct consequences Late consequences

Damage to somatic sensory fibres

Loss of sensibility Anesthetic deformities(ulcers, shortening of digits.)

Damage to motor fibres Muscle paralysis Contracture

Damage to pseudo motor autonomic fibres

Dry skin Deep cracks, hand infections

Lepra reaction Inflammatory edema, osteoporosis, bone destruction, pathological fractures

Severe fixed deformities(specific deformities, bizarre deformities)

Specific Deformities of hand

Banana Fingers (due to heavy infiltration)

“Reaction Hand” (when hand is involved in reactional states)

Foci of acute Inflammation which eventually resolves with dense fibrosis.

Contraction of the dermal collagen draws the fingers dorsally giving rise to swan neck deformity.

Rx. Start systemic corticosteroids therapy(30 mg), Initially hand is rested using splint in functional position Wax baths Active movements after subsidizing acute phase

Paralytic deformities of hand

• Ulnar palsy leads to:- Ulnar claw hand (hyper extended MCP and flexed PIP jts)

• Combined Ulnar and Median nerve palsy:-Complete claw hand

Corrective Surgery are:--Lasso insertionZancolli’s operation Srinivasan’s operationBunnell’sBrandAntia

Anesthetic deformities

Leprosy Damage of sensory nerves Anesthesia Injury Neglect of injury Infection Tissue damage and loss of tissue healing with deformity.

The resulting deformities are:• Contractures• Shortening of the digits• Mutilation of the hand• Disorganization of the hand

Foot Problem In Leprosy Patients

Foot Problem In Leprosy Patients• Common problems are:- Plantar ulceration (Trophic ulcers) Foot drop Fixed deformities of feet and toes Tarsal disorganization.

PLANTAR ULCERATION:-• manifestation of sensory-motor deficit • mostly in front part of sole in MTP joint • augmented by infection through fissures and paralysis

of feet muscles (which counter the stress while walking)

Management and Prevention

• Management:--– Absolute bed rest and elevate foot– Eusol bath, irrigation, dressing– Remove slough or other draining procedures– Start antibiotics– Protective foot wearing

Protective footwear• Feet with only sensory

loss (no muscle paralysis)

• Insensitive feet (with intrinsic muscle paralysis)

Infected ulcer/Cracks

Wounds/injury

weakness/paralysis

• Clean with soap & water• Rest & apply antiseptic dressing• Apply cooking oil/Vaseline

• Soak in water• Clean and apply clean bandage• Protect when working/cooking

• Oil massage• Exercises

FOOT CARE PRACTICE

Foot drop

• Develops due to damage to lateral popliteal nerve.• Paralysis of anterior muscles give rise to foot drop• Characteristic ‘High-stepping gait’ occurs in which • Ball of foot instead of heel hits the ground• Inversion foot leads to overloading on outer part.

Management

• If paralysis is recent; manage under ‘Nerve Care’ therapy.

• If paralysis is of >1 year duration; it is satisfactorily corrected by anterior transposition of tibialis posterior tendon (Srinivasan’ operation)

• If surgical intervention is contraindicated; foot drop appliances like strap, stops or springs are used that hold foot at right angle.

• Splinting of knee: this allows rest to inflamed nerve and result in quicker healing.

• Dropped foot should be supported to hasten recovery. Splint

Deformities of Face

Deformities of Face• Loss of eyebrows (Madarosis)

• Mega lobules of ear (Buddha ear)

• Premature senility(stretching of skin due to heavy infiltration lead to loss of elastic tissue, when infiltration regresses skin become redundant)

• Sunken Nose

Eye Problem• More commonly in BL and LL type

leprosy.o Direct invasion- leprous

conjunctivitis, scleritis and choroidal nodule.

o Acute iridocyclitis- due to immune complex deposition.

o Lagophthalmos - due to damage to facial nerve.

o Corneal sensation lost - due to damage to trigeminal nerve, leads to exposure keratitis and corneal ulceration

Management

• Using spectacles,gogles or eyeshades.• Artificial tears and cover eyes during sleep• Treating acute iridocyclitis using topical

corticosteroids• Surgical intervention for lagophthalmos or

cataract

GynecomastiaEmbarrassing enlargement of breast in males, usually bilateral due to hormonal imbalances because of testicular and liver damage.

Simple mastectomy is the treatment of choice (WEBSTER’S OPERATION)

• Are related to widely held beliefs and prejudices concerning leprosy & its causes.

• They often develop self stigma, low self esteem & depression as a result of rejection and hostility.

• Need to be referred for proper counselling.

PSYCHO- SOCIAL PROBLEMS

• Social banishment is now on decrease following extensive education about leprosy.

• Appropriate economic rehabilitation is provided e.g. sewing machines, handcrafts, carpentry etc.

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REFERENCES:-----• IADVL• IAL• PARK’ Preventive and Social Medicine• Journals