LEPROSYLEPROSY

EPIDEMIOLOGYEPIDEMIOLOGY

8 MILLION PATIENTS8 MILLION PATIENTS 60,000 NEW CASES EACH YEAR WORLD WIDE60,000 NEW CASES EACH YEAR WORLD WIDE LEPROSY IS ENDEMIC IN ASIA & AFRICALEPROSY IS ENDEMIC IN ASIA & AFRICA APPOX. 80% CASES IN THESE AREAS IN THE APPOX. 80% CASES IN THESE AREAS IN THE

WORLDWORLD

Global Leprosy Situation in 2005Global Leprosy Situation in 2005

WHO Region Point PrevalenceWHO Region Point Prevalence Africa 47 596Africa 47 596 Americas 36 977Americas 36 977 East Mediterranean 5 398East Mediterranean 5 398 South East Asia 186 182South East Asia 186 182 Western Pacific 10 010Western Pacific 10 010 World 286 063 World 286 063   

PERVALENCE OF LEPROSY PERVALENCE OF LEPROSY ININSEA REGION SEA REGION WHO 2003WHO 2003

DEFINITIONDEFINITION LEPROSY IS A NONFATAL ,CHRONIC INFECTIOUS DISEASE LEPROSY IS A NONFATAL ,CHRONIC INFECTIOUS DISEASE

CAUSED BY CAUSED BY MYCOBACTRIUM LEPRAE (By G.A.Hansen 1873)MYCOBACTRIUM LEPRAE (By G.A.Hansen 1873) INVOLVING -INVOLVING - SKINSKIN PERIPHERAL NERVOUS SYSTEMPERIPHERAL NERVOUS SYSTEM UPPER RESPIRATORY TRACTUPPER RESPIRATORY TRACT EYESEYES TESTESTESTES M.LEPRAE HAS UNIQE TROPISM FOR PEIPHRAL NERVESM.LEPRAE HAS UNIQE TROPISM FOR PEIPHRAL NERVES REACTIONAL STATE RESPONSIBLE FOR MORBIDITY & REACTIONAL STATE RESPONSIBLE FOR MORBIDITY & DISEASE IF NOT TREATED LEADS TO CHARECTERSTIC DISEASE IF NOT TREATED LEADS TO CHARECTERSTIC

DEFORMITY & PROFOUND SOCIAL STIGMADEFORMITY & PROFOUND SOCIAL STIGMA

DEFORMITYDEFORMITY

M. LEPRAEM. LEPRAE NONCULTIVABLE IN MEDIUMNONCULTIVABLE IN MEDIUM FACULTATIVE OBLIAGTE INTRACELLULAR ORGANISMFACULTATIVE OBLIAGTE INTRACELLULAR ORGANISM GRAM-POSITIVEGRAM-POSITIVE ACID-FAST BACILUSACID-FAST BACILUS PEPTIDOGLYCAN-BACK BONEPEPTIDOGLYCAN-BACK BONE ARABINOGALACTAN & MYCOLIC ACIDARABINOGALACTAN & MYCOLIC ACID PHENOLIC GLYCOLIPD-1 (PGL-1) ATTACHED TO LAMININ 2 OF PHENOLIC GLYCOLIPD-1 (PGL-1) ATTACHED TO LAMININ 2 OF

SCHWANN CELLSSCHWANN CELLS MHC CLASS II FOR DISEASE EXPRESSION NOT FOR MHC CLASS II FOR DISEASE EXPRESSION NOT FOR

SUSCEPTIBILITY OF DISEASESUSCEPTIBILITY OF DISEASE SUSCEPTIBILTY GENE LOCUS ON CHROMOSOME-10P13SUSCEPTIBILTY GENE LOCUS ON CHROMOSOME-10P13

The route of transmissionThe route of transmission Not been definitively established, Not been definitively established, Although Although human-to-human aerosol spread of nasal human-to-human aerosol spread of nasal

secretionssecretions is the most likely mode of transmission in is the most likely mode of transmission in most cases. most cases.

The disease is not spread by touch, since the The disease is not spread by touch, since the mycobacteria are incapable of crossing intact skin. mycobacteria are incapable of crossing intact skin.

Living near people with leprosy is associated with Living near people with leprosy is associated with increased transmission. Among household contacts, increased transmission. Among household contacts, the relative risk for leprosy is increased 8- to 10-fold the relative risk for leprosy is increased 8- to 10-fold in multibacillary and 2- to 4-fold in paucibacillary in multibacillary and 2- to 4-fold in paucibacillary forms. forms.

Animal reservoirs do exist (armadillos, certain Animal reservoirs do exist (armadillos, certain nonhuman primates), and cases of suspected zoonotic nonhuman primates), and cases of suspected zoonotic transmission have been reported. transmission have been reported.

Two indices which depend on observation of Two indices which depend on observation of M. leprae in smears from skin or nasal smears M. leprae in smears from skin or nasal smears are useful in assessing are useful in assessing

the amount of infection,the amount of infection, the viability of the organisms the viability of the organisms the progress of the patient under treatment. the progress of the patient under treatment.

They are -They are - the morphological index (MI) the morphological index (MI) the bacteriological index (BI).the bacteriological index (BI).

1. 1. The bacteriological index (BI)The bacteriological index (BI)

This is an expression of the extent of bacterial This is an expression of the extent of bacterial loads. It is calculated by counting six to eight loads. It is calculated by counting six to eight stained smears under the 100 x oil immersion stained smears under the 100 x oil immersion lens. lens.

A smear stained by the Ziehl-Neelsen method A smear stained by the Ziehl-Neelsen method and decolorized (but not completely) which and decolorized (but not completely) which 1% acid alcohol. 1% acid alcohol.

The results are expressed on a logarithmic The results are expressed on a logarithmic scale. scale.

BACTERIOLOGICAL INDEXBACTERIOLOGICAL INDEX

LOGAITHMIC SCALE AS TO NUMBER OF LOGAITHMIC SCALE AS TO NUMBER OF BACILLI PER OIL IMMERSION FIELD(OIF)BACILLI PER OIL IMMERSION FIELD(OIF)

BI OF 6 IS 1000 OR MORE BACILLI/OIFBI OF 6 IS 1000 OR MORE BACILLI/OIF BI OF 5 IS 100 TO 1000/OIFBI OF 5 IS 100 TO 1000/OIF BI OF 4 IS 10 TO 100 BACILLI/OIFBI OF 4 IS 10 TO 100 BACILLI/OIF BI OF 3 IS 1 TO 10 BACILLI/OIFBI OF 3 IS 1 TO 10 BACILLI/OIF BI OF 2 IS 1 BACILLUS/1 TO 10 OIFSBI OF 2 IS 1 BACILLUS/1 TO 10 OIFS BI OF 1 IS 1 BACILLUS/ 10 TO 100 OIFSBI OF 1 IS 1 BACILLUS/ 10 TO 100 OIFS BI OF 0 IS NO BACILLUS PER 100 OIFSBI OF 0 IS NO BACILLUS PER 100 OIFS

MORPHOLOGICAL INDEXMORPHOLOGICAL INDEX

PERCENTAGE OF SOLIDLY STAINED PERCENTAGE OF SOLIDLY STAINED BACILLI IN STAINED SMEARBACILLI IN STAINED SMEAR

Only the solid-staining bacilli are viable. Only the solid-staining bacilli are viable. It is not unusual for solid-staining M. leprae to It is not unusual for solid-staining M. leprae to

reappear for short periods in patients being reappear for short periods in patients being successfully treated with drugs. successfully treated with drugs.

It is important to recognize that measurement It is important to recognize that measurement of MI is liable for observer variations and of MI is liable for observer variations and therefore not always reliable.therefore not always reliable.

IS LEPROSY HOST IMMUNE DEPENDENT DISEASE?

YES….

CMI OR ANTIBODY MEDIATED ?

CLINICAL PRESENTATIONCLINICAL PRESENTATION

LEPROSY HAS SPECTRUM OF DISEASELEPROSY HAS SPECTRUM OF DISEASE Ridley-Jopling classification systemRidley-Jopling classification system

TT BT BB BL LLTT BT BB BL LL

INDICIES FOR SPECTRUMINDICIES FOR SPECTRUM BACTERIOLOGICALBACTERIOLOGICAL IMMUNOLOGICALIMMUNOLOGICAL CLINICALCLINICAL HISTOPATHOLOGICALHISTOPATHOLOGICAL

WHO Classification system:WHO Classification system: The WHO recommends classifying leprosy according The WHO recommends classifying leprosy according

to the number of lesions and the presence of bacilli on to the number of lesions and the presence of bacilli on a skin smear. a skin smear.

. . Paucibacillary (PB) leprosy is characterized by 5 or Paucibacillary (PB) leprosy is characterized by 5 or

fewer lesions with absence of organisms on smear. fewer lesions with absence of organisms on smear. Includes the tuberculoid and borderline tuberculoid Includes the tuberculoid and borderline tuberculoid

leprosy categories from the Ridley-Jopling system. leprosy categories from the Ridley-Jopling system.

Multibacillary (MB) leprosy is marked by 6 or more Multibacillary (MB) leprosy is marked by 6 or more lesions with possible visualization of bacilli on lesions with possible visualization of bacilli on smear.smear.

Includes Lepromatous, borderline lepromatous, and Includes Lepromatous, borderline lepromatous, and midborderline on the Ridley-Jopling scale .midborderline on the Ridley-Jopling scale .

The cardinal signs of leprosyThe cardinal signs of leprosy Hypoesthesia,Hypoesthesia, skin lesions, skin lesions, loss of hair and sweating & peripheral loss of hair and sweating & peripheral

neuropathy. neuropathy. The first physical signs of leprosy are usually The first physical signs of leprosy are usually

cutaneous. cutaneous. The subtype of leprosy often determines the The subtype of leprosy often determines the

degree of skin involvement. degree of skin involvement.

Physical examination Physical examination

Evaluation of skin lesions Evaluation of skin lesions Careful sensory and motor examination Careful sensory and motor examination Palpation of peripheral nerves for pain or Palpation of peripheral nerves for pain or

enlargement. Particular attention should be paid to enlargement. Particular attention should be paid to the following locations: the following locations:

Elbows - Ulnar nerve Elbows - Ulnar nerve Wrist - Superficial radial cutaneous and median Wrist - Superficial radial cutaneous and median

nerves nerves Popliteal fossa - Common peroneal nerve Popliteal fossa - Common peroneal nerve Neck - Great auricular nerveNeck - Great auricular nerve

TUBERCULOID LEPROSYTUBERCULOID LEPROSY Single or few LesionsSingle or few Lesions Erythematous plaquesErythematous plaques HypopigmantedHypopigmanted HypoasthaticHypoasthatic Macular lesionsMacular lesions Cutaneous nerve Cutaneous nerve thickenedthickened

TUBERCULOID LEPROSYTUBERCULOID LEPROSY

TUBERCULOID LEPROSYTUBERCULOID LEPROSY

TUBERCULOID LEPROSYTUBERCULOID LEPROSY

BORDERLINE LEPROSYBORDERLINE LEPROSY

BORDERLINE LEPROSYBORDERLINE LEPROSY

POSTERIOR AURICULAR POSTERIOR AURICULAR NERVE THICKNINGNERVE THICKNING

LEPROMATOUS LEPROSYLEPROMATOUS LEPROSY

LEPROMATOUS LEPROSYLEPROMATOUS LEPROSY

LEPROMATOUS LEPROSYLEPROMATOUS LEPROSY

POSTERIOR AURICULR NERVEPOSTERIOR AURICULR NERVE

NODULR LESION AT PINNANODULR LESION AT PINNA

NODULAR LESION AT PINNANODULAR LESION AT PINNA

DIFFUSE INFILTRATIONDIFFUSE INFILTRATIONININ

LEPROMATOUS LEPROSYLEPROMATOUS LEPROSY

DIFFUSE INFILTRATIONDIFFUSE INFILTRATIONININ

LEPROMATOUS LEPROSYLEPROMATOUS LEPROSY

BORDERLINE LEPROMATOUS BORDERLINE LEPROMATOUS LEPROSYLEPROSY

LEFT ULNER NERVE PALSYLEFT ULNER NERVE PALSY

ANESTHATIC HANDANESTHATIC HAND

SKIN SMEAR FROM LESION SHOWS AFB++SKIN SMEAR FROM LESION SHOWS AFB++

HISTPATHOLOGYHISTPATHOLOGY

Immunologic tests Immunologic tests Lepromin skin testLepromin skin test Not diagnostic of exposure or infection with Not diagnostic of exposure or infection with M M

lepraeleprae Assesses a patient's ability to mount a Assesses a patient's ability to mount a

granulomatous response against a skin granulomatous response against a skin injection of killed injection of killed M lepraeM leprae. .

Patients with tuberculoid or borderline Patients with tuberculoid or borderline lepromatous leprosy typically have a positive lepromatous leprosy typically have a positive response (>5 mm). response (>5 mm).

Patients with lepromatous leprosy typically Patients with lepromatous leprosy typically have no response.have no response.

Detection of antibodies to phenolic glycolipid-1 (PGL-1) Detection of antibodies to phenolic glycolipid-1 (PGL-1) This is a specific serologic test.This is a specific serologic test.

This test has a sensitivity of 95% for the detection of This test has a sensitivity of 95% for the detection of lepromatous disease but only 30% for tuberculoid disease.lepromatous disease but only 30% for tuberculoid disease.

PCR and recombinant DNA technology PCR and recombinant DNA technology development of gene probes with development of gene probes with M lepraeM leprae–specific –specific

sequences. sequences. This technology can be used to identify the mycobacterium This technology can be used to identify the mycobacterium

in biopsy samples, skin and nasal smears, and blood and in biopsy samples, skin and nasal smears, and blood and tissue sections.tissue sections.

Lymphocyte migration inhibition test (LMIT): Lymphocyte migration inhibition test (LMIT): As determined by a lymphocyte transformation and LMIT, As determined by a lymphocyte transformation and LMIT,

cell-mediated immunity to cell-mediated immunity to M lepraeM leprae is absent in the is absent in the lepromatous form of disease but present in the tuberculoid lepromatous form of disease but present in the tuberculoid form of disease.form of disease.

Contact or family screening for history of leprosyContact or family screening for history of leprosy

REACTIONIONAL SATESREACTIONIONAL SATES

ININ

LEPROSYLEPROSY

TYPE -1 REACTIONTYPE -1 REACTION OCCURS IN BORDERLINE CASES NOT IN POLAR OCCURS IN BORDERLINE CASES NOT IN POLAR

LEPROSY LEPROSY ACTIVATION OF PREVIOUSLY INVOLVED SKIN ACTIVATION OF PREVIOUSLY INVOLVED SKIN

LESIONSLESIONS PANFUL & TENDER NERVESPANFUL & TENDER NERVES DOWNGREADING REACTION DOWNGREADING REACTION - WHEN OCCURS - WHEN OCCURS

BEFORE INITIATON OF CHEMOTHERAPYBEFORE INITIATON OF CHEMOTHERAPY REVERSAL REACTION REVERSAL REACTION AFTER INITIATION OF AFTER INITIATION OF

CHEMOTHERAPY- TH1 RESPONSES WITH IFN-CHEMOTHERAPY- TH1 RESPONSES WITH IFN-GAMMA,IL2 GAMMA,IL2

CORTICOSTEROID TREATMENT OF CHOICECORTICOSTEROID TREATMENT OF CHOICE

TYPE -1 REACTIONTYPE -1 REACTION

TYPE -2 REACTIONTYPE -2 REACTION OCCURS IN BL/LL FORM OF LEPROSYOCCURS IN BL/LL FORM OF LEPROSY IN 50% OF CASESIN 50% OF CASES IN 90% OF CASES MAY BE PRESENTING SYMPTOM OF DISEASEIN 90% OF CASES MAY BE PRESENTING SYMPTOM OF DISEASE ENL- ERYTHEMA NODOSUM LEPROSUMENL- ERYTHEMA NODOSUM LEPROSUM FEVERFEVER ARTHRITISARTHRITIS UVEITISUVEITIS ORCHITISORCHITIS GLOMERULONEPHRITISGLOMERULONEPHRITIS TNF- PLAYS CETERAL ROLE, TNF- PLAYS CETERAL ROLE, IMMUNE COMPLEX DEPOSITIONIMMUNE COMPLEX DEPOSITION TH2 CYTOKINE PROFIL-IL6,IL8TH2 CYTOKINE PROFIL-IL6,IL8 THALIDOMIDE IS CHOICE OF TREATMENTTHALIDOMIDE IS CHOICE OF TREATMENT

ERYTHEMA NODOSUM ERYTHEMA NODOSUM LEPROSUMLEPROSUM

Erythema NodosumErythema Nodosum

TREATMENT-MDTTREATMENT-MDT

MULTIMULTI DRUGDRUG THERAPYTHERAPY

What is WHO MDT?What is WHO MDT?                                    Multi drug therapy (MDT) is a key element of the Multi drug therapy (MDT) is a key element of the

elimination strategy.elimination strategy. MDT is available free of charge from WHOMDT is available free of charge from WHO The drugs used in WHO-MDT are a combination of The drugs used in WHO-MDT are a combination of

Rifampicin,Rifampicin, clofazimine and Dapsone for MB leprosy patients and clofazimine and Dapsone for MB leprosy patients and Rifampicin and Dapsone for PB leprosy patients. Rifampicin and Dapsone for PB leprosy patients. Treatment of leprosy with only one anti leprosy drug Treatment of leprosy with only one anti leprosy drug

will always result in development of drug resistance.will always result in development of drug resistance. Treatment with Dapsone or any other anti leprosy Treatment with Dapsone or any other anti leprosy

drug used as monotherapy should be considered as drug used as monotherapy should be considered as unethical practice. unethical practice.

  

MULTI DRUG THERAPYMULTI DRUG THERAPY

Yes, it is the best combination available today, Yes, it is the best combination available today, as proved by its successful application in as proved by its successful application in leprosy control under varying conditions since leprosy control under varying conditions since 1982. 1982.

The combination not only cures leprosy but is The combination not only cures leprosy but is also highly cost-effective. also highly cost-effective.

TREATMENT REGIMENSTREATMENT REGIMENS WHO WHO

TUBERCULOID- PAUCIBACILLARYTUBERCULOID- PAUCIBACILLARY DAPSONE 100 mg/D UNSUPERVISED +DAPSONE 100 mg/D UNSUPERVISED + RIFAMPIN 600mg/MONTH SUPERVISED FOR 6 MONTHRIFAMPIN 600mg/MONTH SUPERVISED FOR 6 MONTH

MULTIBACILLARY DISEASEMULTIBACILLARY DISEASE DAPSONE 100mg /D PLUSDAPSONE 100mg /D PLUS CLOFAZIMINE 50mg/D UNSUPERVISED PLUSCLOFAZIMINE 50mg/D UNSUPERVISED PLUS RIFIAMPIN 600mg + CLOFAZIMNE 300mg MONTHLY RIFIAMPIN 600mg + CLOFAZIMNE 300mg MONTHLY

SUPERVISED FOR 1 YEAR SUPERVISED FOR 1 YEAR

PhysiotherapyPhysiotherapy Reconstructive surgeriesReconstructive surgeries Rehabilitation programesRehabilitation programes Health educationHealth education

THANK THANK YOU…….YOU…….

MDTMDT Rifampicin:Rifampicin: The drug is given once a month. No toxic effects The drug is given once a month. No toxic effects

have been reported in the case of monthly administration. The have been reported in the case of monthly administration. The urine may be coloured slightly reddish for a few hours after its urine may be coloured slightly reddish for a few hours after its intake, this should be explained to the patient while starting intake, this should be explained to the patient while starting MDT. MDT.

ClofazimineClofazimine: It is most active when administered daily. The : It is most active when administered daily. The drug is well tolerated and virtually non-toxic in the dosage drug is well tolerated and virtually non-toxic in the dosage used for MDT. The drug causes brownish black discoloration used for MDT. The drug causes brownish black discoloration and dryness of skin. However, this disappears within few and dryness of skin. However, this disappears within few months after stopping treatment. This should be explained to months after stopping treatment. This should be explained to patients starting MDT regimen for MB leprosy. patients starting MDT regimen for MB leprosy.

DapsoneDapsone: The drug is very safe in the dosage used in MDT : The drug is very safe in the dosage used in MDT and side effects are rare. The main side effect is allergic and side effects are rare. The main side effect is allergic reaction, causing itchy skin rashes and exfoliative dermatitis. reaction, causing itchy skin rashes and exfoliative dermatitis. Patients known to be allergic to any of the sulpha drugs should Patients known to be allergic to any of the sulpha drugs should not be given dapsone. not be given dapsone.