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HISTORY Leprosy is one of the oldest maladies and is well recognized in the

oldest civilization of China, Egypt and India as a contagious, mutilatingand incurable disease. The humans feared it because it resulted indisfigurement and physical disabilities, which are irreversible. Leprosy is also associated with a lot of stigma and in ancient times thecommunity shunned people affected with leprosy into separate lepercolonies

 Leprosy is believed to have existed in Egypt as long ago as 4000 BC andin India and Japan earlier than 1000 BC. It is also called as theinfectious disease of the East. It later spread to Europe and British Isles

and by 13th centaury it reached epidemic proportions.

Leprosy is a disease that has been known since biblical times. It causesskin sores, nerve damage, and muscle weakness that gets worse overtime.

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Gerhard Armauer Hansen discovered M.leprae in 1873and hence came to be called as Hansen's disease. It was

the first bacterium to be identified as a disease-causingagent in man, yet it remains as one of the disease that isleast understood. It is prevalent in warm, wet areas inthe tropics and subtropics.

Leprosy is a chronic infectious disease affecting theskin, eyes, testes, the peripheral nerves and mucosa of the upper respiratory tract but capable of affecting any tissue or organ.

Other than humans the bacteria affects armadillos,mangabe monkeys, rabbits and mice.

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Definition A chronic bacterial disease of the skin,peripheral nerves and the upper airway 

One of the most feared diseases

Causal organismM. Leprae

Early stagepainless depigmented patch

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Differential diagnosis •Tinea vesicolor•Pityriasis rosea•Birth mark depigmentation•Granuloma multiforme•Psoriasis•Contact dermatitis• Avitaminosis B•

Neurofibromatosis•Scleroderma• Xathomatosis

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MYOBACTERIUM LEPRAE   Mycobacterium leprae, which is an aerobic

(oxygen dependant) rod shaped acid-fast bacillus thatspreads through droplet infection. It has never been

grown in culture media but has been grown infootpads of the nine-banded armadillos. Thisbacterium has a long incubation period of 5 years inman and multiplies very slowly. Children are more

susceptible than adults. Man is the only source of infection. They mainly spread through dropletinfection. A large number of bacteria are shed in thenasal secretions and from the superficial lesions andnasal secretions of the multibacillary type of leprosy.

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Mycobacterium leprae •General

• Acid fast•occurs in intracellular and extracellular

•Occurs in clumps or bundles•globi

• Affinity for•Schwann cells•cells of the reticulo- endothelial system

•They remain dormant in various sites•can cause relapse

Leprosy is highly infectious disease•but low pathogenecity 

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•Mode of transmissionContact•not clearly established

•Household•prolonged close contact

•Droplet infection

•Millions of bacilli are liberated daily •in the nasal discharge

•remain viable for 7days in driednasal secretions

Cutaneous ulcers also shed largeamounts of bacilli

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•Incubation Period•9 months

–20 years

•average 4 years for tuberculoid•3-5 years for lepromatous

•Disease seen children <3 years•50 cases so far• youngest: 2 1/2 month

•Period of communicability •Infectivity is lost in most instances (continuous &regular treatment)

• within 3 months• with Dapsone (DDS) or clofazimine

• within three days• with rifampine

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•Susceptibility and resistance•Persistence and form of leprosy depend uponability to develop cell mediated immunity 

•Lepromin test•Intradermal injection of autoclaved M. Leprae& the presence or absence of induration at 28

days is called Mitsuda reaction•Reaction

•lepromatous leprosy •-ve immune reaction•

Mitsuda reaction•tuberculoid disease

•+ve immune reaction•The test gives prognostic information but it isnot diagnostic

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Intermediate lesion•Small macules

irregular•raised edge•pale skin lesions•anywhere on the body 

•Most common on•back•

forearm•thighs•face

•No sensory loss•Normal sweating•Pathology –non specific inflammatory reaction•

90% spontaneous recovery •may progress to any of the three later types•depending on the cell-mediated response

•Tuberculoid leprosy •Lepromatous leprosy •Borderline leprosy 

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Epidemiology •Infectious agent:

Mycobacterium leprae•acid fast bacilli•cannot grow in bacterial media/culture•Grow on

•mouse foot pads•in nine banded armadillo

Occurrence• World prevalence 10-12 million•Prevalence rates >5 per/1000 rural tropics and subtropics

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Endemic areas•

SE Asia•South Asia•Philippines•Indonesia•India•Bangladesh•Pacific Islands•Tropical Africa•Latin America

Reservoir•Man is the only reservoir of proven significance•Feral Armadillos in Louisiana & Texas are affected•Naturally acquired leprosy Manageby monkey & chimpanzee

captured in Nigeria and Sierra Leone\

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Mode of entry: respiratory tract or skin. Asymptomatic infections are very common.

Leprosy – 

Incidence 

 Worldwide, nearly 41000 new leprosy cases were detected in the year 2004,among which 47% were multibacillary. Nearly 12%children were found to have leprosy. It is estimated thatapproximately 1-2 million people are permanently disabled due tothe disease. According to the latest World Health Organization(WHO) report, 70% of cases are present in South East Asiancountries, with India having the majoritycase load.

Indian situation 

Most of the leprosy cases in India are present in Bihar followed by Uttar Pradesh and Jharkhand.

Currently the main features of leprosy control is based on early detection of new cases and followed by treatment with effectivechemotherapy namely the multidrug therapy with special emphasis

on providing quality patient care o leprosy patients.

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Signs and symptoms of leprosy usually appearthree to five years after becoming infected withMycobacterium leprae -- the bacteria responsiblefor the disease. Leprosy usually affects the skinand peripheral nerves. However, once signs andsymptoms of leprosy begin, there can be a wide

 variety of symptoms and severity. The type of leprosy a person has is also a factor.

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Leprosy Symptoms and Signs: An Overview When a person becomes infected with the bacteria thatcause leprosy ( Mycobacterium leprae), the bacteria begin to multiply 

 within the body. After three to five years, signs and symptoms of leprosy  will usually begin. This period between becoming infected and the startof symptoms is the "leprosy incubation period." Although theincubation period is typically between three and five years, it can range

from six months to several decades.

Leprosy usually affects the skin and peripheral nerves. However, once aperson starts experiencing signs and symptoms of leprosy, they canrange in type and severity. Symptoms can also vary based on the form of 

leprosy that a person has (tuberculoid leprosy or lepromatous leprosy).

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 Signs and Symptoms of Tuberculoid Leprosy Tuberculoid leprosy (also known as paucibacillary leprosy) is the mild form of the disease. Early signs and symptoms of tuberculoid leprosy can include oneor more light or slightly red patches of skin that appear on the trunk orextremities. This may be associated with a decrease in light-touch sensation inthe area of the rash.

Other signs and symptoms can include:

Skin stiffness and drynessLoss of fingers and toesEye problems, which leads to blindnessSevere pain

Muscle weakness, especially in the hands and feetEnlarged nerves, especially those around the elbow (ulnar nerve) and knee(peroneal nerve).

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It is important to note that not all people with leprosy lose their fingers and toes. With early diagnosisand leprosy treatment, many of these signs andsymptoms of leprosy can be prevented. Many patients

 with tuberculoid disease can even self-heal without

benefit of treatment. In order to prevent problems withfingers or toes, people should avoid injury and infectionsto these areas and take their medicines as prescribed.

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Signs and Symptoms of Lepromatous Leprosy Lepromatous leprosy (also known as multibacillary leprosy) is the

severe form of leprosy. Signs and symptoms of lepromatous leprosy caninclude a symmetrical skin rash more commonly found on the:

•Elbows•Knees•Buttocks•

Face•Ears• Wrists.• •This skin rash can be:• 

•Small or large•Flat or raised•Light or dark.

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Other signs and symptoms include:

•Thinning of eyebrows and eyelashes•Thickened skin on face•Nasal stuffiness•Bloody nose•Laryngitis•Collapsing of the nose•Swelling of the lymph nodes in the groin and armpits•Scarring of the testes that leads to infertility •Enlargement of male breasts (gynecomastia).

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Clinical manifestations •Signs of peripheral nerves involvement

•Skin lesions•Test for light touch, pin prick & temperaturediscrimination•Hyperesthesia & anesthesia

Peripheral nerves•Bilateral palpation of peripheral nerves forenlargement and tenderness

•ulnar at elbow•peroneal nerve at head of fibula•great auricular nerve

•Muscles•Paralysis•muscle wasting

•Trophic ulcers

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Complications of Leprosy•Leprosy is probably the most common cause of crippling inthe hands worldwide. Leprosy complications can include:• •Blindness•Loss of fingers or toes following an injury or infection• An increased risk for arthritis and amyloidosis.

 Worldwide, 1 to 2 million people are permanently disabledbecause of leprosy.

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CLASSIFICATIONS

Leprosy is classified into several types based on the bacterial load presentin the lesions, the extent of skin and nerve involvement and based on thepresence of deformities. Several types of classification like Madridclassification, Ridley & Jopling classification Indian Classification, WHOclassification , Field Worker's Classification etc.

Based on the 2 commonly used classifications, leprosy is classified into sixtypes based on the clinical features (Ridley & Jopling classification):The type of the disease is a reflection of the immune status of the host.

The first sign of the disease is the feeling of numbness or loss of sensation

for temperature (heat) followed by touch and pain which usually begins atthe extremities. The skin lesions appear later during the course of thedisease.

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Indeterminate Leprosy

They are the firsttype of skin lesions

characterized by hypo-pigmentedspots. The lesionsundergo healing

spontaneously  

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Paucibacillary (tuberculoid leprosy)

 A large red patch with well-defined raised borders or alarge hypo pigmentedasymmetrical lesion. Lesion is

dry and hairless Infectivity isminimal at this stage Loss of sensation is seen Nervesbecome thick followed by lossof function It either progresses

to the borderline stage orspontaneously get cured

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Borderline tuberculoid leprosy Characterized by smalland numerous skinlesions The disease goes

back to the tuberculoidstage or progresses tothe next stage

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Borderline Borderline Leprosy

Several small,irregular red lesionsare seen Moderate

sensory loss isseen It either goesback to the previousstage or progresses

to the next

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Borderline Lepromatous Leprosy

Several lesions suchas plaques,macules, papules,

and nodules areseen. Lesions have acharacteristicinverted saucer like

appearance.

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Early symptoms: Several lesions such as plaques, macules, papules, andnodules are seen. Nasal congestion, discharge and bleeding isseen Inflammation of the leg and ankles Progressivesymptoms: Thickening of the dermis (skin) in the forehead and earlobes Loss of eyebrows and eyelashes Eye defects such as glaucoma and

blindness are seen Nodules in the legs break and formulcers Enlargement of the breast and sterility occurs in themales Internal infection results in the enlargement of the liver andlymph nodes Loss of sensation in the peripheral nerves. Deformationof the fingers and toes results due to painless repeated trauma.

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Physical examination: The doctor should look for hypo-pigmented patches or nodular lesions and also loss of sensation inthe extremities.

Skin scrapings: Samples from the skin are obtained from the edgeof the lesion, which is smeared on the slide and stained with Ziel-Neelsen technique. This is very helpful in demonstrating the bacilliin the skin scrapings.

Biopsy: Biopsy of the nodular lesions, thickened nerves and lymphnode puncture is useful in demonstrating the presence of the

bacilli.

 A skin lesion biopsy is the removal of a piece of skin to diagnoseor rule out an illness.

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Lepromin skin test It is a skin test not to diagnose leprosy but to

efficiently measure the Cell Mediated Immunity (CMI) of theperson. The person is injected with the antigen (lepromin A). Theearly reaction consists of erythema and induration, which remainsfor 3-5 days and is not of much significance. The late reactioncommences after 1-2 weeks and reaches a peak in 4 weeks time. Itconsists of indurated skin nodule, which later ulcerates. Itdistinguishes between people who can mount a CMI responseagainst the bacilli with those who are not capable of eliciting aresponse.

It is positive in case of Tuberculoid type and negative in

Lepromatous Leprosy.

 Antibody detection: Detection of antibody against M.lepraeantigen is a very useful and specific diagnostic test.

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Mouse footpad inoculation test: It is a very sensitive test for thedetection of leprae bacilli in the tissue but it is unsuitable for routinediagnosis. Hence it is used only for drug resistance testing andresearch studies.

 Advanced Molecular Testing: Polymerase chain reaction (PCR)-based methods have been useful in confirming the diagnosis inpaucibacillary leprosy where few bacilli are present. It is also accuratein the detection of rifampicin/dapsone resistant strains.

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Multidrug therapy (MDT) Combinations of •Rifampicin

•urine slightly reddish for few hours•Clofazimine

brownish black discoloration•drness of skin

•Dapsone•allergic reaction towards sulpha drugs

•itchy skin rashes•exfoliative dermatitis

•do not give to patients who are allergic•May develop drug resistance if only 1 drug used

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Reactions in leprosy  •Non-Lepromatous lepra reaction (Type 1 lepra reaction)

•Seen following treatment of boderline leprosy •Type 4 delayed hypersensitivity reaction

•Last for few days to several weeks•Reactions

• Acute inflammation of preexisting borderline lesion•Skin lesions become swollen and erythematous•Neurological lesions

ulnar nerve palsy may occur abruptly •Both upgrading or reversabile reaction

•more tuberculoid or more lepromatous

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Erythema Nodosum Leprosum (Type 2lepra reaction) •Humeral antibody response to antigen antibody complex

•type III hypersensitivity reaction•systemic manifestations

•Fever• Athralgia•Painful subcutaneous erythematous nodules•Iritis

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Prevention consists of avoiding close physical contact with untreated

people. People on long-term medication become noninfectious (they donot transmit the organism that causes the disease).

Primary prevention•Health promotion•improve housing standards•

standard of living•BCG (Limited protection)

Secondary prevention•Early diagnosis & treatment• WHO-Multi drug treatment

•follow up 5 years,•Tuberculoid

–6 months

•Borderline & lepromatous – 2 years

Tertiary prevention•Disability limitation•Care of the hands, feet, neuropathy and loss of sight

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•Rehabilitation is part and parcel of effective leprosy control. Preventing deformities by early detection andprompt treatment is one of the essential steps inRehabilitation Secondly for those patients who are havingdeformities either special accessories or correctivesurgical procedures have to be undertaken.

•Social and vocational Rehabilitation are integralcomponents for the leprosy patients to lead a life of dignity.