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LEPROSY

Dawn Ambrose

Department of Dermatology

Hospital Kuala Lumpur

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LEPROSYFirst described in India

In 600 BC

A chronic infectiousdisease principallyaffecting

Skin Peripheral nerves Upper respiratory tracts

Eyes

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Leprosy

Worldwide estimate of 5.5 million cases

Registered cases 600 000 world-wide Tropics and subtropics 15 endemic countries

Asia (India, Nepal, Myanmar)Africa (Madagascar, Mozambique)

Latin America (Brazil) 90% registered cases in the world

1991, WHO Leprosy Elimination programme Prevalence rate of

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Leprosy

Race

all racesAfrican blacks: tuberculoid leprosy

Light skin & Chinese: lepromatous type

Recent study

chromosome 6- that increase susceptibility Confirm chromosone 10 that determine clinical types

Sex:

male:female ratio of 2:1

Age

10-14 & 35-44 year-old

rare in infants

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Leprosy

Mode of transmission- inhalation, droplet Incubation period

3-7 years

6 months to 40 years or longer

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PathogenesisM. lepraeenter body

Sub-clinical infectionSpontaneous

healing

Indeterminate leprosy

Lepromatous Borderline Tuberculoidleprosy leprosy leprosy

Cell-mediated immunity

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Tuberculoid (TT)well-defined, raised granularmargin, hypoaesthetic patch

Borderlinetuberculoid (BT)well-defined margin,hypoaesthetic patch with

satellite lesions

Borderlinelepromatous (BL)numerous symmetrical patchessloping towards the periphery

Lepromatous (LL)symmetrical, diffuse infiltrationswith nodules at eyebrows,cheeks,nose, chin and ear lobes

Indeterminatesolitary, ill-defined, hypopigmentedmacule, minimal or no loss ofsensation

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Global Situation

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Indeterrminate Leprosy(IL)

Children Single or fewhypopigmented orerythematous macules

Mild sensory loss +/- Decreased sweating May heal or remain the

same

25% develop intoclassifiable leprosy Ill-defined hypopigmentedmacule on cheek 1stsign ofleprosy

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Tuberculoid Leprosy ( TT )

Lesions

Few < four Erythematous, hyper-

or hypo-pigmented

plaques Annular/arciform Anaesthetic Dry

Hair lossSingle erythematousannular anaestheticplaque (SLPB)

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Tuberculoid Leprosy (TT)

Lesions

Face, limbs orelsewhere

Spare intertriginousareas and the scalp.

Slit skin smear-negative

Lepromin test

Positive indicates host

resistance (CMI)

Dry, anaesthetic annularplaques with hair loss

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Tuberculoid Leprosy (TT) Neural involvement

is common

great auricular nerve

superficial peroneal nerves

Ulnar nerve

5th & 7th cranial nerve

Spontaneous resolution leaving pigmentary

disturbances or scars ordeformities

90% burnt out in 20 years

10.9% per year

Progression can occur

Burn: medial 31/2, Ulnarnerve

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Borderline Tuberculoid Leprosy ( BT )

Lesions like TT butmore

Multiple nervesinvolved

Slit skin smears-neg. Lepromin test- weak

positive

Remain in this stage,improve or worsen

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Borderline Borderline Leprosy(BB)

Numerous, red,irregularly shapedplaques that are less welldefined

Widespread nerveinvolvement

Slit skin smear-positivefor AFB

Lepromin test - neg. Remain in this stage,

improve or worsen

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Borderline LepromatousLeprosy (BL)

Lesions are numerous& polymorphous

Asymmetrical

Centre of largelesions - anaesthetic

Positive AFB Lepromin test

negative Remain in this stage,

improve or worsen

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Lepromatous Leprosy (LL)

Lesions are numerous &polymorphous

Symmetrical No sensory loss

No thickened nerves Loss of lateral eyebrow Leonine facies Nerve involvement - late

Systemic disease Cannot convert to the

less severe types

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Lepromatous Leprosy (LL)

Eye Testicular atrophy

results in sterility andgynecomastia.

Lymphadenopathyand hepatomegaly Larynx- Stridor and

hoarseness

Nasal infiltration:saddle-nosedeformity.

Kidney

L t L

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Lepromatous Leprosy(Teleconsultation)

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Diagnosis of Leprosy

Anaesthetic skin lesions: leprosy unless proven otherwise

Slit skin smears: BI.MI BI (bacteriological index)

number of AFB per high power field

MI( morphological index) % solid staining AFB & considered viable bacilli.

Skin biopsy

Think of thepossibility of Leprosy

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Management of Leprosy

General principles

Multiple drug therapy ( MDT ) for all patients Patient education to dispel myths of disease and

to ensure compliance Curable

Treatment break transmission chain and preventdeformities

Possible side effects of drugs

Reactions can occur

Identify and treat Leprosy reactions Treat complications of nerve damage

Rehabilitate patients

Notify the cases

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TreatmentWHO Multi-drug therapy regime

Paucibacillary

Rifampicin 600mg monthly (supervised)Dapsone 100mg daily 6 months

Clofazimine 50mg daily

Multibacillary

Rifampicin 600mg monthly (supervised)Clofazimine 300mg monthly (supervised) 2 yearsDapsone 100mg dailyClofazimine 50mg daily

T M l i

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Sungai Buloh Augmented Regime

Paucibacillary

Rifampicin 600mg monthly (supervised)Dapsone 100mg daily 1 yearClofazimine 50mg daily

Multibacillary

Intensive phase :Rifampicin 600mg daily

Clofazimine 100mg daily 3 weeks orDapsone 100mg daily till MI=0

Maintenance phase :Rifampicin 600mg monthly (supervised)Clofazimine 300mg monthly (supervised) 3 year or tillDapsone 100mg daily smear -veClofazimine 50mg daily

Treatment - Malaysia

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Immunological reactions in leprosy

Immunological reactions inleprosy up to 30% of patients under

treatment develop reactions

Precipitating factors: anti-leprosy drugs other drugs eg. progesterone,

vitamin A

infections

anaemia mental / physical stress surgery pregnancy, child birth

Type 1 (Reversal) reaction

Type 2 reaction (ENL)

Complications of Leprosy

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Neuropathic ulcer Claw hand Extensive neuropathic ulcersand foot deformities

Bilateral lagophthalmos Corneal opacity

Leonine facies

Complications of Leprosy

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Summary

Hansens disease is now a curable disease with theavailability of potent and effective treatment

Early detection and treatment prevent morbidity However, it is still a public health problem in Malaysia,

especially with the influx of immigrants and foreignworkers in recent years

Current statistics of cases probably only represent thetip of the iceberg

Undetected and untreated cases serve as a reservoir forthe disease which is an obstacle of disease eradication Improving health education to the public as well as to

the medical personnel may be an answer to the successof control and eradication of Hansens disease

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THANK YOU