INTERNAL IONAI. JOURNAL OF LEPROSY^ Volume 50, Number 2Printed in the U.S.A.

Structure and Function of the SmallBowel in Lepromatous Leprosy'Nirmal Kumar, Veena Malhotra, Rattan Singh,

J. C. Vij, and B. S. Anand'

In leprosy the most commonly involvedareas are the skin and peripheral nerves.Less frequently, some of the internal or-gans such as the liver, spleen, and lymphnodes are also affected. However, involve-ment of the small bowel in leprosy is con-troversial. Reports, most of which are basedon post-mortem studies, vary from essen-tially normal histological appearances ( 7) tosignificant mucosal atrophy (''). In order toexamine this in more detail, a prospectivestudy of the histological appearances andabsorptive functions of the small bowel wascarried out in ten patients with leprosy.

MATERIALS AND METHODSTen untreated patients with lepromatous

leprosy were included in the study. The fol-lowing routine blood tests were carried out:complete hemogram, total and differentialproteins, serum bilirubin, SGOT, SGPT, andalkaline phosphatase. Hepatitis B surfaceantigen was assessed by the counter-cur-rent immunoelectrophoresis technique. Abarium contrast study of the small bowelwas performed in all the cases. Stool ex-aminations for ova and cysts were carriedout on three consecutive days.

Fat balance test. Patients were put on ahigh (75 g) fat diet for six days and all stoolsamples over the last three days werecollected. Fat content was estimated by themethod of van de Kamer (''). The resultswere expressed as grams of fat per 24 hrstool sample.

' Received for publication on 3 August 1981; ac-cepted for publication on 14 December 1981.

N. Kumar, M.D., Senior Resident, Department ofGastroenterology; V. Malhotra, M.D., Lecturer, De-partment of Pathology, G. B. Pant Hospital, New Del-hi, India; Prof. R. Singh, D.V., M.D., Head of De-partment of Skin and V.D., Irwin Hospital, New Delhi,India; J. C. Vij, M.D., D.M., Lecturer; B. S. Anand,M.D., Ph.D., Assoc. Prof. and Head, Department ofGastroenterology, G. B. Pant Hospital, New Delhi,India.

D-Xylose test. A 5 g dose of D-xylose wasadministered orally. One hr later a bloodsample was obtained and was analyzed forxylose by standard techniques (").

Peroral jejuna' biopsy specimens wereobtained using the Watson capsule. Thecapsule was positioned under fluoroscopyjust beyond the duodeno-jejunal junction.The biopsy specimens were orientated us-ing a dissecting microscope and stained withhemotoxylin and eosin and Ziehl-Neelsenstains.

RESULTSThere were eight males and two females

with a mean (±S.D.) age of 35.8 (±11.2)years, range, 20-52 years. The duration ofillness varied from one to ten years with anaverage of 3.9 years. The BI (") varied from2+ to 6+. One patient had concomitant pul-monary tuberculosis. All patients were onan adequate diet and all were free from anysymptoms related to the gastrointestinaltract.

The mean hemoglobin (±S.D.) concen-tration was 10 (±2.8) g%. The mean (±S.D.)total serum proteins were 6.8 (±0.32) g%with a mean albumin of 3.1 (±0.31) andglobulin of 3.65 (±0.32) g%. Other liverfunction tests were within normal limits. Theerythrocyte sedimentation rate was signifi-cantly raised in all patients with a mean of74 (±44) mm per hr. Stool examinationsshowed Ankylostowa duodenal(' in one pa-tient. Hepatitis B surface antigen was neg-ative in all patients. No abnormality of thesmall bowel was detected on barium con-trast studies.

Tests of absorption. Table 1 summarizesthe results of the absorption tests. All pa-tients except one had normal fat absorp-tion. The one exception had a mild steator-rhea with fat excretion of 7.1 g/24 hr.Similarly, D-xylose absorption was normalin all patients except two (case nos. 6 and10) and both showed only a mild derange-

148

50, 2^Kumar, et al.: Smmll Bowel in Lepromatous Leprosy^l49

ment. Barium contrast studies showed noabnormality in any of the patients.

Jejuna! mucosa. The histological appear-ances of the jejunal mucosa are shown inFigures I and 2 and the detailed assessmentsummarized in Table 2. The villous patternwas normal in eight patients: while the re-maining two (case nos. 6 and 9) showed mildbroadening and stunting of the villi. Jejunalcrypts were of normal length in all biopsyspecimens, including those with villousstunting. No acid-fast bacilli or granulomaswere seen in any of the biopsy specimens.The surface absorptive cells were tall andcolumnar with a uniform basal arrangementof the nuclei. A subjective assessment ofthe chronic inflammatory cellular infiltratedid not reveal any appreciable increase incells either in the surface epithelium or inthe lamina propria in all patients except one.The exception showed an increase in thenumber of chronic inflammatory cells in thelamina propria and was, incidentally, theone with the Anky/ostoma infestation.

DISCUSSIONSkin and peripheral nerves are invariably

involved in leprosy. In addition, internalviscera can be extensively involved in lep-romatous leprosy particularly those that arerich in reticuloendothelial cells, such as theliver, spleen, bone marrow and lymph nodes("- 1 . 8 .".'"). Involvement of the gastrointes-tinal tract, on the other hand, is a subjectof much controversy. Post-mortem studiesgive conflicting results; some studies show-

Fici. I. Jejuna] mucosa of a patient with leproma-

tous leprosy showing normal histological appearances(H & E x63).

ing invasion by leprosy bacilli (') and evensevere villous atrophy (u), others reportingperfectly normal histological appearances('). From a therapeutic viewpoint, it is ofimportance to assess the state of absorptionin leprosy patients since treatment is de-pendent upon the ability of the small bowelto absorb orally administered drugs. Thepresent study shows that intestinal absorp-

TABLE I. Sinai/ bowel functions in patients with hpromatous leprosy.

Ridley

CaseNo.

Age/sexBacteri-ologicIndex

Fecal fat"Mean

BloodD-xylose"

Barium mealfollow-throughDay 1 Day 2 Day 3

(mean)

35/F 2.3 1.2 1.6 3.3 2.03 33.0 Normal25/M 2.7 5.9 3.1 3.1 4.03 22.2 Normal

3 20/M 3.5 4.0 3.1 4.7 3.93 22.211 Normal4 52/M 3.0 2.4 2.2 3.0 2.53 25.0 Normal5 35/M 3.5 4.2 5.6 5.1 4.96 25.0 Normal6 30/M 6.0 4.2 4.4 4.2 4.26 16.6 Normal7 50/M 3.0 7.6 7.2 6.6 7.13 22.2 Normal8 25/M 3.0 4.0 3.2 2.8 3.33 12.1 Normal9 38/F 3.5 4.1 3.7 2.8 3.53 11 1......- Normal

10 48/M 2.8 2.3 1.7 2.8 2.26 20.0 Normal

Grams per 24 hr; normal < 6 g/24 hr.Concentration I hr after 5 g oral dose; normal > 22 mgr/.

150^

International Journal of Leprosy^ 1982

FIG. 2. Normal jejuna! mucosa] appearances in

lepromatous leprosy as seen under high power (HE x250).

Lion is well preserved in subjects with ex-tensive lepromatous leprosy and is in agree-ment with the observations made by Kaur,et al. ( 7 ). Therefore, oral drug therapyshould be perfectly adequate in treatingsubjects, even those with a severe disease.

Histological assessment of the small in-testinal mucosa did not reveal any signifi-cant abnormality as judged by light micro-scopic examination of the specimens (Figs.1 and 2). Furthermore, specific staining foracid-fast bacilli failed to reveal any organ-isms in the mucosa and submucosa. How-ever, it is not possible to comment upon theinvasion of the muscle coat, as noted byother workers ('), since peroral biopsyspecimens are limited to the muscularis mu-cosa.

Theoretically, it is of interest to deter-mine why the small bowel is spared in thisdisease despite a continuous bacillemia inuntreated subjects ( 5 . It is known thatthe central nervous system, lung paren-chyma, heart, great vessels, and female re-productive organs are not involved in lep-rosy ( 2 ."-'). This is not difficult to understand

TA 11 1. 1: 2. Ilistopathology of jejuna) mu-cosa in patients with lepromatous leprosy.

CaseCase .Villous patternNo.

Crypts

Inflammatory Acidinfiltrate of^fast

himtrii"^bacillipropria

I Normal Normal Increasedlymphoidcollection

Nil

2 Normal Normal Normal Nil3 Normal Normal Normal Nil4 Normal Normal Normal Nil5 Normal Normal Normal Nil6 Mild broadening Normal Normal Nil7 Normal Normal Normal Nil8 Normal Normal Normal Nil9 Mild broadening Normal Increased Nil

10 Normal Normal Normal N il

in view of the fact that these organs aredeficient in reticuloendothelial cells. Thegastrointestinal tract, on the other hand, hasan abundance of macrophages and, there-fore, it is somewhat surprising that the smallbowel is not affected. One explanation maylie in the optimal physical requirements ofleprosy bacilli, since these organisms thriveonly at low temperatures ("). It is possiblethat the small bowel has a relatively highertemperature in view of the marked meta-bolic activity taking place there, and thismay protect this organ from infection.

SUMMARYThe structural and functional status of the

small bowel was examined in ten patientswith lepromatous leprosy. The absorptivefunctions were essentially normal in all pa-tients except for minor abnormalities; onepatient had mild steatorrhea and two othershad derangement of D-xylose absorption.Barium examination did not reveal any ab-normality in any patient. Histological studyof the small intestinal mucosa showed mild,partial vinous atrophy in two patients andnormal appearances in the remaining eight.

The above abnormalities were mild andwere not considered to be of any clinicalsignificance. It is therefore concluded thatthe small bowel is not commonly involvedin lepromatous leprosy.

RESUMENSe examine el estado estructural y funcional del in-

testino delgado en 10 pacientes con lepra lepromatosa.

50, 2^Kumar. et al.: Small Bowel in Lepromatons Leprosy^151

Las funciones de absorciOn fueron esencialmente nor-males en todos los pacientes, except() por algunas al-teraciones menores: un paciente tuvo esteatorreamoderada y otros dos tuvieron alteraciones en la ab-sorci(in de D-xilosa. El examen con bario no revel()ninguna anormalidad en ningiin paciente. Los estudioshistolOgicos de la mucosa del intestino delgado reve-laron una atrolitt vellosa parcial y moderada en 2 pa-cientes, y una apariencia normal en los ocho restantes.

RESUMEL'etat structure] et fonctionnel de l'intestin grele a

etc examine chez 10 malades atteints do lepre lepro-mateuse. Les functions d'absorption se sort reveleesabsolument normales chez toils les malades, ninon pourquelques anomalies minellres. Un patient presentaitone steatorhee legere, et deux autres soulfraient detroubles de ('absorption du D-oxylose. Les examensau baryum ll'ont pas revele d'anomalies chez aucunmalade. L'etude histologique de la muqueuse de l'in-testin grele a mis en evidence one atropine pet pron-oncee et partielle des villosites chez deux malades,alors que les huit mitres patients presentaient des im-ages normales.

Acknowledgment. We should like to thank Dr. N.K. Ganguly for his critical suggestions.

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