Leprosy

this presentation gives a detailed information about leprosy,its signs and symptoms,treatment,management.

1. LEPROSY
-Rajnee Mishra
BPT Final Year
BIMLS

2. LEPROSY
Leprosy, also known as Hansen’s disease, is a
chronic mycobacterial disease of humans.
The term ‘Leprosy’ is
taken from a Latin word, ‘lepra’
means Scaly, while the Hansen’s
disease was named after the
Physician, Gerhard Armauer
Hansen, who first identified the
Mycobacteria.

3. Background of Leprosy
In the 1990s, the World Health Organization
(WHO) launched a campaign to eliminate
leprosy as a public health problem by 2000.
Elimination, as per WHO, was defined ass a
reduction of patients with leprosy requiring
multidrug therapy to fewer than 1 per 10,000
population. This goal was achieved in 2002 as
global prevalence .

4. The goal of WHO by the end of 2015 is to reduce
the rate of new cases with grade-2 disabilities
worldwide by atleast 35%. This will be carried
out by enforcing activities to decrease the delay
in diagnosis the disease and actuate treatment
with multidrug therapy. This will also have the
impact of reducing transmission of the disease
in the community.

5. History of Leprosy
In the primitive years, the disease was
considered as a CURSE of Almighty, but not
merely an infection.
The patients being treated as a culprit, were
used to be isolated from the society.

6. Epidemiology
Leprosy is a disease which is still endemic in
120 developing countries and also continues to
be a significant cause of blindness.
80% of the worldwide cases are found in five
countries, namely India, Myanmar, Indonesia,
Brazil and Nigeria.
Though it is a disease of developing countries,
it affects all the races.
20% of cases results in deformities.
Prevalence rate- 5.7/1000.

8. Facts about Leprosy
It is an infectious disease but not
1.Hereditary disease.
2.A curse of God.
3.Result of past sins.
Leprosy is a 100% curable disease, whereas
diabetes and hypertension are not.
It is not dependent on caste or class.
Early diagnosis and treatment with MDT
prevent deformities.

9. Etiology
The disease, Leprosy, occurs due to
mycobacterial infection.
The causative organism are
Mycobacterium leprae and Mycobacterium
lepromatosis .
The infection may also be
transmitted to humans by Armadillos.

10. Morphology of Organism
Mycobacterium leprae is a or straight
or slightly curved, acid-fast bacillus
which shows considerable various
morphological variations. They are
microaerophilic, gram-positive.
The live and dead bacilli can be
differentiated in smears by Ziehl-Neelsen method
and are stained by Carbon fuchsine.

11. Source of infection
The source of infection in
leprosy is patient itself.
Nasal discharge, skin lesions of patient and close
contact with the untreated patients leads to the
transmission of the infection.

12. Pathogenesis
The bacilli enters the host body via two entry points: 1.
Skin , 2. Upper respiratory tract.
After invading into host body, i.e, human,
primarily localise in the skin, peripheral nerves and nasal
mucosa of the patient.
The bacilli primarily affects Schwann cells in the
peripheral nerves leading to nerve damage,
demyelination and the development of disabilities.
The bacilli lives in the host body in two forms:
1. Generalised, 2. Localised.
The bacilli has also two routes for its exit:
1. Nasal mucosa, 2. Skin. It has been assumed that the
bacilli exits along with sebaceous secretions.

14. Incubation Period
The incubation period is long and variable.
The minimum period of incubation can be a
few weeks and a maximum of 10-40 years.

15. Classification of Leprosy
WHO (World health organisation) has classified
Leprosy depending upon the involvement of nerves
and skin lesions into two types:
1. Paucibacillary : No or 1 nerve trunk involved with
a maximum of 5 skin lesions.
2. Multibacillary : Involvement of more than 1 nerve
trunk and 5 skin lesions.

16. Ridley and Jopling classified leprosy into
5 types depending upon the clinical and
histological findings:
1. Tuberculoid
2. Borderline tuberculoid
3. Borderline
4. Borderline lepromatous
5. Lepromatous

17. Indian classification of Leprosy:
1.Intermediate
2.Tuberculoid
3.Lepromatous
4.Borderline
5.Neuritic

18. Clinical Features
•In early stages:
Hypopigmentation/Skin lesions: It may be dark
or light, single or multiple, present in the form
of macule(flat), papule(raised) or nodule.
Sensory loss – at the skin lesion is mandatory.
Sensory loss in fingers and toes.
Numbness.
Thickened nerves.
Positive smears.

19. •In late stages:
Trophic ulcers.
Foot drop/claw toes.
Claw hand.
Loss of fingers or toes.
Nasal bridge collapse leading to flat n runny
nose.
Muscle weakness.
Dry scalp.
Smooth, shiny diffuse thickening of hand,
facial skin and ear.

20. •Foot deformities in leprosy:

22. •Hand deformities in Leprosy:
1.Partial claw hand.
2.Complete claw hand.
3.Triple nerve palsy, which affects-
Ulnar nerve at the elbow.
Median nerve at the wrist.
Radial nerve at the spiral groove.

24. Typical Skin lesions in Leprosy

25. Sensory Involvement

26. Leprosy and Glaucoma
As such there is no association between the
increased incidence of glaucoma in leprosy
patient.
Following are the contributory factors:
Due to excessive use of topical steroids.
An early neuropathy autonomic nervous system
may compromise trabecular system.
In case of iridocyclitis may occur synechia
anterior and posterior, leading to secondary
glaucoma.

27. Other features that are found in
long-term course
Atrophy of testes and Impotency.
Visual impairments.
Hand and Foot deformities.
Malfunction of kidney.
Infertility.
Hoarseness of voice.
Skin ulcerations.
Flat nose.
Secondary infections.

30. Risk Factors
People living in close contact with leprosy
patient for a long time.
People living in areas with polluted water and
surroundings.
People suffering from diseases that
compromise the immune system.
Defect in cell-mediated immunity.
Some interactions exists between HIV (human
immunodeficiency syndrome) and risk of leprosy.

31. Diagnosis
Appropriate signs and symptoms,e.g; skin lesion with
definite sensory loss, thickening of peripheral nerve, etc.
Positive skin smears.
Sensory test.
Nerve function test.
Nerve Conduction Studies.
Nerve Biopsy.
Skin Biopsy.
Skin Scraping.

32. For detecting humoral
antibodies and cell mediated
immunity
ELISA Test.
Lepromin Test.
Lymphocyte Transformation Test.

33. oTesting Sensation

34. oNerve function test

36. oSpecific Nerve Testing
Great Auricular.
Median Nerve.
Ulnar Nerve.
Radial Cutaneous.
Common Peroneal Nerve.
Posterior Tibial.

37. oLepromin Test
This test was described by Mitsuda for the
diagnosis of Leprosy in 1919.
Procedure: 0.1ml of lepromin(antigen) is
injected intradermally, which gives two types
of reactions-
1)Early reaction of Fernandez- erythema
develops in 24-48 hours.
2)Late reaction of Mitsuda- nodule appears
after 1-2 weeks.

38. Results of lepromin test:
1. The test is used to assess the severity of the
disease.
2. The lepromin test assesses the prognosis of
the disease.
3. This test is positive in localised forms, whereas
negative in generalised form of the disease.

39. oNerve Conduction Studies
It reveals the following findings-
1.Segmental slowing of conduction at common
sites of entrapment (e.g, elbow segment of the
ulnar nerve).
2.Prolonged distal latencies.
3.Reduced nerve conduction velocities.
4.Reduced amplitude of compound muscle
action potentials.
5.Absent or low-amplitude sensory nerve action
potentials.

40. oNerve Biopsy
It is less specific for the diagnosis of Leprosy. It
includes the following specimens:
1.Formaline for hematoxylin and eosin and silver
stains for axons.
2.Flemming solution for myelin stains
(WeigertPal technique).
3.Glutaraldehyde for electron microscopy.
4.Formal-calcium solution for teased-fibre
preparations.
5.Frozen specimen for enzyme histochemical
technique.

41. oSkin Biopsy

42. Skin biopsy is a biopsy technique in
which skin lesion is removed to be sent to
a pathologist to render a microscopic
diagnosis.
It is usually done under local
anesthetic in a physician’s office, and
results are often available in 4-10days. It is
commonly performed by dermatologists.

43. oSkin Scraping

44. Technique
It is a bedrock technique in dermatology in
which full thickness of the epidermis and the
contents of the hair follicles are sampled.
Generally several sites are sampled. Mites can
be very difficult to find in some cases.

45. oOther Tests
Pilocarpine Test:- Sweating is
dependent upon the integrity of the
parasympathetic nerve endings.
If hypopigmentation is due to leprosy the
response of sweat glands will be
diminished.
Histamine Test:- In leprosy patients, the
response of the skin to the histamine will
be delayed.

46. Differential Diagnosis
Various disease conditions that mimics the
leprosy must be ruled out.
Tinea versicolor/ Pityriasis versicolor.
Pityriasis alba.
Early vitiligo.
Nevus anemicus.

47. Management
The treatment of leprosy involves multi-
disciplinary approach-
 Multidrug therapy.
Sensory care.
Surgical approach.
Physiotherapy.
Occupational therapy.
Patient counselling.

48. Multi drug Therapy
MDT has highly effective role in
the treatment of leprosy.
For multibacillary/lepromatous leprosy :- Daily
dapsone and clofazimine, along with rifampicin
once in a month for 12months.
For paucibacillary/tuberculoid leprosy :- Daily
dapsone and rifampicine once a month for
6months.
Other drugs :- Salicylates, Thalidomide,
Prednisolone, NSAIDs (Non Steroidal Anti-
inflammatory Drugs) are also effective in the
treatment of the disease.

49. The duration of treatment with
the multidrug(chemotherapy)
should be atleast for 2 years till the
smear is negative.

50. Sensory Care
Moisturising the skin.
Cleaning the part regularly.

51. Maintaining proper protection to the
skin/ cover the part properly.

52. Avoid exposure to too hot or cold object;
prevent holding/touching any sharp object.

53. Avoid barefoot walking.
Avoid too much tight shoes or
garments.

54. Surgical Approach
Surgery is offered mainly in
cases with severe motor paralysis
and unremetting nerve pain.
It includes:- draining of acute nerve
abscess; fascicular dissection; nerve grafts;
canthoplasty; tarsorrhaphy; cosmetic
surgery for removal of excess skin, nasal
reconstruction, replacement of eye-brows,
removal of breast tissue formation.

55. Some orthopaedic approaches in
management of leprosy
Tendon transfer or arthrodesis for claw-hand
and Z-thumb.
Z-plasty for hand contractures.
Tenodesis for joint instability.
Capsulotomy for tight joints.
Epicondylectomy.
Ulnar nerve transpositon.
Removal of carpel tunnel roof.
Amputation- last option.

56. Foot drop:-
For recent or incomplete- Toe rising spring,
short wave diathermy, ultrasound, local
steroids, splinting etc.
For chronic or complete- Complete surgical
correction, e.g., tibialis posterior transfer,
triple arthrodesis of Lambrunidi (for fixed
equinovarus deformity of the foot).

58. Plantar Ulcers:-

59. Surgery for the Hand
•Ulnar claw hand: S. Bunnel’s operation.
•Tripal nerve palsy: Difficult to operate surgically.
•Brand’s many tailed tendon transfer operation,
developed by Paul Brand.
•Extensor carpi radialis longus is released from
its insertion and brought into flexor aspect of
forearm
•Flexor digitorum superficialis is detached from
the palm and attached into lateral margin of
extensor expansion.

60. Nerve lesions:-

61. Physiotherapy Management
Before Surgery
Active assisted or active movement to
maintain joint flexibility.
Isometric exercises to increase the
strength.
Modalities, e.g, TENS can be given to
reduce pain.
Mild Mobilization can be done to prevent
stiffness of joint.

62. Physiotherapy Management
After Surgery
 Passive movement following Hydrotherapy
helps in increasing the range of motion.
Active and isometric exercises are taught to
the patient in order to increase the strength
and to maintain joint flexibility.
Manual stretching and gentle mobilization
are given to prevent mild contractures.
Facilitated stretching techniques(PNF) are
also effective techniques.

63. Role of Physiotherapy after Amputation
Proper positioning of the limb,i.e,elevation.
Friction massage is given to prevent adherent
scar tissue.
An intermittent compression unit is used to
prevent swelling.
Gait training after fitting of Prosthesis.
Muscle re-education.

64. Goals of Physiotherapy
management in Leprosy
To increase range of motion of joint.
To maintain the flexibility of the joint.
To increase the muscle strenght.
To prevent post-operative swelling ,
contracture and stiffness.
To prevent further disability and deformity.
To preserve the possible functional
movements.
To teach home self-care.

65. Role Of Occupational Therapy
The role of occupational therapy is also of great
concern in the management of the Leprosy. It
enables those affected by disabilites to learn
new skills for coping with the lasting effects of
their condition.
Learning new job skills, tricks and
techniques for managing every-day tools of
trade and domestic duties, and adapting to
modified protective tools, appliances, and items
of clothing to protect themselves from further
injury, are its part.

66. Patient Counseling
It is an important
approach after the first
line management in such
patients, as these patients,
who are prone to so many
disabilities require counseling in order to cope
with their illness with lot of mental strength.

68. Follow-up
•Monthly follow-up is mandatory.
•Multi drug therapy will be continued for a long
time even after the completion of treatment.
•Patient counseling.
•Yearly skin scrapings taken from 3-4 most active
lesions should be tested.
•Laboratory tests- complete blood count,
urinalysis, Liver function test.
•Patient monitoring is done for 5-10 years after
the completion of treatment.

69. Prevention
Public education and awareness.
Isolation of the untreated cases.
Early detection of the disease.
Prophylaxis with single dose of Rifampicin
provides 57% effectiveness against the
infection.
Bacillus Calmette Guerin (BCG) vaccine gives
variable protection against Leprosy in addition
to Tuberculosis.

70. Prognosis
Leprosy is an infectious disease which is of
progressive form.
Proper medical facilities and early treatment
can give enormous results.
Multi-drug therapy plays a crucial role in the
treatment and thereby prognosis.

71. Involvement of NGO’s
It helps to reduce the burden of leprosy.
Serve in remote, inaccessible, uncovered,
urban slums, industrial/labour populations and
other marginalised population groups.
Nippon Foundation, WHO, World Bank,
Danida, Novartis, ILEP agencies, National
governments all along with NGO’s are the
partners in Leprosy Elimination.

72. Anti Leprosy Missions in India

74. References
Physical Rehabilitation by Susan B. O’Sullivan
and Thomas J. Schmitz.
Textbook of microbiology by Dir. Prof. CP
Baveja.
Essentials of Orthopedics for Physiotherapists
by John Ebnezar.
Wikipedia.
www.slideshare.net
Medline Medical Encyclopedia.

75. THANK YOU