Leprosy

leporsy disease

1. Leprosy(Hansen’s) disease DR SUBODH KUMAR SHAH

2. Etiology Mycobacterium leprae (M. leprae ) , an acid fast organism . Route of infection : respiratory transmission .(droplets infection)

3. Classification: 1.Ridley– Jopling classification: Tuberculoid leprosy (TT) Borderline tuberculoid (BT) Mid borderline ( BB ) Borderline lepromatous (BL) leprosy Lepromatous leprosy ( LL) 2.Skin smear result (WHO) classification : • 1- Paucibacillary leprosy (PB) – few Bacilli; • Two to five skin lesions with negative skin smear results at all sites. • 2 . Multibacillary leprosy (MB); • Any form of leprosy in which the patient shows positive smears at any site

4. Morphology: Prototype skin lesion: atrophic, hypopigmented , an(hypo)esthetic macules or plaques ( with papules and nodules seen in lepromatous end of spectrum ) with loss of appendages (so absent hair and sweating). Depending on number, size, symmetry, morphology and degree of sensory deficit in skin lesions and numbers of nerves affected, classified as : Indeterminate leprosy: Ill-defined macule(always a macule) ± sensory impairment on face of children. Tuberculoid leprosy (TT): Single (or few ),well-defined anesthetic lesion(s). Regional nerve(s)thickened.

5. . Borderline tuberculoid (BT): Few, welldefined,hypoesthetic lesions with satellite lesions.Few nerves involved. Borderline (BB): Multiple, bilateral(not symmetrical) annular plaques ( inverted saucer appearance) with hypoesthesia. Few nerves involved . Borderline lepromatous (BL): Multiple ( with tendency to symmetry), minimally hypoesthetic illdefined lesions . Many nerves (bilateral, tendency to symmetry) involved. Lepromatous leprosy (LL ): Widespread symmetrical normoesthetic macules,papules , nodules, and infiltration. Symmetrical nerve involvement with glove and stocking sensory impairment . Systemic involvement common: Lymphadenopathy. Hepatosplenomegaly. Ocular involvement. Testicular atrophy.

6. Indeterminate leprosy : ill-defined, hypopigmented , hypoesthetic lesion on the face; the lesion is always macule. Tuberculoid leprosy: well-defined hypopigmented , hypoesthetic plaque. Note the feeder nerve

7. Borderline tuberculoid leprosy: A : welldefined,hypoesthetic , erythematous plaque Borderline lepromatous leprosy : A : multiple plaques present almost symmetrically

8. Lepromatous leprosy A: diffuse infiltration of face. B: infiltration of ear lobule.

9. nasal deformity and supraciliary madarosis

10. lepromatous nodules on infiltrated skin on chin. histoid nodules on normal skin

11. Clinical Features Cardinal signs According to WHO, in an endemic area, an individual should be regarded as having leprosy if he or she shows ONE of the following cardinal signs : Skin lesion(s) consistent with leprosy with definite sensory loss, with or without thickened nerves . Skin smears positive for acid fast bacilli. A person presenting with skin lesions or with symptoms suggestive of nerve damage, in whom the cardinal signs are absent or doubtful, should be called a ‘suspect case’ in absence of an obvious alternate diagnosis ..

12. Such individuals should be counselled and advised to follow up if signs persist for more than 6 months or if there is any worsening . Suspect cases may be also sent to referral clinics with more facilities for diagnosis

13. Nerve involvement Thickened peripheral nerves is typical. Apart from larger nerve trunks, a feeder nerve to the skin lesion may be thickened. In distal extremities— glove and stocking anesthesia (in BL, LL) and weakness of muscles supplied by the affected nerve .

14. Reactions in leprosy ( lepra reactions) Two types of reactions occur in leprosy—type 1 and type 2 reactions Type 1 lepra reaction: Occurs in borderline leprosy (the unstable varieties—BT , BB and BL). Pathogenesis : Is due to alteration in the host’s CMI, Manifestations : Characterized by: Erythema, edema, and scaling of the preexisting lesions Appearance of new lesions. Neuritis, clinically manifesting as nerve tenderness, and appearance of increasing new areasof sensory impairment and motor deficits.

15. Leprosy in type 1 reaction: erythema, edema and scaling of pre-existing lesions.

16. Type 2 lepra reaction (erythema leprosum or ENL) Occurs most commonly in LL and sometimes in BL leprosy. Pathogenesis : Immune complex reaction . Manifestations : Characterized by : ENL: appearance of several tender, evanescent ( quickly fading or disappearing),erythematous nodules on face, flexures ,and legs; sometimes these lesions may become pustular and ulcerate. Neuritis. Arthralgia, orchitis , and iridocyclitis .

17. evanescent, tender, erythematous nodules . necrotic ENL.

18. Investigations Positive skin smears: Slit smear Smears are taken from skin lesions, ear lobules,eye brows, and sometimes dorsae of fingers.on Zeihl – Neelsen staining , rod-shaped, red-stained leprosy bacilli may be seen . Tests to confirm diagnosis of leprosy Biopsy:

19. Tests to evaluate systemic involvement: Hematological parameters: Anemia: Leucocytosis : Renal function tests Chest X-ray: Ruling out concomitant pulmonary tuberculosis is important

20. Treatment General measures: Reassuring patient. Education regarding low contagiousness. Advice regarding sensory impairment especially with regard to hands and feet. Care of hands, feet, and eyes. Counseling regarding regularity of treatment.

21. Treatment of disease WHO regimen:

22. complication  • disfigurement • hair loss, particularly on the eyebrows and eyelashes • muscle weakness • permanent nerve damage in the arms and legs • inability to use the hands and feet • Nosebleeds • iritis (inflammation of the iris of the eye), glaucoma (an eye disease that causes damage to the optic nerve), and blindness • Infertility • kidney failure