Leprosy: Case Presentation , Facts & Management

Presented By Dr Raghunandan Khandelwal

1. CASE PRESENTATION ON LEPROSY GUIDE- DR. DHARMESH SHARMA Asst. Professor (PSM) S.M.S MEDICAL COLLEGE, JAIPUR PRESENTED BY DR. R.N. KHANDELWAL M.B.B.S, D.P.H (1 st year) S.M.S MEDICAL COLLEGE, JAIPUR

2. NAME OF PATIENT : AMIR CHAND SAHA FATHER’S NAME: JANADHARAN SAHA AGE : 21 YRS SEX: MALE CAST: SAHA RELIGION : HINDU OCCUPATION: LABOUR (~5000 P.M.) MARITAL STATUS: MARRIED FAMILY MEMBERS: TOTAL 5 (3 CHILDREN = 2 F +1 M) ADDRESS: VILLAGE- BHAGWANPUR, V.P.O RAJPUR, DIST. BAXAR, BIHAR (MOB. [phone]) CHIEF COMPLAINTS : Reddish PATCH WITH NUMBNESS at rt. leg – 4 months HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic about 4months back then reddish patch develop at Rt. outer leg. Gradually it increased in size and numbness. HISTORY OF PAST ILLNESS: No history of any specific past illness and previous hospitalization.

3. FAMILY HISTORY: Not significant. 5 members in the family , one male i.e. patient himself 21 yrs old and one female his WIFE 20 yrs old. 3 CHILDREN, one male & 2 female . PERSONAL HISTORY : Patient is purely vegetarian, Non Alcoholic Smoker 10~15 biddies per day, Tobacco chewer 5~7 packet per day, Bowel and bladder habit normal. DRUG HISTORY : No history of any drug allergy. IMMUNISATION HISTORY : Unknown SOCIO ECONOMIC STATUS : Patient is migratory from Bihar. Residing at Kachhi basti near Transport nagar ; J aipur since 2 years. And lives in rented pucca house 2 rooms without latrine and bathroom facilities . Labour by occupation and earns a monthly income of Rs.5000.

4. GENERAL PHYSICAL EXAMINATION: general condition fair. Patient is well conscious and well oriented to time place and person VITALS : Blood pressure: 120/70 mmHg, pulse rate: 84/min/regular RR- 20/min/regular , temp- afebrile No P allor, Icterus, Cyanosis, Lymphadenopathy, O edema . LOCAL EXAMINATION : Single Erythamatous skin patch is present over the Rt. Leg lower on lateral side. Well define margin; Size~ 5cm *2.5 cm Decrease sensation of touch, temperature, pain No other patch and thickened peripheral nerve seen.

5. SYSTEMIC EXAMINATION: Respiratory system: bilateral symmetry of the chest is normal bilateral chest sounds clear. CVS : S1 S2 normal, no murmur sound heard. CNS : Normal . INVESTIGATION DONE: HEMATOLOGICAL INVESTIGATION: C.B.C ~ NAD SKIN BIOPSY : TUBERCULLOID LEPROSY TREATMENT : started on 19.09.2014 MDT 6 BLISTER PACKS FOR P.B. STARTED FOR 6 MONTHS ONCE A MONTH = 2 CAP. REFAMPICIN 300 MG + TAB. DAPSONE 100MG ONCE A DAY = TAB. DAPSONE 100MG

6. INTRODUCTION LEPROSY ( HANSEN’S DISEASE) Leprosy is the oldest disease afflicting mankind In Vedic reference it is mentioned as Kushta Rog .(In Sanskrit means eating away)

7. OCCURRENCE & SPREAD CAUSE- MYCOBACTERIUM LEPRAE INFECTION- VERY SLOW GROWING (15-20 days for multiplication) EARLY SIGNS ~ APPEAR 3-5 YEARS (LONG INCUBATION PERIOD) SUSCEPTIBLES- ONLY 2-5% (95-98% population is immune to disease ) SPREAD- Only untreated infectious smear + MB pt. By throwing out large no. of germs from URT while sneezing & coughing.(only 10-15% of all leprosy pt.) ONLY HUMANBEING Close skin to skin contact , Breast milk & Tattoing needle.

8. Indian classification of Leprosy 1. Indeterminate :- One o two vague hypo pigmented patch or definite sensory impairment. Bacteriologically Negative. 2. Tuberculoid :- One or two well defined hypo pigmented or erythematous and anesthetic patch may be flat or raised. Bacteriologically positive. 3. Borderline Type : - 4 or more flat/ raised, well or ill defined, hypo pigmented or erythematous patch with sensory impairment or loss. Bacteriologically positive. 4. Lepomatous Type : Diffuse , Infiltrate or numerous flat or raised, poorly defined shiny, smooth, symmetrically distributed lesion. Bacteriologically positive. 5. Pure Neuritic type: Nerve involved but do not have any skin lesion. Bacteriologically Negative.

9. DIAGNOSIS OF LEPROSY …. BE CAREFUL………….. EXAMINE IN DAY LIGHT OR IN WELL LIT ROOM. EXAMINE THE ENTIRE BODY (DON’T SHY ) A HAND SHAKE CREATES CONFIDENCE AND ESTABILISHES RAPPORT B/W PATIENT & DOCTOR. IT INDUCES A SENSE OF CO-OPERATION AND HELPS IN THE HEALING PROCESS. IF YOU THINK ABOUT LEPROSY, YOU CAN DIAGNOSE IT

10. INCREASE SIZE & NO. OF LESION DURING TREATMENT ….. SEND TO NEAR REFFERAL CENTER INCREASE NO. DURING TREATMENT …..REACTION INCREASE NO. DURING AFTER TREATMENT ….REACTION OR RELAPSE *LESION OVER NERVE TRUNK OR ON FACE…. RISK FOR DEVELOPING SENSORY/MOTOR DEFICIT. MARGIN – ILL DEFINE / WELL DEFINE COLOUR – HYPOPIGMENTED / ERYTHEMATOUS SIZE – NUMBER – SINGLE / MULTIPAL SITE - 1.SKIN PATCH WITH LOSS OF SENSATION

11. SIGN. THAT LOOK LIKE LEPROSY… TINIA CIRCINATA, PSORIASIS , VITILIGO, NAEVUS (BIRTH MARK) DERMAL LESHMANIIASIS NEUROFIBROMATOSIS NUTRITIONAL DYSCHROMIA LICHEN PLANUS PITYRIASIS ROSEA LUPUS VULGARIS SCAR & KELOID XANTHOMATOSIS DIABETIC NEUROPATHY ALCOHOLIC NEURITIS SYRINGOMYELIA TABES DORSALIS SKIN CONDITION NEROLOGICAL CONDITION LESION SHOULD NEVER HURT NEVER ITCH TAKEN PROPER HISTORY….

12. 2 .EXAMINE FOR THICKENED PERIFERAL NERVES… Ulnar nerve, Lateral popliteal nerve Post. Tibial nerve R adial nerve, Median nerve Trigeminal nerve, F acial nerve Facial n .

13. CONSEQUENCES OF NERVE DAMAGE Examine hands for injuries, blisters and stiff joints. Examine feet for dryness, cracks, swelling, wounds. Recurrent ulceration with infection due to repeated injuries may cause destruction of bones & joints and develops severe functional handicap. Examine face for lagophthalmos & facial palsy. Risk for eye complications and eventually blindness. Patient with depressed nose will have difficulty in breathing normally & social rejection due to gross deformity. In india 7% of leprosy is pure neuritic type.

14. 3.SUSPECTED CHANGES IN SKIN…. without sensory loss If doubt Refer for SKIN SMEAR examination to referral centre . SKIN SMEAR examination is not mandatory to start MDT NLEP no longer routinely advises skin smear.

15. Sign. Of infectious leprosy Look for any infiltration (thickness) of the skin, oily and shiny skin. It could be early sign of infectious type of leprosy. Look for nodules with normal skin or redish colour ; may be soft or hard & small or large. Lepromatous leprosy is usually a generalised disease. Multiple hypopigmented patches seen in lepromatous leprosy typically do not show loss of sensation. Glove and Stocking type of anesthesia is a common feature of lepromatous leprosy. Nose, Testes & eyes are frequentally affected in advanced leprosy. Look for loss of eye brows & eye lashes

16. MDT Grouping & Treatment…..

17. Grouping for MDT…… PB LEPROSY 1-5 SKIN PATCHES WITH SENSORY LOSS ONLY ONE NERVE TRUNK THICKENED WITH SENSORY OR MOTOR INVOLVEMENT MB LEPROSY 6 OR MORE PATCHES WITH SENSORY LOSS 5 SKIN LESIONS + ONE NERVE TRUNK = 6 2 OR MORE NERVE TRUNKS THICKENED SKIN SMEAR + FOR AFB

18. MDT for P.B.~ 6 months (maximum complete with in 9 months)

19. MDT for MB~ 12 months (Maximum complete with in 18 months)

20. LEPRA REACTIONS…. REACTIONS MAY OCCUR BEFORE, DURING, AFTER TREATMENT. DO NOT STOP MDT….. NOT CAUSE BY MDT TYPE -1 TYPE -2

21. TYPE 1… Reversible reaction Ag from broken bacilli react with T-CELL (Delayed hypersensitivity reaction ). Usually in the first 6 months . Existing patches become raised, erythematous, and oedematous . Neuritis is a common feature . reaction is severe if pain & tenderness is severe and paralysis or anesthesia threatens to follow the neuritis . Rx~ Steroids/ chloroquine /aspirin

22. TYPE 2……. ENL Reaction *Circulating Ab against m. leprae react with the m. leprae Ag. (Ag- Ab reaction) *Usually 6 months after treatment *New erythematous & tender nodules (ENL’s) appear in crops. B/l symmetrical. *ENL may rupture in severe case. *swelling of joints with systemic complaints +nt. *other organs may involve . Rx…… steroids / clofazimine / thalidomide/Znso4/ pentoxyphyllin

23. Disability and its Management Grading Of Disabilities Hands & Feet • Grade 0: No anaesthesia , over palm/sole no visible deformity or damage • Grade 1 : Anaesthesia present, over palm/sole but no visible deformity or damage • Grade 2 : Visible deformity or damage present Eyes • Grade 0 : No eye problem due to leprosy; no evidence of visual loss • Grade 2: Severe visual impairment (vision worse than 6/60; inability to count fingers at six meters), lagophthalmos , iridocylitis and corneal opacities.

24. Process of deformity…. Nerve damage

25. Disability can be prevented by: Early diagnosis of leprosy and treatment with MDT. Adequate counseling and follow high risk patient. Possible signs and symptoms of reaction (loss of nerve function , lapra reaction , neuritis )and need to report immediately in case of unusual . Check muscle strength and sensation . Management earlier ……….

26. NATIONAL LEPROSY ERIDICATION PROGRAME

27. Milestones of Leprosy eradication 1898 – Leper Act, British India abolish later on 1948 – Hind Kusht Nivaran Sangh 1955 – National Leprosy Control Program 1982 – MDT 1983 – National Leprosy eradication Program MDT started) 1991 – WHO resolution to eradicate leprosy by 2000 AD 1993 – World bank supported the MDT program Phase NLEP-1 1998-2004 :- Modified Leprosy elimination campaign 2001-2004 :- NLEP project phase II 2005 :- National wide evaluation of project II 2005, Dec : Prevalence rate 0.95/ 10,000 and govt. declared achievement of elimination target. 2005 : NRHM covers NLEP . 2012 : Special action plan for 209 high endemic Districts in 16 States / UTS

28. NLEP progress report year 2013-14 1.27 lakh new cases were detected, gives ANCDR of 9.98 per 1,00,000 population . from 2012-13 (10.78). A total of 0.86 lakh cases are on record as on 1st April 2014, giving a PR of 0.68 per 10,000 population . from 2012-13 (0.78). A total of 5256 Gr. II disability detected amongst the New Leprosy Cases during 2013-14, gives Gr. II Disability Rate of 4.13 / million population . 12043 child cases were recorded, gives Child Case rate of 0.95/1,00,000 population . Shows reduction in child case rate from the year 2012-13 (1.07) by 11.21% 33 States/ UTs had already achieved the level of elimination ( PR less than 1 case per 10,000). Chhattisgarh & Dadra & Nagar Haveli has PR between 2 and 4 per 10,000 population. O disha , Chhattishgarh and Lakshadweep which achieved elimination earlier have shown slight increase in P.R. (1-2), in the current year.. PB Child proportion was high in 4 States/UTs namely (i) Bihar 11.04% (ii) D&N Haveli 21.88%, (iii) A&N Islands 12.50% and (iv) Pondicherry 10.53%

29. RAJASTHAN PR . 17 per 10000 population. (~.68) ANCDR 1.48 per 100000 population(~9,98) child case rate .03 per 100000 ,(~.95) new gd 2 disability rate0.55 per million(~4.13) DPMR Services =Disability Prevention and Medical Rehabilitation 1. Total 111 (Govt.- 60 and NGO- 51) Institutions have been recognized for conducting Reconstructive Surgery to correct the disability in Leprosy. 2. During the year 2013-14 a total of 2707 RCS (Govt. – 921 and NGO – 1786) were conducted. 3. A total of 12901 Reaction/Neuritis episodes were recorded and treated at PHCs and in Secondary level Institutions. 4. At the PHC level 486 Relapse Cases were suspected and referred to the District Hospitals. A total of 433 Relapse were confirmed and treated at District Hospital. 5. MCR footwear were provided to 69331 Leprosy Affected Persons. 6 . Self Care Kits were provided to 44412 Leprosy Affected Persons.

30. B. ASHA Involvement During 2013-14, their participation has substantially improved . C. Active case detection = Search activities for early detection of New Leprosy cases were carried out during the year 2013-14 . Intensive Case Detection Drive ( ICDD ) was carried out in all the high endemic blocks of low endemic districts, along with special action plan activities in the remaining blocks of High endemic districts, that were left out during 2012-13.. A total of 8398 New Leprosy cases were detected during these search. (ii ) House to house visit were also carried out in low endemic areas during the Anti leprosy fortnight from 30th January to 13th February 2014. A total of 3215 New Leprosy cases were detected during these search. ** a total of 11613 New cases were detected through active search in the year 2013-14. Amongst these cases MB 4846 (41.7%), Child 1093 (9.4%), Gr I disability 651 (5.6%) and Gr. II disability 443 ( 3.8%) were detected.

31. MORE FACTS ABOUT LEPROSY FOUR LEPROSY VACCINES ARE CURRENTLY IN TRAIL 1)BCG –34.1% PROTECTION 2)BCG+KILLED M.LEPRAE – 64.0% 3)M.W – 25.7% 4)ICRC – 65.5% 7 CONTROLLED TRAILS AND 9 CASE –CONTROL STUDIES EVALUATING THE ROLE OF BCG IN PREVENTION OF LEPROSY WERE CARRIED OUT AROUND THE WORLD

32. Thank you