Leprosy.ppt

LEPROSY

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2. 2 Presented By: Dr. Ravi Prakash JR-II Department of Community Medicine Katihar Medical College, Katihar

3. Cardinal Features Hypo-pigmented patches Partial or total loss of cutaneous sensation in the affected area (light touch is the earliest sensation to be lost) Presence of thickened nerves Presence of acid-fast bacilli in the skin or nasal smear 3 Clinical Signs & Symptoms

4. Indeterminate leprosy : Hypopigmented patch (1 or 2) Definite Sensory impairment . No palpable peripheral nerve and slit skin smear negative. 4

5. Tuberculoid Leprosy : Annular , erythematous , ana e sthetic patch with well defined and raised borders and SSS Negative. 5

6. Tuberculoid leprosy : Two hypopigmented patches, hypoasthetic well defined borders and SSS negative. 6

7. 7 Tuberculoid Leprosy: a well defined, hypopigmented , anaesthetic macule with anhydrosis and a raised granular margin

8. Borderline Leprosy : Less defined, asymmetrically distributed hypoaesthetic patches. SSS positive (variable) Borderline Lepromatous Leprosy: Numerous, hypoaesthetic almost symmetrically distributed patches . SSS positive 8 Borderline Tuberculoid Leprosy: Well defined large anaesthetic patches with satellite lesions. SSS negative

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10. Signs Of Advanced Disease : Lumps or nodules in the skin of the face and ears Plantar ulcers Loss of fingers or toes Nasal depression Foot drop and claw toes Other deformities 10

11. External ear infiltration - megalobule(Buddha ear) 11

12. Rat bitten appearance of ear Irregular & scalloped due to loss of skin & bits of cartilage 1/2/2019 47 12

13. Infiltration of the nasal structure- sunken nose deformity Negligence of nasal hygiene- myiasis Septal perforation 1/2/2019 48 13

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16. NERVE INVOLVEMENT : leads to muscle weakness, muscle atrophy, severe neuritic pain, and contractures of the hands and feet . Ulnar nerve is most commonly involved , least common is radial . Most common cranial nerve involved is Trigeminal . First sensation to go is thermal (cold>fine touch). Proprioception is usually preserved. 16

17. Ulnar Median R a d i al Lateral (common) Popliteal Posterior Tibial 17

18. b. H ands showing neurotrophic atrophy. 18 a. Claw Hand- Due to Median & Ulnar nerve damage

19. 19 Claw Hand

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21. WRI S T D R OP 21

22. F O O T D R OP 22

23. Neuropathic plantar ulcer Insensitive sole injured from outside Dry anaesthetic skin develops fissure & cracks Stress & strain on forefoot Loss of arches of foot 23

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27. Lagophthalmos with ectropion 27

28. Madarosis -super ciliary & ciliary 1/2/2019 44 28

29. Complications Of Bones Bone damage in Leprosy is confined to bones of hand , feet & skull. 29

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31. Corrugations-deepening of skin markings Leonine facies (sagging face ) Premature senile appearan c e 1/2/2019 45 31

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34. DONE BY: History & Clinical examination Bacteriological examination: By: skin smears, nasal smears or blows, nasal scrappings Foot pad culture Histamine test Biopsy 34 Diagnosis

35. Immunological Test: (A) Tests For Detecting Cell Mediated Immunity Lepromin test Lymphocyte transformation test (LTT) Leucocyte migration inhibition test(LMIT) (B) Tests For Humoral Response To M.Leprae Flourescent leprosy antibody absorption test (FLA-ABS) Monoclonal antibodies ELISA – based on Phenolic glycolipid antigen (PGL) 35

36. HIS T O R Y : Patients Bio data : name, age, sex, address Presenting complaints Family history of leprosy Contact with leprosy cases Previous history of treatment for leprosy, if any CLINICAL EXAMINATION: A thorough inspection of the body surface(skin). Palpation of commonly involved superficial nerves . 36

37. Ulnar N. near the medial epicondyle. Greater Auricular N as it turns over SCM muscle. Lateral Popliteal N. Dorsal branch of Radial N . TESTING FOR : Loss of sensation : heat, cold, pain, touch . Paresis or paralysis of muscles of hands and feet. 37

38. Nerve palpation 38

39. BACTERIOLOGICAL EXAMINATION: Skin Smears : Simple and valuable test. It is needed for diagnosis. Monitor the progress of the treatment Pinch the site tight, Incise, Scrape & collect material Smear on a slide , Air dry & fix, Stain (Z-N method) Sites are: Ear lobe, Forehead, Gluteal region , Active edge of patch . 39

40. Nasal Smears or blows : Nasal smears can be best prepared from early morning mucus material. Nasal Scrapings : After going in 4.5 cm the blade is rotated towards the septum and scrapped a few times and withdrawn. BACTERIAL INDEX: It is the only objective way of monitoring benefit of treatment. It indicates the density of leprosy bacilli in smears and includes both living (solid staining) and dead (fragmented or granular) bacilli. 40

41. According To Ridley’ s Logarithmic Scale , It Ranges From To 6+ and is based on the no. of bacilli seen in an average microscopic field. B stands for no bacilli in any of 100 oil immersion field. 41

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43. MORPHOLOGICAL INDEX: The MI is calculated after examining 200 pink-stained free standing bacilli. The percentage of solid staining bacilli in a stained smear is referred to as MI. It is a valuable indicator of the patient’s response to treatment during the first few months and helps to signal drug resistance . SOLID FRAGMENTED GRANULAR(SFG) PERCENTAGE: It gives a better picture as solid fragmented and granular bacilli are mentioned separately. It is similar to MI but a more sensitive indicator of the patient’s response to treatment. 43

44. FOOT-PAD CULTURE: Only certain way of identifying M. Leprae is to inoculate the material into foot pads of mice and demonstrate its multiplication 10 times more sensitive at detecting the bacilli than slit skin smear. Time consuming : requires 6 to 9 months. Used for : 1. Detecting drug resistance. 2. Evaluating the potency of anti-leprosy drugs. 3. Detecting the viability of bacilli during treatment . 44

45. HISTAMINE TEST: Reliable test for detecting at an early stage peripheral nerve damage due to leprosy. Method : carried out by injecting 0.1ml of a 1:1000 solution of histamine phosphate into hypopigmented patches or in areas of anesthesia. Result : in normal person it gives rise to a wheal surrounded by erythematous flare(Lewis triple response). In case of leprosy where the nerve supply is destroyed , flare response is lost. 50 45

46. BIOPS Y : Usually resorted to when there is high clinical suspicion but the other test are unyielding. It also gives information about the bacterial content of skin. IMMUNOLOGICAL TESTS: LEPROMIN TEST T est of cell mediated immunity METHOD : it is performed by injecting 0.1ml of lepromin into inner aspect of the forearm. The reaction is read at 48 hours and 21 days . Two types of reaction have been described : 46

47. ANTIGENS USED: Dharmendra antigen Mitusda antigen EARLY REACTION ( FERNANDEZ REACTION) : A n inflammatory reaction develops within 24 to 48 hours and this tends to disappear in 3 to 4 days. If the diameter of the red area is more than 10mm the test is considered positive. It is a delayed type hypersensitivity reaction indicating prior exposure or infection to soluble constituents of lepra bacilli. Superior to late reaction 47

48. LATE REACTION ( MITSUDA REACTION) : It is characterized by the appearance of a nodule which becomes apparent in 7 to 10 days and reaches its maximum in 3 to 4 weeks. The test is read at 21 days . If the nodule is more than 5 mm it is considered positive. It is induced by the bacillary component and indicates cell mediated immunity. In the first six months of life most children are lepromin negative. BCG vaccination is capable of converting lepra reaction from negative to positive. 48

49. VALUE OF LEPROMIN TEST : E valuating the immune status of leprosy patients. Aid to classify the type of disease. Estimating the prognosis Strongly positive in a typical tuberculoid case and getting weaker towards the lepromatous end, the typical lepromatous case being lepromin negative indicating failure of CMI. The greatest drawback being:- Positive in non cases Negative in lepromatous cases hence not used as a diagnostic test. 49

50. LTT & LMIT : Newer in in vitro tests such as lymphocyte transformation test and leucocyte migration inhibition test has been developed They give a measure of CMI Used to detect sub clinical infection FLA-ABS TEST : Tests for humoral antibodies(serological tests) used for detecting subclinical infections. 92.3 percent sensitive and 100 percent specific in detecting specific antibodies in all types leprosy irrespective of type and duration of disease. 50

51. MONOCLONAL ANTIBODIES These against M. leprae antigens have been produced If antibodies against specific antigens are found, they will become reagent of choice for identifying M . L eprae ELISA TEST - based on a phenolic glycolipid ( pgl ) antigen 51

52. MEDICAL MEASURES ESTIMATION OF THE PROBLEM EARLY CASE DETECTION MULTIDRUG THERAPY SURVEILLANCE IMMUNOPROPHYLAXIS CHEM O PRO P HYLA X IS DEFORMITIES REHABILITATION HEALTH EDUCATION SOCIAL SUPPORT PROGRAMME MANAGEMENT E VALUATION 52 Leprosy Control

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54. MULTI DRUG THERAPY In the absence of effective primary prevention by a leprosy vaccine leprosy control is based on effective multidrug chemotherapy(secondary prevention). OBJECTIVES : To interrupt transmission of infection Early detection and treatment of cases to prevent deformities To prevent drug resistance 54 Treatment

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57. IMPORTANT POINTS : MDT is not contraindicated in patients with HIV infection. MDT is safe during pregnancy. Drugs are excreted in breast milk but no reports of adverse reaction except for mild discoloration of infants skin by clofazimine Leprosy is exacerbated during pregnancy, it is important that MDT is continued 57

58. S U R V E IL L ANCE: Paucibacillary leprosy- recom m ended to be examined clinically atleast once a year for minimum 2 years Multibaccilary leprosy- recommended to be examined clinically at least once a year for minimum 5 years . IMMUNOPROPHYLAXIS : BCG can provide some protection against leprosy Several alternative vaccines are under development 58

59. DEFORMITIES : It is due to damage of peripheral nerve trunks or injury from infection to hand and feet's Approx. 25 percent of cases who are not properly treated at an early stage develop deformities of hands and feet . DEFORMITIES PREVENTION: Measures include care of dry and denervated skin of palms and soles . Treating wounds, ulcers, and cracks in palms & soles Use of protective gloves and footwear 59

60. Adductor splint for abductor deformity of little finger 60

61. Opponens splint for ape thumb deformity & first web space contracture 61

62. 62 Cock up splint

63. 63 Finger loop splint

64. 64 Knuckle bender splint

65. Immobilisation 65

66. Lateral tarsorraphy 66

67. REHABILITATION Rehabilitation includes all the measures used for reducing the impact of disability for an individual, enabling him/her to achieve independence, social integration, a better quality of life and self actualization. 67

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69. MCR Footwear 69

70. Grip Aids Indications – Grossly deformed hand with loss of fingers, fixed contractures, loss of sensory input, total fixed claw hand Made up of – epoxy resin putty grip aids Fitted to any tool / utensils Adheres to any surface Washable and autoclaved Improve grip & protect skin from abrasion and ulcer Improves quality of life Disadvantage – not suitable for heating 70

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72. HEALTH EDUCATION Health education aims at helping people to avoid this type of diseases . It should be direct towards the patient and his/her family . It should educate people on the true facts about leprosy and removes superstation and the social stigma associated with leprosy . SOCIAL SUPPORT Chemotherapy alone is not likely to solve this problem It needs social support also . 72

73. During the course of leprosy, immunological mediated episodes of acute or subacute inflammation known as reaction may occur. There are two types of reactions : Type 1 or Reversal reaction Type 2 or erythema nodosum leprosum Both types can occur before the start of MDT, during treatment or after completion of treatment. 73 Lepra Reaction

74. REVERSAL REACTION T he leprosy skin lesions themselves become inflamed red, swollen and painful. It is type of delayed type of hypersensitivity. Occurs in both PB and MB Nerves may be enlarged, tender and painful with loss of function. General symptoms are uncommon Do not affect other organs. 74

75. ERYTHEMA NODOSUM LEPROSUM In ENL new inflamed, red nodules appear under the skin, while the original lesions remain same. Commonly on face, arm and legs & bilaterally symmetrical. subside within few days even without treatment It is antigen antibody reaction. Seen in MB cases only. Nerves may be affected but is uncommon Other organs like testis, eye, kidney may be affected General symptoms of fever, joint pain, red eyes and watering may be associated. 75

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77. TREATMENT Because of high risk of permanent nerve damage reversal reaction needs to be promptly diagnosed and treated adequately Standard 12 wk. regimen of prednisolone is the treatment of choice. Treatment also includes bed rest, splinting of affected nerves, analgesics and prednisolone. 77

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79. ANTI-LEPROSY ACTIVITIES IN INDIA 1874-Mission To Leprosy was found by Baily at Chamba in the Himachal Pradesh. (now in Purulia in West Bengal) After that a lot of organizations are established Hindu Kusth Nivaran Sangha Gandhi Memorial Leprosy Foundation National Leprosy organization(1965) German Leprosy Relief Association Damien Foundation Danish save the child foundation National Leprosy Control Program(195 5 ) was converted in to Eradication Programme(1983) 79

80. Mile stones of leprosy eradication 1898 – Leper act Later abolished by British india 1948 – Hind Kush Nivaran Sangh 1955 – National leprosy control program 1982 - MDT 80

81. 1983 – National leprosy eradication program (MDT started) 1991 – World health assembly resolution to eradicate leprosy by 2000. 1993 – World bank supported the MDT program phase NLEP 1 81

82. 1997 – Midterm appraisal 1998-2004 - Modified leprosy elimination campaigns 2001-2004 - NLEP project phase 2 2005 – National wide evaluation of phase2 82

83. 2005 December – Prevalence rate 0.95/10,000 and Govt declared achievement of elimination target. 2005 – NRHM covers NLEP 83

84. NLEP NLEP was launched on 1983 The NLEP is a centrally sponsored health scheme of the Ministry of Health and Family Welfare, Govt. of India The programme is headed by the deputy director of health services(Leprosy) under the administrative control of the Directorate General Health Services, Govt. of India The programme is also supported as partners by WHO The International Federation of Anti-leprosy Associations Non-Govt. Organizations 84

85. The emblem The NLEP Emblem symbolizes Beauty and purity in lotus Leprosy can be cured and a leprosy patient can be a useful member of the society in the form of a partially affected thumb Normal fore-finger representing the shape of a house The symbol of hope and optimism in a rising sun The emblem captures the spirit of hope positive action in the eradication of Leprosy 85

86. Current activities under NLEP Diagnosis and treatment of leprosy MDT provided to all PHCs free of cost . D ifficult to diagnose cases & complicated cases referred to district hospitals . ASHAs under NRHM helps bring out leprosy cases from villages for diagnosis and treatment completion . 86

87. Training Training to Medical officers, health workers, lab technicians, ASHAs conducted every year Training of state & district Leprosy officers organized at Schieffline institute of health research & leprosy centre Vellore, TN and RLTRI Raipur 87

88. Involvement of NGOs Help reduce burden of leprosy . Serve in remote, inaccessible, uncovered, urban slums, industrial/labour populations and other marginalised population groups. 88

89. Information, education & communication IEC help reduction of stigma & discrimination against leprosy affected persons. Carried out through mass media, out door media, rural media & advocatory meetings . More focus on inter personal communication 89

90. Disability prevention and medical rehabilitation . Patients provided with dressing materials, supportive medicines & MCR footwear Correction of disability through reconstructive surgery 90

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92. Urban leprosy control Implemented in 422 urban areas with population size more than 1 lakh Includes MDT delivery services & follow up of patients with treatment completion, providing supportive medicines and dressing materials. 92

93. Monitoring & Supervision By analysis of monthly progress reports, through field visits by supervisory officers, and programme review meetings held at central, State & District levels. 93

94. New initiatives Reconstructive surgery Amount of Rs 5000 provided as incentive to leprosy patients from BPL families for undergoing major reconstructive surgeries in identified Govt/NGO institutions 94

95. Involvement of ASHAs Incentives provided for ASHAs for bringing out cases from their villages . Rs 100 for confirmed diagnosis of cases . On completion of treatment within specified time Rs 200 for PB & Rs 400 for MB. 95

96. Special activities in High Endemic areas Involves training, intensified IEC, case detection & prompt MDT through health care staff 96

97. National sample survey By N ational JALMA I nstitute , Agra Started in 2010. House to house survey to access the burden of active leprosy cases, leprosy persons with grade 1 & 2 disability and magnitude of stigma and discrimination in society. 97

98. Budget and international support Since 2005, the program is being conducted with Govt of India funds with technical support from WHO & International federation of anti leprosy association(ILEP) 98

99. Officials/ Staff attached to District Leprosy Organisation Deputy Director of Medical Services (Leprosy) Medical Officer- Deputy Director (Leprosy) Health Educator Non Medical Supervisor Physio Technicians Health Inspectors Lab technician 99

100. Anti Leprosy Activities in India Leprosy Mission - founded in 1874 in H.P. Hind Kush Nivaran Sangh Gandhiji Memorial Leprosy Foundation, Sevagram, Wardha The German Leprosy Relief Association Damien Foundation The Danish Save the Child Fund JALMA- taken over by ICMR in 1975 National Leprosy Organisation- 1965 100

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103. R e f e r ence National leprosy eradication programme,Annual report ( 201 5 -1 6 ), M/O H&FW, Govt of India. National leprosy eradication programme,Annual report ( 201 4 -1 5 ), M/O H&FW, Govt of India. Health Policies and Programs in India , D.K.Taneja National Health programs of India , J.Kishore IAL Textbook of Leprosy , Park’s Textbook of Preventive and Social Medicine , K.Park , 25 th edition. 103

104. “Leprosy work is not merely medical relief; it is transforming frustration of life into joy of dedication, personal ambition into selfless service...” Mahatma Gandhi THANK YOU 104