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1. Leprosy Manasseh Mvula

2. Definition Leprosy ( Hansen’s disease) is a chronic infectious disease caused by the acid-fast, rod-shaped bacillus    Mycobacterium leprae The disease mainly affects the skin, the peripheral nerves, mucosal surfaces of the upper respiratory tract and the eyes Can occur at all ages ranging from early infancy to very old age

3. Properties of M. leprae Acid fast rod-shaped bacillus Grow very slowly taking up to 20 years to develop signs of the infection  Obligate intracellular pathogen – lacks several genes needed for independent survival Incubation period : 6 months - 40 years or longer (4 years for tuberculoid leprosy (TT) and 10 years for lepromatous leprosy (LL).

4. Prevalence Race occurs in all races Leprosy is endemic in Asia, Africa, the Pacific basin Sex Leprosy is generally more common in males than in females, with a male-to-female ratio of 2:1. Age can occur at any age, though very rare in infants

5. Transmission The exact mechanism of transmission of leprosy is not known The principle means of transmission is by aerosol spread from infected nasal secretions to exposed nasal and oral mucosa It is believed that leprosy is transmitted by Prolonged, and close contact with someone with untreated leprosy over many months

6. Classification Classified into 2: Tuberculoid Lepromatous

7. Tuberculoid Leprosy Skin lesions are single or few Sharply demarcated Anesthetic or hyperesthetic and bilaterally symmetrical Peripheral nerve involvement tends to be severe

8. Lepromatous Leprosy Nodules, papules, macules Diffused infiltration are bilaterally symmetrical and usually numerous and extensive Involvement of the nasal mucosa may lead to crusting, obstructed breathing and epistaxis Ocular involvement leads to iritis and keratitis

9. Cont’d Another classification (WHO) depends on the number of lesions and bacterial index (BI) Paucibacillary Multibacillary

10. Ridley- Jopling Classification Tuberculoid leprosy Borderline Tuberculoid Borderline Borderline Lepromatous Lepromatous Leprae

11. Paucibacillary Has fewer than 5 lesions No bacilli on smear testing Has two other classes Indeterminate Leprosy (IL) Tuberculoid Leprosy (TT)

12. Cont’d Indeterminate Leprosy (IL) This early form causes one to a few hypopigmentated or sometimes erythematous macules Sensory loss is unusual Tuberculoid Leprosy (TT) Skin lesions are few One erythematous large plaque is usually present, with well-defined borders that are elevated and that slope down into an atrophic center

13. Multibacillary Has Five or more lesions with or without bacilli Classes include: Borderline Lepromatous

14. Cont’d Borderline Tuberculoid leprosy (BT) Lesions in this form are similar to those in the tuberculoid form, but they are smaller and more numerous. Borderline borderline leprosy (BB) Cutaneous lesions consist of numerous, red, irregularly shaped plaques that are less well defined than those in the tuberculoid type.

15. Cont’d Borderline lepromatous leprosy (BL) Lesions are numerous and consist of macules, papules, plaques, and nodules Lepromatous Leprosy (LL) Early cutaneous lesions consist mainly of pale macules Late infiltrations are present with numerous bacilli Macular lesions are small, diffuse, and symmetric

16. Pathophysiology In general, leprosy affects the skin, peripheral nerves, and eyes Systemic symptoms may occur Specific symptoms vary with the severity of the disease

17. Cont’d Leprosy can manifest in different forms, depending on the host response to the organism Individuals who mount cellular immune response to  M. leprae  have the tuberculoid form of the disease that usually involves the skin and peripheral nerves

18. Cont’d Individuals with minimal cellular immune response have the lepromatous form of the disease, which is characterized by extensive skin involvement The strength of the host’s immune system influences the clinical form of the disease

19. Cont’d A strong cell-mediated immunity and a weak humoral response results in mild forms of disease, with a few well-defined nerves involved and lower bacterial loads A strong humoral response but relatively absent cell-mediated immunity results in LL, with widespread lesions, extensive skin and nerve involvement, and high bacterial loads The organism grows best at 27-30°C; therefore, skin lesions tend to develop in the cooler areas of the body, with sparing of the groin, axilla, and scalp

20. Signs and Symptoms Prodromal: Pts have a history of numbness first, sometimes years before the skin lesions appear Patient cannot sense extremes of hot or cold The next sensation lost is light touch, then pain, and finally deep pressure. These losses are especially apparent in the hands and feet; therefore, the chief complaint may be a burn or ulcer in an anesthetic extremity

21. 21 Signs and Symptoms Tuberculoid leprosy Asymetrical Localised circular hypopigmented patches. Hypoasthetic (sensation will be reduced or no sensation) Thickening of peripheral nerves.e.g alna nerve

22. 22 Signs and Symptoms Lepromatous leprosy Insideous onset Has wide spread symetrical hypopigmented patches. Mucosal thickening and becomes yellow discolouration, particulary the nasal mucosal. Conjuctivitis which may progress to blindness. Autoamputation (digits; fingers fall off) Colapse of the nasal bridge inwards causing difficult in breathing.

23. 23 Investigations History Physical examination Lepromin test + ve in tuberculoid - ve in lepromatous Skin smear for AAFB + ve lepromatous - ve in tuberculoid Biopsy of skin lesions Caseating lesions in tuberculoid

24. 24 Treatment Medical Dapsone 250mg twice weekly or daily Rifampicin 600mg Steroid- prednisolone Supportive Orthopaedic treatment for deformities. Psychological treatment

25. 25 NURSING CARE OF A PATIENT WITH LEPROSY Admission Patients are admitted to a hospital called leprosarium in the initial phase To stabilise on treatment For monitoring of side effects of drugs For constructive surgery if needed.

26. 26 NURSING CARE OF A PATIENT WITH LEPROSY Psychological care Patient will be worried about self-esteem and that they will be treated as an outcast. Involve the family members, educate them on the disease and their attitude which will affect the patient on self image. Allow patient to get involved in family affairs.

27. Cont’d Family should not isolate patient. Explain that when the patient is on treatment, there is no possibility of contracting infection. Patient needs to be kept busy. They can be taught simple skills e.g gardening, cooking, sewing, making mats. These measures prevent boredom and lessens emotional problems. It also gives an art which they can use to earn an income.

28. 28 NURSING CARE OF A PATIENT WITH LEPROSY Nutrition Build and maintain the nutritional status of the patient to help build patient’s resistance to the disease. Patient requires a high nutritious diet with iron and vitamin supplements for tissue repair as well as for maintenance of normal haemoglobin levels.

29. 29 NURSING CARE OF A PATIENT WITH LEPROSY Observations Routine vital sign check Keep on monitoring the degree of loss of sensation. Observe for drug reaction, e.g skin reaction like rashes, psychosis etc. Protect the patient from injury i.e burns, broken bottles because patient wont feel any pain when hurt.

30. 30 NURSING CARE OF A PATIENT WITH LEPROSY I.E.C Teach the patient about this condition in simple terms. Teach them about the importance of drug administration to achieve effectiveness and control progress of disease. Teach them on food and personal hygiene.

31. 31 NURSING CARE OF A PATIENT WITH LEPROSY Tell patient that the affected parts like the legs, hands should be kept dry and clean all the time to prevent infection. Teach them to wear protective foot wear to prevent injury. Teach them on the importance of plastic surgery in order to correct deformity.

32. 32 REHABILITATION IN LEPROSY Measures to regain usefulness of an individual and also making the patient psychologically dependence are done. There are 3 types of rehabilitation: Physical Occupational emotional

33. 33 REHABILITATION IN LEPROSY Physical rehabilitation Prevention Help patient to get over physical disabilities of leprosy e.g physical deformities and blindness. To prevent disability there is need for early diagnosis, early treatment and the need to recognise early reactions of nails and eyes and treat them promptly.

34. 34 REHABILITATION IN LEPROSY Management of disability Control the ulcerations Avoid destruction of extremities Teach patient on the care of anaesthetised part. Make him be aware of the abnormality; he should have protective foot wear.

35. 35 REHABILITATION IN LEPROSY Restrict the use of the anaesthetised part. Advise patient to protect the hands by using gloves. Dead and coloured tissues can be removed in the hospital. Skin grafting should be done on ulcerations, reserving paralysed muscles and those not in use to prevent atrophy.

36. 36 REHABILITATION IN LEPROSY Physiotherapy Aims To prevent contractures To retain full range of motion To prevent muscular atrophy To prevent overstretching of paralysed muscles To assist in gaining normal muscle power

37. 37 REHABILITATION IN LEPROSY Implementation Do passive exercises Massage Electrical stimulation splinting of immobile parts

38. 38 REHABILITATION IN LEPROSY Reconstructive surgery Indications Functional purposes Entropion inversion of eyelid so that they rub against the eyeball. Facial nerve palsy Hand paralysis Foot drop Amputation Claw toes

39. 39 REHABILITATION IN LEPROSY Cosmetic reasons Replacement of eyebrows Nasal collapse Sagging face or earlobes Gynaecomastia Prosthetic reasons Artificial leg or amputation

40. 40 REHABILITATION IN LEPROSY Emotional (social & physical) rehabilitation Socially patient is fearful, anxious and feels rejected and he/she might think that he/she can transmit infection to the family. Reasure patient Talk to the family and community on the importance of accepting the patient. Explain on the condition and how they will protect the patient.

41. 41 REHABILITATION IN LEPROSY Occupational (vocational ) rehabilitation This varies according to peoples’ attitudes, opportunities and the availability of farm land. Control of Leprosy Early diagnosis and treatment of infectious cases. Out patient care should be within reach

42. 42 CONTROL OF LEPROSY Case finding and surveys IEC to infected cases and community Immunisation for those at risk i.e babies in infected families. Children below 10 years with infected parents are put on prophylactic treatment.

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