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Talhari2015 PDF
Talhari2015 PDF
Abstract Leprosy is a chronic, infectious disease caused by Mycobacterium leprae. It mainly affects the
peripheral nervous system, skin, and certain other tissues such as the reticulo-endothelial system, bones
and joints, mucous membranes, eyes, testes, muscles, and adrenals. Leprosy clinical presentation varies
from few to widespread lesions. In most patients, early leprosy presents as macular and hypopigmented
lesions. This initial clinical presentation is known as indeterminate leprosy and occurs in individuals
who have not developed cell-mediated immunity against M leprae yet. The number of lesions depends
on the genetically determined cellular immunity of the patient. Individuals presenting a vigorous cellular
immune response and limited humoral immune responses to M leprae, usually present few skin lesions.
Without treatment, those patients tend to evolve into the polar tuberculoid or borderline tuberculoid form of
leprosy. Due to the inability to mount an effective cellular-mediated response to M leprae and the consequent
hematogenous spread of the bacilli, some patients may present with numerous and symmetrically distributed
hypochromic lesions. Without treatment these patients evolve to a nonresistant form of leprosy,
polar lepromatous.
2015 Elsevier Inc. All rights reserved.
Clinical leprosy debate for many years.4 The first classifications were based
only upon clinical parameters, generating confusion and
Leprosy is a chronic, infectious disease caused by controversies. In 1953, during the Madrid congress, a
Mycobacterium leprae. It mainly affects the peripheral classification based on four main disease groups was
nervous system, skin, and certain other tissues such as the proposed: lepromatous leprosy, tuberculoid leprosy, indeter-
reticulo-endothelial system, bones and joints, mucous minate leprosy, and borderline or dimorphous leprosy.5,6
membranes, eyes, testes, muscles, and adrenals. The clinical In 1962 2 and 1966 3, Ridley and Jopling proposed a new
presentation of leprosy clinical presentation varies from few classification based not only on the clinical features, but also
to widespread lesions.1 Similarly, histopathology of skin on histopathology, bacterial load and the degree of cell-
lesions varies from compact granulomas to diffuse infiltra- mediated immune response (CMI) against M leprae, which is
tion of dermis, which largely depend upon the immune status evaluated by the result of Mitsuda's intradermal test. Based on
of the patient and may not be in agreement with the clinical these immunopathological criteria, patients are divided into a
diagnosis.24 Leprosy classification has been a matter of five-group spectrum that extends from tuberculoid leprosy
(TT) with heightened CMI (hyperegic pole) through borderline
Corresponding author. tuberculoid (BT), borderline-borderline (BB), borderline
E-mail address: gpenna@gpenna.net (G.O. Penna). lepromatous (BL), to the poorly resistant (anergic) lepromatous
http://dx.doi.org/10.1016/j.clindermatol.2014.07.002
0738-081X/ 2015 Elsevier Inc. All rights reserved.
Clinical aspects of leprosy 27
Fig. 6 Tuberculoid leprosy. Unique lesion showing well-defined Fig. 8 Infantile nodular tuberculoid leprosy. A nodular lesion on
and elevated borders on the hand. the face of a child.
A particular type of leprosy, usually characterized by the hyperchromic, atrophic and scarring aspect; sensitivity
presence of nodular lesions may be observed in children and is tests are preserved.
known as infantile nodular tuberculoid leprosy (Figure 8).20 It 3. Annular granuloma. The lesions are characterized by the
exclusively appears during infancy and affects children younger presence of anular plaques very similar to T leprosy but
than 5 years of age. It is considered the most benign of all forms with normal sensitivity tests (Figure 10).
of the disease. In many instances this is a difficult diagnosis. 4. Secondary syphilis. The previous history of penial or
The epidemiology and the biopsy are very helpful.21 vulvar ulcerated lesion is important when differentiating
In all types of leprosy, except indeterminate, involvement such lesions from T leprosy; however, lesions on the
of peripheral trunk nerves such as ulnar, median, radial, and cervix may not be acknowledge by most of the women;
common peroneal or posterior tibial may be severe and cause anti-treponemal screening is mandatory.
disabilities 1. In TT leprosy, the possibility of peripheral 5. Gilberts pityriasis rosea. This disease of viral etiology is
nerve enlargement is low and if so, it occurs near the lesions. characterized by erythematous and round lesions present-
Neuritis pain may be the first symptom of leprosy.19 ing with collarette desquamation; these lesions evolve
The slit-skin smear of T leprosy is negative.22 rapidly, usually beginning with patch that heralds the
TT leprosy lesions may mimic the following diseases eruption, the so-called herald patch (Figure 11); the
1,10,16,17: lesions usually disappear in 1 to 2 months.
1. Tinea. As in T leprosy, there is a tendency to central Seborrhoeic dermatitis, lobomycosis, chromomycosis, pso-
healing; the presence of pruritus, local excoriation and riasis, parapsoriasis, sarcoidosis, mycosis fungoides, morphea,
superficial scars is important to differentiate such lesions necrobiosis lipoidica, Kaposis sarcoma, cutaneous tuberculosis
from T leprosy (Figure 9). and leishmaniasis are other diseases that may mimic T leprosy.
2. Cutaneous erythematous lupus. The lesions are localized
mainly on the face and other exposed areas of the body; Borderline leprosy
there is a tendency to spontaneous healing with residual
According to the Ridley and Jopling classification, the
vast majority of patients fit in this group.2,3 Usually there is
Fig. 7 Tuberculoid leprosy. An unique macule showing papules Fig. 9 Tinea. A pruriginous plaque showing local excoriation on
on the edges of the lesions. the forehead; differential diagnosis of tuberculoid leprosy.
30 C. Talhari et al.
size, become erythematous and infiltrated. The lesion edges spread of the bacilli, some patients may present with numerous
are irregular and invade normal skin (Figure 16).23 Progres- and symmetrically distributed hypochromic lesions. Without
sively, extensive areas become infiltrated (Figure 17). Plaque- treatment these patients evolve to a nonresistant form
like lesions, papules and nodules may appear simulating of leprosy - polar lepromatous (LL). This leprosy form may
lepromatous leprosy.11 also occur as a result of downgrading BB and BL without
Type 1 and 2 leprosy reactions are frequently observed in treatment.1,10,11
these patients.24 There are two clinical subforms of lepromatous leprosy,
Peripheral nerve enlargement is observed in most of the subpolar (LLs) and polar (LLp). LLs patients are not
patients (Figure 18). Nerves are less commonly tender than in completely anergic and after treatment become bacteriologi-
BT but during reactions severe nerve damage may occur.11 cally negative more rapidly when compared with LLp. Patients
Bacilloscopy is strongly positive.22 presenting with the first clinical form can develop type 1
reaction.25
Lepromatous leprosy (LL) In LLs the macules, nodules and plaques have well-defined
borders. LLp occur in extremely anergic patients and are
Due to the inability to mount an effective cellular-mediated characterized by the presence of diffuse infiltration of the skin
response to M leprae and the consequent hematogenous with indistinct edges.11 In such patients, a diffuse infiltration of
the hypochromic lesions and the apparently normal skin
slowly involves extensive areas or the entire body. Without
treatment, the skin becomes more and more infiltrated, the
Fig. 18 Borderline lepromatous leprosy. Erythematous and infiltrated Fig. 20 Lepromatous leprosy. Diffuse infiltration of the face with
auricular pavilion with auricular nerve enlargement. bilateral involvement of auricular pavilions.
Clinical aspects of leprosy 33
ulcers (perforating plantar disease), infection, bone these cases have been reported in association with an
involvement (osteomyelitis), clawing and loss of the immunopathological phenomenon called Immune Reconsti-
toes, and severe disabling are progressively observed tution Inflammatory Syndrome (IRIS).5864 IRIS occurs in a
without adequate treatment/prevention of the nerve subgroup of AIDS patients with apparent clinical deterioration
damage.1,10,46,47 despite the T-CD4 + cell count improvement induced by
Facial nerve. The temporal and zygomatic branches may highly active antiretroviral therapy (HAART).59
be damaged. Lagophthalmos is a very important and One particularly challenging aspect of leprosy-HIV/AIDS
frequent complication. Rarely and in advanced disease, co-infection is the diagnosis of patients with peripheral
paralysis of bucal, mandibular and cervical branches, may neurological manifestations. It may be confounded by
cause loss of facial expression and inability to close the neuropathy associated with HIV itself or with stavudine
mouse.1,10,46,47 and other nucleoside-analogue reverse-transcriptase inhibi-
tors. The clinical findings such as nerve enlargement,
Differential diagnosis of nerve involvement sensory loss, muscle force impairment, and electromyoneur-
The most important diseases include in the differential omyography results are important for the diagnosis.58
diagnosis of nerve involvement in leprosy are the polyneuro- Recently, it was suggested that even though leprosy-
pathy associated with Aids, Djrine-Sottass disease (periph- HIV/AIDS co-infection does not manifest homogenously
eral nerves may be thickened!), diabetes, amyloidosis, systemic across affected populations, immunological features seem
lupus erythematosus, systemic scleroderma, etc.; neurotoxicity to be shared by certain sub-groups. In this context, a clinical
associated with drugs (isoniazid, poisoning with arsenic, classification of M leprae and HIV/AIDS co-infected
mercury, thallium and others). Nerve compression (carpal patients was proposed and include the following: 1
tunnel syndrome, cervico-brachial syndrome and others), M leprae-HIV true co-infection: this group is composed
neurogenic muscular atrophy (Tooth-Charcot-Hoffman), by HIV-positive individuals that do not fulfill AIDS
hereditary sensory neuropathy (Thevenards syndrome), criteria, therefore, not under HAART; behaving similarly
and syringomelia are among the many differential diagnosis to immunocompetent subjects; 2 opportunistic leprosy
with leprosy.4347 disease: composed by AIDS patients not receiving
HAART, presenting usually multibacillary leprosy; this
Coinfection HIV/AIDS/leprosy group would be composed by individuals manifesting
leprosy as an opportunistic mycobacteriosis, as expected in
immunosuppressed individuals; and 3 HAART related
HIV prevalence rates are still increasing in many countries leprosy: including AIDS patients presenting all clinical
where leprosy is endemic. According to the Joint United Nations forms of leprosy related or not to IRIS. Combined HAART
Programme on HIV/AIDS (UNAIDS), in 2011, the number of and multidrug therapy might cause upgrading shift
people living with HIV worldwide continued to grow, reaching within the leprosy clinical spectrum, as may be revealed
an estimated 34 million (31.4-35.9 million).48 by long-term follow-up. 58
In such scenario, it would be expected that the Finally, there is still a lot to learn about this ancient
geographical overlap of these two diseases would result in disease that, despite intense research efforts throughout the
an increasing number of co-infected individuals.49 Global past centuries 65,66, is yet not fully understood. Although
data indicates that, contrary to the early expectations, there important progress has been made concerning the treatment
seems to be no significant increase in leprosy and HIV co-
infection.50 Most of the larger studies on the subject were
done in the early to mid-1990s, examining the rate of HIV
serum positivity among leprosy patients.5157
An interesting aspect of the pathogenesis of leprosy in Aids
patients with low T-CD4 + cell count is what has been called
the granuloma paradox: an apparent preservation of the ability
to form granuloma among these patients, in clear contrast with
what is observed in M tuberculosis and HIV co-infected
patients. It has been shown that histopathologic features of
leprosy appear to be maintained in co-infected patients.49
Recent findings demonstrate a possible impact of HIV-
infection, HAART, and MDT over leprosy granuloma
formation, contrasting with the granuloma paradox initially
proposed and reinforce the need of careful follow-up of co-
infected patients.58
The most often observed clinical form of leprosy in co- Fig. 25 Borderline tuberculoid leprosy in an AIDS patient. An
infected patients is BT (Figure 25). The large majority of erythematous and infiltrated lesion with well-defined edges on the trunk.
36 C. Talhari et al.
of leprosy, as published by WHO in 2010 67, a major effort 28. Latapi F, Chvez-Zamora A. The spotted leprosy of Lucio: an
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30. Magaa M, Fernndez-Dez J, Magaa ML. Lucio's phenomenon is a
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