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Lep
Lep
Pathophysiology
Leprosy can manifest in different forms, depending on the host response to
the organism.
Individuals who have a vigorous cellular immune response to M leprae have
the tuberculoid form of the disease that usually involves the skin and
peripheral nerves. The number of skin lesions is limited, and they tend to be
dry and hypoesthetic. Nerve involvement is usually asymmetric. This form of
the disease is also referred to as paucibacillary leprosy because of the low
number of bacteria in the skin lesions (ie, < 5 skin lesions, with absence of
organisms on smear). Results of skin tests with antigen from killed organisms
are positive in these individuals.
Individuals with minimal cellular immune response have the lepromatous form
of the disease, which is characterized by extensive skin involvement. Skin
lesions are often described as infiltrated nodules and plaques, and nerve
involvement tends to be symmetric in distribution. The organism grows best at
27-30C; therefore, skin lesions tend to develop in the cooler areas of the
body, with sparing of the groin, axilla, and scalp. This form of the disease is
also referred to as multibacillary leprosy because of the large number of
bacteria found in the lesions (ie, >6 lesions, with possible visualization of
bacilli on smear). Results of skin tests with antigen from killed organisms are
nonreactive.
Patients may also present with features of both categories; however, over
time, they usually evolve to one or the other (indeterminate or borderline
leprosy). Interestingly, most individuals who are exposed to leprosy never
develop the disease.
Classification of leprosy
Leprosy has 2 classification schemas: the 5-category Ridley-Jopling system
and the simpler and more commonly used WHO standard. [4]
Ridley-Jopling: Depending on the host response to the organism, leprosy can
manifest clinically along a spectrum bounded by the tuberculoid and
lepromatous forms of the disease. Most patients fall into the intermediate
classifications, which include borderline tuberculoid leprosy, midborderline
leprosy, and borderline lepromatous leprosy. The classification of the disease
typically changes as it evolves during its progression or management. The
Ridley-Jopling system is used globally and forms the basis of clinical studies
of leprosy. It may also be more useful in guiding treatment regimens and
assessing risk of acute complications. Physical findings in each subtype are
presented in the Clinical section.
According to the WHO, in an endemic area, an individual is considered to
have leprosy if he or she shows either of the two following signs: [4]
A skin lesion consistent with leprosy and definite sensory loss, with or
without thickened nerves
Positive skin smears
Epidemiology
Frequency
United States
In 2014, according to the U.S. Department of Health and Human Services,
175 new cases of leprosy were detected in the United States. [5]
Eighty-five percent of leprosy cases in the United States are found in
immigrants, [6]although endemic foci exist in parts of Louisiana, Florida, and
Texas along the Gulf of Mexico; in Mexican and Asian California populations;
and in Spanish Americans in New York City.
Some cases among native US citizens can be accounted for by exposure to
leprosy overseas. Some cases can be attributed to a contact with a known
case of leprosy or exposure to infected armadillos.
Based on genetic analysis studies, wild armadillos and many patients with
leprosy in the southern United States are infected with the same strain of M
leprae. [7]Leprosy may be a zoonosis in the southern United States because
armadillos are a large reservoir for this disease.
Nonetheless, history of exposure cannot be verified in many patients. [8]
International
According to WHO figures and as reported by 130 countries, the global annual
detection rates have declined from 2004-2010, when 407,791 and 228,474
new cases were reported, respectively (see the images below). The
prevalence registered worldwide at the beginning of 2010 was 192,246 cases.
Of the new cases, 95% were detected worldwide during 2010 in the following
countries: Angola, Bangladesh, Brazil, China, Democratic Republic of the
Congo, India, Ethiopia, Indonesia, Madagascar, Mozambique, Myanmar,
Nepal, Nigeria, Philippines, Sri Lanka, Sudan, and United Republic of
Tanzania. [2] These countries still exhibit pockets of high endemicity.