REVIEWS OF INFECTIOUS DISEASES. VOL. 9. NO.3.

MAY-JUNE 1987
© 1987 by The University of Chicago. All rights reserved. 0886-0I62/87/0903-00II$02.00

Environmental Nonhuman Sources of Leprosy

Leslie A. Blake, Burton C. West, Cynthia H. Lary, From the Section of Infectious Diseases, Department of
and John R. Todd IV Medicine, Louisiana State University School of Medicine,
Shreveport, Louisiana

Leprosy has been considered to occur only after exposure to a human case. However,
evidence has been accumulating that this conventional view is wrong and that an environ-
mental nonhuman source is critical to some human infections with Mycobacterium leprae.
Observations, some of which date back to the nineteenth century, support soil, vegeta-
tion, water, arthropods, and armadillos (Dasypus novemcinctusi as environmental sources
of leprosy. Disparate clinical, epidemiologic, and microbiologic evidence has been criti-

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cally reviewed in light of the fact that 50010-70070 of sporadic cases of leprosy in well-
studied populations occur in persons who have had no known contact with human leprosy.
Historical data and current information alike substantiate the concept of nonhuman sources
of the disease; recent observations with monoclonal antibody have shown that phenolic
glycolipid-I antigen, which is unique to the M. leprae cell wall, is present in soil. In the
absence of a technique for in vitro cultivation, indirect methods and the body of observa-
tions reviewed here persuasively favor but do not prove the existence of environmental
nonhuman sources of M. leprae.

Close human contact has been the traditionally ac-
cepted mode of infection with Mycobacterium
leprae; throughout history, those stricken with
leprosy have been cast out and subjected to segrega-
tion and shunning. However, both impressions and
statistics argue that such proverbial transmission of
M leprae through close contact is the exception
rather than the rule. In fact, as many as 70% - and
no fewer than 50070 - of patients with leprosy have
no history whatsoever of contact with another
known leprosy patient [1, 2]. It is in this curious con-
text that other potential sources of M. leprae, par-
ticularly environmental foci, become significant.
The leprosy bacillus itself was discovered by Han-
sen in 1873. In fact, leprosy was the first disease to
be correctly attributed to a specific microorganism.
Only since 1941 has effective sulfone therapy been
available [3]. New findings pertaining to the microbi-
ology of the bacillus and its potential effects on the
host's immune status [4-6] have shed light on for-
Received for publication September 29, 1986, and in revised
form December 24, 1986.
This work was supported in part by medical student research
funds from the Department of Medicine at Louisiana State Univer-
sity School of Medicine and by the Ed E. and Gladys Hurley Foun-
dation.
We thank Tommie Lue Maddox for secretarial assistance.
Please address requests for reprints to Dr. Burton C. West, Sec-
tion of Infectious Diseases, Department of Medicine, LSU Med-
ical Center, P.O. Box 33932, Shreveport, Louisiana 71130-3932.
merly unknown aspects of the disease, while further
biochemical tests have contributed to specific
methods of identifying the bacillus [7-10]. The de-
velopment of these tests and of animal models of
leprosy is especially important because no culture
medium for M. leprae yet exists and the bacillus has
therefore only indirectly fulfilled Koch's postulates.
In a consideration of the environmental sources
of leprosy, the epidemiology of the disease must be
examined. Leprosy is a chronic disease with a spec-
trum of manifestations and a host specificity limited
to humans, armadillos, and certain primates. M. lep-
rae multiplies in 12-14 days; thus it is the slowest-
growing bacterial pathogen known. It follows that
the incubation period for leprosy, though widely
variable, is measured in years. The infection is charac-
terized by nerve, skin, and upper respiratory tract
involvement and appears to disseminate via the
bloodstream [3].
Today, 90% of leprosy cases are found in sub-
Saharan Africa and southern Asia, although in the
past the disease has been prevalent as far north as
the Arctic Circle. It is also found in South and Cen-
tral America, the United States, eastern Canada, the
Pacific islands, Australia, and (to a lesser extent)
northern Europe and Mediterranean regions [3]. In-
cidence rates are difficult to calculate, as the time
of onset of disease is often not known, and preva-
lence rates vary widely throughout the world, rang-
ing from 0.1% to 1070 in countries where the disease

562
Nonhuman Sources of Leprosy
is endemic [3]. Among children there is little differ-
ence between the sexes in the type of leprosy that
is prevalent, while among adults the lepromatous
form is clearly more prevalent in men. No real sex-
related distinction is seen in tuberculoid leprosy. The
age of onset is difficult to establish; however, the
peak incidence in most countries is seen between the
ages of 10 and 29 years. The incidence of cases of
adult onset plateaus and then declines after the age
of 50 years [3]. The age of onset is lower in coun-
tries where leprosy is highly endemic than in those
where the disease is rare [11].
Historically, skin-to-skin contact has been consid-
ered the means of spread of leprosy, in part because
of the obvious cutaneous lesions expressed in both
primary and secondary cases. This concept was sup-
ported by the tendency of leprosy to cluster in groups
of people; the incidence of the lepromatous type is
higher among persons exposed at home than among
those not so exposed [3]. Yet within familial or close
associations are many shared factors that contrib-
ute to disease spread, such as living standards, en-
vironmental exposure, and genes. Furthermore, the
body sites frequently affected by leprosy (hips, but-
tocks, thighs, and arms) do not correspond to areas
frequently touched in any society [12]. Recent studies
in nude mice have cast doubt on the facility of in-
fection through contact with skin lesions unless the
lesions contain significant quantities of viable bacilli,
as in untreated lepromatous cases [13]. Even if the
bacillus were shed, it could not penetrate intact skin,
as the organism is inert, nonmotile, and nontoxic;
instead, it would enter through existing lesions [14].
Lately, the concept of airborne infection, which
received some consideration at the beginning of the
twentieth century, has returned to favor. As in tuber-
culosis, the portal of entry is thought to be the up-
per respiratory tract, to which M /eprae is trans-
ported by aerosolized droplets from nasal secretions
or sputum [15]. Fourteen months after using a Hen-
derson apparatus to simulate airborne infection with
M. /eprae in nude mice, Rees and McDougall found
that 33% of the mice had countable numbers of acid-
fast bacilli in the lungs and at such distant sites as
the ears, footpads, and nose [16]. Chehl et al. ex-
posed groups of nude mice to M. /eprae by ad-
ministering an inoculum in several ways: into the
nose, lungs, mouth, or stomach; onto intact or
abraded skin; and into subcutaneous tissue [13]. Only
those mice with nasal exposure or subcutaneous in-
oculation developed disseminated diseae [13]. It ap-
563
pears likely that droplets of different sizes could af-
fect the nasal mucosa or the lungs differently, as in
tuberculosis [13].
A 24-hr specimen of nasal mucus from a patient
with untreated lepromatous leprosy can contain up
to 2.4 X 108 M. /eprae organisms, and M. /eprae can
survive in desiccated nasal secretions for up to seven
days (longer in moist soil) [17]. Thus, prolonged,
close contact with an open case may not be a pre-
requisite for transmission, despite what has tradition-
ally been thought. Broad implications arise for cer-
tain leprosy-endemic countries such as India, where
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the custom of depositing nasal secretions on the
ground is commonplace [18]. Moreover, between
50% [18] and 70070 [1, 2] of new leprosy cases can-
not be traced to a known contact. Speculation also
exists about potential asymptomatic or "carrier"
states in leprosy [1]. Chatterjee in 1975 found acid-
fast bacilli in 5.8070 of earlobe skin samples from a
clinically normal population in India. He followed
persons with positive test results to see whether they
developed the disease; he noted that these individu-
als seemed to develop leprosy at the same rate, or
at even higher rates, than did contacts of leprosy pa-
tients [19]. Conclusive evidence of the infectivity of
these subclinical states is still lacking.
Pedley reported the presence of 2 x 106 acid-fast
bacilli in 120 ml of human breast milk, leading to
speculation about transmission by afflicted nursing
mothers [20]. No cases of pharyngeal or intestinal
infection are known, however, and there has been
no confirmation of distant spread from the gastroin-
testinal tract. There is also the possibility of urogen-
ital or venereal spread, as acid-fast bacilli have been
found in the testes of patients with lepromatous dis-
ease, but not in semen or urine [21]. In addition,
there are accounts of leprosy following tattooing
[22], trauma [23], and vaccination with bacille Cal-
mette-Guerin [24]. Whilepostinoculation leprosy has
been witnessed experimentally, it cannot be verified
in any case whether the inoculum caused disease or
whether the disease was present subclinically and was
precipitated by the trauma and subsequent immune
response.
These possible modes of transmission of M. /ep-
raetacitly support the premise that infection requires
direct and extensive human contact. Yet many cases
do not fit that mold. In Colombia there are accounts
of casas malditas, or "cursed houses," where persons
have contracted leprosy merely by spending the night
[25]. A sequence of events that occurred on a small
564 Blake et al.

island in the Baltic Sea is also relevant. Only one fam-
ily at a time lived in the sole house on the island.
In succession, four families came and went, all from
different regions of Finland, in none of which leprosy
was endemic; in succession, the wives in each of the
four households contracted leprosy [25]. These
events give new meaning to biblical advice; Leviti-
cus exhorts the priests to destroy houses where
leprosy comes again (Lev. 14:33-47). The "house-
bound" nature of the disease implies a human ori-
gin without direct spread. The bacilli appear to have
entered an environmental reservoir from which they
among household contacts of patients increases by
more than fivefold for the polar lepromatous type
and by more than threefold for the polar tuberculoid
type over the incidence among persons not so ex-
posed [26]. Although the concept of direct spread
from an active human case has caused some investi-
gators to ascribe all new cases to unremembered
sources or unwitting exposure to undiagnosed cases,
the existence of one or more environmental foci of
M. leprae is a distinct possibility. Leprosy can be
"housebound." On the other hand, a male prepon-
derance among patients with leprosy (male-to-female

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infect susceptible human beings at a point separated
in time and space from the original active case.
We do not contest human-to-human contact as
critical to some cases of leprosy. Human-to-human
transmission has been demonstrated as well as non-
culture methods permit. The incidence of leprosy
ratio, 3:2 [27]) follows the pattern of environmen-
tal/occupational diseases such as tularemia [28] and
scrub typhus [29], which are related to exposure to
organisms outdoors. Furthermore, various accounts
suggest rural environmental sources; many observers,
including Irgens, Leiker, and Guinto, have com-

Table 1. Soil, water, and vegetation as sources of leprosy-like diseases and possibly of leprosy.
Source, Refer-
associated finding Description Location Test method (result) ence(s)

Soil
Noncultivable AFB 1 of 4 soil samples positive Bombay, India Mouse footpad inoculation, histopathologic 34
tests, and MAB to PGL-I antigen
(positive)
Noncultivable AFB Soil from 2 of 12 armadillo Pointe Coupee MAB to PGL-I antigen (positive) 35*
burrows positive Parish, La.
Water
Lepra bubalorum Mycobacterial leprosy-like disease Indonesia Histopathology of nodules and macro- 36
of water buffaloes scopic observations (positive); cultivation
attempts (negative)
Noncultivable AFB Organism in pond water Ivory Coast Mouse footpad inoculation, armadillo 37
inoculation, pyridine and DOPA
oxidase (positive)
AFB in well water 17 samples tested: cultivable Bombay, India Mouse footpad inoculation, histopathologic 34
and noncultivable AFB tests (positive)
Vegetation
Buruli disease Organism as saprophyte on Uganda Characteristic growth on Lowenstein- 38
(Mycobacterium grass, entry via skin lesions Jensen medium
ulcerans)
Cultivable AFB Optimal qualities of sphagnum Germany, Culture on sphagnum moss medium; 39,40
moss for growth of AFB Sweden, and identification by standard biochemical
Norway and taxonomic methods
Noncultivable AFB Thought to exist in sphagnum Norway DOPA oxidase, pyridine, and mouse 37, 41
footpad tests (positive)
Unknown
Batrachian leprosy Lepra-like granulomas in Bolivia Stains for AFB and histopathology 42
tree frogs (positive); cultures for AFB (negative)
Leprosy in two Chimpanzee and mangabey Sierra Leone Histopathology and biochemical analysis 43
primates monkey and Nigeria (positive); cultures (negative)
NOTE. Abbreviations: AFB = acid-fast bacilli; MAB = monoclonal antibody; PGL-I = phenolic glycolipid-I; DOPA =
3,4-dihydroxyphenylalanine.
* Personal communication, R. W. Truman.
Nonhuman Sources of Leprosy
mented on the rural distribution of the disease (cited
in [3]). Perhaps M. leprae can survive in plants, wa-
ter, and soil as well as in dust, fomites, furniture,
and clothing. Moreover, insects and other arthropods
have been extensively investigated as potential vec-
tors and sources of M. leprae. In addition, the ar-
madillo, now the prize experimental model for
leprosy, has been shown to harbor a disease indis-
tinguishable from human leprosy [30]; to the ar-
madillo has been attributed the ability to infect
humans, particularly men who handle the animal
[31- 33]. These three broad types of environmental
sourcesof M lepraewillnow be consideredseparately.
Soil, Vegetation, and Water
As relatively"inert" substances, soil, water, and vege-
tation have not received much notice as possible sites
for M leprae, but throughout this century pieces of
evidence have supported their roles as sources (ta-
ble 1). As early as 1910, Dr. Sand from Norway
postulated at the Second Leprosy Congress that
leprosy is not transmitted by direct contact but indi-
rectly through a natural medium such as soil (cited
in [34]). In 1930 Lobel described a leprosy-like dis-
ease in Indonesian water buffaloes. Named "lepra
bubalorum," it manifested itself with skin nodules,
nasal ulcers, and granulations of the nasal mucous
membranes. Globi of acid- fast bacilli were seen in
the skin, nasal mucous membranes, and lymph
nodes. Attempts at cultivation were made, but no
growth was observed over two years. While its iden-
tity was not established definitively, a close resem-
blance existed between this disease and human lep-
rosy [36]. The photographs showed nodules and
ulcers located at points where water or mud would
come into contact with the animals: legs, belly,
neck, and head were all affected, whereas the rest
of the body was spared. Although no environmen-
tal cultures or stalns were done, these findings sug-
gested that the pathogenic organism existed in wa-
ter or mud [30].
In 1954 Machicao and La Placa noted lepra-like
granulomas in Bolivian tree frogs. Closer investiga-
tion of skin, liver, and gastrointestinal organs re-
vealed that the granulomas contained noncultivable
acid-fast bacilli arranged in globi in macrophages
and foamy histiocytes. Because the frog's diet con-
sists of insects, an intestinal route of transmission
to the frogs was suggested when acid-fast bacilli were
found in the local insect population. Also suspected
565
werewater and dung; however, no acid-fast bacteria
were found in tested samples [42]. Whether this
batrachian leprosy is the same as human leprosy has
not been explored, and the source of the acid-fast
bacilli has not yet been established. In light of how
ubiquitous mycobacteria are in nature, this infection
might be caused by another species altogether.
Nevertheless, the appearance of the disease is sug-
gestive of leprosy.
In 1970 Barker et al. reported that M. ulcerans
could exist as a saprophyte on certain grasses and
that the Ugandan Buruli disease was contracted by
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the contact of broken skin with grass. This concept
was reinforced by the location of the lesions on the
lower legs, the age and sex of those most often af-
fected, and the geographic distribution of the dis-
ease [38]. These findings were significant as M ulce-
rans had never before been isolated from a
nonhuman source. A parallel mode of transmission
of M. leprae may exist in India, where early lesions
on the feet are found more often in patients from
hilly and stony districts than in patients from allu-
vial regions [12]. Broken skin or trauma appears to
play a role in transmission.
Other animals also have been found to have a dis-
ease indistinguishable from leprosy. A chimpanzee
from the Sierra Leone and a mangabey monkey from
Nigeria developed the disease a few years after en-
tering the United States [43]. It is suspected that they
contracted it through human contact in their native
countries, although other sources of leprosy - such
as animals, insects, water, or vegetation - cannot be
discounted.
The quest for inanimate or plant sources of M lep-
rae falls short when compared with the more appar-
ent findings in arthropods and armadillos. Yet the
very fact that M. leprae can be found in insects and
certain feral animals posits-the existence of a more
fundamental source as a reservoir. Recent studies re-
vealed that soil samples from two of 12 armadillo
burrows in Pointe Coupee Parish, Louisiana, were
positive for the apparently species-specific phenolic
glycolipid-I (POL-I) antigen of M. leprae. These
studies capitalized on unique characteristics of the
POL-I antigen, identifying it by ELISA and by its
reaction with a specific monoclonal antibody ([35]
and R. W. Truman, personal communication). The
possibility of cross-reacting antigens is nearly ex-
cluded because of the specific nature of the test; thus,
the results strongly support the identity of the or-
ganism as M. leprae in the soil. The POL-I antigen
566
may be a remnant from excretions or secretions of
infected armadillos. On the other hand, the antigen
may be part of viable bacilli that could serve as a
source of infection for armadillos and human beings.
The work of Kazda and associates sheds new light
on potential sources of M. leprae. These researchers
established that the sphagnum vegetation of moor
biotopes provides a suitable environment for the
reproduction of mycobacteria. Heat accumulates un-
der the surface of the vegetation, raising the tem-
perature to a level 28°C higher than the surround-
ing air, and nutrients circulate easily in this acidic
environment, creating favorable conditions for the
growth of mesophilic organisms [39]. Fifty percent
of the tested sphagnum samples in northwestern Ger-
many contained cultivable acid-fast bacteria [40]. In
moors in southern Sweden and on the west coast of
Norway (an area where leprosy was formerly en-
demic), one-third of the samples tested contained
cultivable acid-fast bacteria, and the varieties of both
sphagnum and mycobacteria differed in the two
countries [39].
In 1980 Kazda et al. initiated an indirect test for
the presence of M. leprae in Norway. Since M leprae
has a characteristic growth pattern in mouse foot-
pads that is distinct from the growth patterns of all
cultivable acid-fast bacteria [41],these investigators
tested samples that contained acid-fast bacilli and
that were culture-negative by inoculating them into
footpads. From 122samples, 21070 of 759 inoculated
footpads demonstrated growth typical of M. leprae,
with 105-106 acid-fast bacilli per footpad. Auto-
trophic enzymatic properties that help the organism
maintain viability were also identified. As yet, the
organism has not been identified, but biochemical
analysis and armadillo inoculation continue [41].
The most comprehensive of Kazda's studies in-
volved samples of soil, water, and vegetation from
sites throughout the world in which leprosy was en-
demic or had been endemic. Noncultivable acid-fast
bacilli were found in Norway, the Ivory Coast, Por-
tugal, Peru, India, and Louisiana. No acid-fast bacilli
were found in Sweden, Scotland, or Germany. Af-
ter many noncultivable acid-fast bacilli were tested
in mouse footpads, armadillos, and biochemical sys-
tems, the organisms from a sphagnum sample from
Norway and a water sample from the Ivory Coast
were found to be indistinguishable from M. leprae;
they showed characteristic growth in mouse footpads,
produced typical disease in armadillos, and gave
positive results in both a 3,4-dihydroxyphenylalanine
Blake et 01.
(DOPA) oxidase test and a pyridine extraction of
acid-fastness. On the other hand, two samples from
other sites in Norway and the Ivory Coast produced
extensive mycobacteriosis in armadillos and grew in
mouse footpads but were negative for DOPA oxi-
dase and pyridine extraction [37]. Although their
identification is incomplete, perhaps the latter bacilli
serve as cofactors with the M. leprae-like bacillus.
Additional studies of water and soil were per-
formed in Bombay in 1981 through the mouse foot-
pad technique and growth on sphagnum nutrient
substrate. Noncultivable samples were tested by
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DOPA oxidase and pyridine decoloration and ulti-
mately were analyzed through screening for the
M. leprae-specific PGL-I antigen with monoclonal
antibodies. One soil sample contained noncultiva-
ble acid-fast bacilli that were consistent with
M leprae in tests with monoclonal antibody to PGL-
I [34].
Are these environmental organisms indeed
M. leprae? If environmental organisms are con-
firmed to be M. leprae, are they viable pathogens?
Does their presence mean that individuals could be
exposed to M leprae while walking, washing, or
drinking water? The epidemiology of leprosy in Nor-
way indicates that, in the past, close contact with
sphagnum enhanced the risk of infection by a fac-
tor of at least four [44]. However, viable acid-fast
bacilli closely resembling M. leprae persist today in
sphagnum moss, while leprosy has been eradicated
from Norway. Either the source played but a small
part in the disease or the significance of its role has
changed. Convention argues that improvement in liv-
ing standards, better nutrition, and possibly immu-
nity have contributed to the decline of leprosy [3].
How much exposure would cause disease in a sus-
ceptible individual? If the organism is M leprae and
is ubiquitous in nature, one might expect more cases
of leprosy, particularly in countries where the prev-
alence of the disease is low. With a potential attack
rate of 5070 [45] but a much lower actual prevalence,
this discrepancy is unresolved. Certain environmen-
tal sources may be more infective than others, and
pathogenicity may depend more on the innate sus-
ceptibility of a population than on the mere exis-
tence of M. leprae in other sources. Newell suggests:
"One must conclude from these dissimilar ex-
periences that the presence of M. leprae, although
probably essential for the development of leprosy,
must be placed in conjunction with other facto 's that
might be of dominating importance in influencing
Nonhuman Sources of Leprosy 567

the occurrence of the disease in a population. . . .
By exclusion, one is left with the conclusion that the
method of spread and environmental factors must
be dominant" [12]. Newell speaks of environmental
"factors," while wespeak of environmental "sources";
both environmental factors and environmental
sources appear to be important to an understand-
ing of leprosy.
Arthropods
It has been observed that leprosy coexists with low
ing conditions were such a tremendous part of the
quotidian reality that the prevailing view was that
"to be without lice was a sign of bad health" [46].
In Iceland, too, when the standard of living rose and
arthropod infestation was reduced, leprosy disap-
peared [46].
In East Africa, Innes describes yet another rela-
tionship between leprosy and scabies: "Where there
is much gross, untreated scabies, there is liable also
to be much leprosy in the community, and instances
are numerous of the two diseases being coincident
in the same person .... The explanation of the corre-

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standards of living, contributing factors being mal-
nourishment, poor hygiene, crowding, and infesta-
tions by lice, fleas, ticks, flies, and mosquitoes (ta-
ble 2). The relationship between arthropods and
leprosy appears to be strong, if only by negative as-
sociation: Ockland points out that fleas and un-
hygienic conditions were the norm in Norway when
leprosy was endemic, but when living conditions im-
proved, both the fleas and the leprosy vanished (cited
in [25]). Similarly, Dungal states that leprosy in Ice-
land at the turn of the century went hand in hand
with squalor, scabies, lice, and fleas [46]. These liv-
lation may be that chronic scabies means chronic
scratching and, altogether, many minute abrasions
through which the causal germs of leprosy are in-
oculated, repeatedly and frequently" [47]. Other
authors have noted the association of scabies and
leprosy in Norway (Danielson and Boeck, 1847)and
in Brazil (Bassewitz, 1905), as cited by Dungal [46].
In light of these observations, the possibility that
mites (Sarcoptes [formerly Acarus] scabieii serve as
a vector or an intermediate host for the leprosy ba-
cillus does not seem far-fetched.
As early as 1911 an interest in arthropods and

Table 2. Possible arthropod sources of leprosy.

Finding Description Location Test method and result Reference(s)

Association of leprosy Leprosy and scabies; leprosy Iceland, Norway, Surveys 25, 46-49
with arthropods and fleas; leprosy and Africa,
mosquitoes Martinique
Leprosy and fleas Fleas and larvae from Bogota, Colombia Stain positive for AFB and Cited in 46
homes of cases: positive monkey "inoculation"
forAFB
Mycobacterium leprae AFB available to blood- United States and 5 x l()3 to 5 X lOs bacillilml 50,51
bacteremia sucking insects India of blood
Acquisition of AFB Culex and Cimex species India Stain positive for AFB and 52
from blood by mos- fed on untreated patients mouse footpad test positive
quitoes and bedbugs
M. leprae in Field-collected arthropods India Stain positive. for AFB and 53,54
arthropods mouse footpad test positive;
culture for AFB negative
Flies as vectors AFB (from mucus) India Stains of fly gut, mouthparts, 55
deposited elsewhere and legs sometimes positive
Mosquitoes as vectors Infection of mouse footpads India Histopathology of mouse 56
via mosquitoes footpad tests positive and
characteristic
Viability of M. leprae Test of duration of AFB India Mouse footpad test positive 57
in mosquitoes viability in mosquitoes for maximum of 42-144 hr
after a blood meal
Possibility of arthropod Proboscis length vs, depth United States Measurement of proboscis 58
transmission of lepromatous leprosy length of various species
skin infiltrate

NOTE. AFB = acid-fast bacilli.

568
leprosy was manifest. Ehlers et al. caused arthropods
to bite lepromatous patients, then dissected and
stained the stomach contents of the arthropods. Only
one of 21 fleas and one of 12 mosquitoes were posi-
tive for acid-fast bacilli, while 53 bedbugs and 16
head lice were negative (cited in [25]). In 1912 Sandes
allowed insects to bite patients and found one of 80
mosquitoes, 20 of 60 fleas, and 20 of 75 bedbugs
positive for acid-fast bacilli. He also found a mac-
ule that developed where a bedbug had bitten one
patient, but it is impossible to determine whether
the bedbug caused the macule or whether the already
leprous patient responded to the bite with the erup-
tion of a new lesion (cited in [25]).
The most compelling early work on this subject
is that done by Munoz-Rivas in the 1940s. Noting
that leprosy patients from around Bogota, Colom-
bia, tended to livein huts where fleas were abundant,
he looked for evidence of acid-fast bacilli in fleas.
In an area near an antileprosy dispensary, he found
that 16070 of 200 fleas contained acid-fast bacilli; he
found no acid-fast bacilli in fleas collected from
places free of leprosy, and he found these bacteria
in 11070 of fleas allowed to bite lepromatous patients.
In studying larvae of fleas from contaminated places,
he found that 2% of the progeny contained acid-
fast bacilli. He also found that when fleas that had
bitten patients were subsequently allowed to bite
monkeys, two of four monkeys developed a leprosy-
like disease (cited in [46]). It is unfortunate that more
specific tests for the identification of this acid-fast
bacillus were not available to confirm an associa-
tion between leprosy and fleas. The implications of
these findings, however unpolished, are great: fleas
can live severalhundred days and can bite everynight
for a month. With their longevity and the potential
infectiveness of their larvae, they may serve as an in-
visible reservoir of the bacillus, contributing to a
base-line level of endemic leprosy.
Dungal cites a case in Martinique in which the
child of a mother with leprosy received nine
mosquito bites. From fluid in one bite, great num-
bers of acid-fast bacilli, apparently M. leprae, were
recovered. The house was infested with both Culex
fatigans and Aedes aegypti, and one Culex mosquito
contained numerous acid-fast bacilli [46]. Circum-
stantial evidence points to the mosquito as the vec-
tor for the bacillus; however, inoculation by a small
insect bite does not necessarily indicate transmission
of the disease; while the bacillus is vital for infec-
tion, we do not yet know what degree or type of ex-
Blake et 01.
posure is sufficient to cause disease. As the child re-
ceived sulfone treatment, the possibility that leprosy
would have developed is a matter of speculation.
Dungal also compares the insect populations of
42 leprosy-endemic territories with that of Iceland,
whose insect population is sparse. If all countries
shared the same insect vectors, the candidate spe-
cies would be limited to lice (Pediculus capitis and
Phthirus [formerly Pediculus] pubis), fleas (Pulex
irritansi, and mites (S. scabieii [46].This survey does
not establish a definitive vector, as these four insects
are plentiful allover the world, nor does it preclude
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the possibility of different vectors existing in in-
dividual countries, but it does provide a worthwhile
starting point.
While M. leprae bacteremia has been scrutinized
in attempts to establish the severity of leprosy, this
condition also becomes a significant premise with
regard to the insect vector's role in the spread of dis-
ease. An interest in leprosy bacteremia existed be-
fore the turn of the century, and later studies doc-
umented precise figures. Drutz et al, demonstrated
lOS bacteria/ml of blood [50], while Manja et al.
noted between 5 x 103 and 5 x lOS viable bacilli/ml
of blood [51]. Although the number of bacilli con-
stituting an infectious dose has yet to be established,
these studies showthe high concentration of M /eprae
that is accessible to a biting insect and that could be
picked up and transmitted to another human being.
In India Narayanan et al. observed that laboratory-
reared mosquitoes (C.jatigans) and bedbugs (Cimex
hemipterus) harbored acid-fast bacilli taken up from
the blood of untreated lepromatous patients; 70070
and 50%, respectively, of these two insect species
were positive. The typical growth pattern of the
bacilli from a homogenate injected into mouse foot-
pads and the absence of growth on LOwenstein-
Jensen medium suggest that these wereviable leprosy
bacilli [52]. We do not know, however, how many
mosquitoes or bites it would take to cause a similar
infection in the mouse footpad.
Narayanan et al. also collected arthropods from
dwellings of lepromatous patients and dwellings of
controls. Mosquitoes were taken from inside the
dwellings; bedbugs weretaken from furniture, walls,
and floors; and lice and mites were collected from
individuals. These authors found acid-fast bacilli in
both the leprosy and the control pools; in fact, the
bacilli were commoner in samples from unaffected
persons' homes. A few mycobacteria were cultiva-
ble in virtually all samples. When homogenates were
Nonhuman Sources of Leprosy
injected into mouse footpads, organisms in two sam-
ples from Culex species grew in a manner character-
istic of M leprae; one sample was from a control
dwelling and the other from a leprosy-affected home
[53]. The distribution is accounted for either by a
ubiquity of M leprae, which would consequently be
picked up by mosquitoes, or by the ability of mosqui-
toes to move easily among homes of patients and
controls. Either scenario suggests a potential for
transmission of leprosy throughout the range of the
mosquito. The acid-fast bacilli found in the other
arthropods may not be M leprae or may be nonvia-
ble M leprae. Pools negative for acid-fast bacilli oc-
casionally contained organisms that multiplied in
mouse footpads; this finding suggests that the foot-
pad method is more sensitive than staining - a com-
mon observation in clinical microbiology. Another
detailed survey of noncultivable acid-fast bacilli in
arthropods collectedwithout regard to their proximity
to leprosy cases also seems to indicate that these non-
cultivable acid-fast bacilli could be M leprae [54].
Additional innovative work was accomplished
by Geater in East Bhutan. He allowed three genera
of flies to feed on the nasal mucus of untreated
lepromatous patients. No control fliesharbored acid-
fast bacilli; however, all flies from each genus took
up acid-fast bacilli from the mucus. The bacilli were
found mostly in the guts of the insects but also oc-
casionally on their mouthparts and legs. Flies al-
lowed to bite intact skin did not take up any acid-
fast bacilli except when placed on the earlobes of
patients. In contrast, most of the flies that fed on
ulcerated skin took up acid-fast bacilli. Finally,
Geater established that flies could deposit acid-fast
bacilli on a receptor surface: he placed sugar cubes
on albumin-covered slides near some patients' mu-
cus. The flies fed on both sources, tracking back and
forth. After 2 hr, nine of 10 slides showed acid-fast
bacilli [55].
That flies can take up acid-fast bacilli from ulcer-
ated skin and nasal mucus and deposit the organ-
isms on distant surfaces creates a dispersed pool
of M leprae in the environment, although the in-
fectious dose remains unknown. Davey [18] notes
that "in endemic countries the nasal discharge is
commonly deposited on the ground whenever the
nose is cleared" and states that the potential for trans-
mission of M. leprae through flies should not be
taken lightly: "Bearing in mind the millions of via-
ble M. leprae that may be involved, there is nothing
to prevent the nasal discharge from a single untreated
569
lepromatous patient, via the medium of fly trans-
mission, from becoming the source of infection for
100 people in a single day, up to a range of 8 km
from the patient."
Proven transmission of M leprae has been shown
best by Narayanan et al., who observed the multipli-
cation of acid-fast bacilli in mouse footpads on
which mosquitoes (A. aegyptii were allowed to feed
up to 48 hr after they had fed on lepromatous pa-
tients [56}. The persistence of solid bacilli in differ-
ent parts of the insect declines rapidly, as docu-
mented by the presence of bacilli that are less intact
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at later times. In A. aegypti, solid bacilli are found
in the proboscis after 96 hr, in the gut after 48 hr,
and in the fecesafter 42 hr. In C fatigans, solid bacilli
are found in the proboscis after 144hr and in the gut
after 48 hr but are not found in the feces [57]. This
short-lived viability is not considered sufficient to
permit multiplication of the bacillus in mosquitoes,
but mechanical transmission of M lepraeby mosqui-
toes could nonetheless occur [57]. These elegant
studies not only demonstrate that mosquitoes can
be infective but also establish a tentative time frame
for transmission and possible infection.
In 1983 McDougall and Cologlu related the depth
of penetration of the biting apparatus of certain ar-
thropods (particularly those that had already been
implicated in the possible transmission of M. leprae)
to the depth of the cellular infiltrate and bacillary
mass found in the skin of lepromatous leprosy pa-
tients. Among the arthropods that these researchers
studied were A. aegypti, Culex moles/us, Anopheles
atroparvus, Pediculus humanus, S. scabiei, Cimex
lectularius, and flies of the Stomoxys species. As
M leprae cannot survive in the epidermis or in the
subepidermal "free zone," it would have to be inocu-
lated to the deeper level of the cellular infiltrate and
bacillary mass. The findings indicate a feasible rela-
tionship between the position of the affected cellu-
lar infiltrate and the .depth of penetration of the
mouthparts except in the case of S. scabiei [58].
Other investigators have attempted to implicate
arthropods in the transmission of leprosy [48, 49,
59]. It is uncontested that several genera of arthro-
pods can take up M. leprae from a heavily bacillifer-
ous patient's blood or nasal mucus, that they can
both deposit the bacilli on distant surfaces and in-
fect mouse footpads, and that the mycobacteria can
retain their viability long enough to be transmitted.
While the public health risks are obvious, it is un-
clear how these facts relate to human disease. To
570
infect humans, an insect would have to feed long
enough to retain sufficient viable bacilli, and it would
be restricted to a certain area by its range and life-
span. Perhaps the "housebound" nature of leprosy
can be partly explained by the range of the infected
insect, while certain flying insects with larger ranges
could introduce distant cases.
Positive evidence notwithstanding, the arthropod
vector theory has been widely criticized. Some
authors argue that transmission by insect vectors re-
lies on open cases of leprosy in the community as
sources and is hindered by the segregation of infected
individuals. For example, Newell states: "In a given
area, the local segregation of the clinically ill appar-
ently decreases the risks of infection to the commu-
nity, although it is still exposed to the same vectors.
M. leprae cannot apparently pass over walls" [12].
While the existence of special hospitals for the treat-
ment of leprosy has generally been associated with
a decreased incidence, in the Philippines and on St.
Croix this has not been the case [25]. Moreover, one
might question whether the disease decreases sec-
ondary to segregation alone or in response to segre-
gation along with conditions that result in improved
immunity - e.g., improved nutrition or living stan-
dards. Currently, segregation is instituted primarily
for the purpose of treatment, with a resultant de-
crease in the availability of viable bacilli to any vec-
tor. Perhaps because of treatment or because of the
hygienic conditions in hospitals and leprosaria, the
disease is rare among members of hospital staffs [11].
Other critics of the arthropod vector theory main-
tain that the geographic distribution of leprosy does
not conform to the distribution of anyone vector.
This situation calls for either a cosmopolitan vector
(e.g., bedbugs, fleas, mites) or a uniquely nonspecific
relationship between bacterium and arthropod. Per-
haps different countries harbor different vectors, as
has been noted for the vectors of Borrelia recurren-
tis. Furthermore, while arthropod vectors may not
function in every country with leprosy, they may
maintain prominence, particularly in regions with
low standards of living and poor sanitation. Con-
sistent with this concept is the disappearance of
leprosy from Norway and Iceland when fleas, ticks,
and lice were controlled (albeit in conjunction with
other improvements).
Armadillos
When efforts were being made to establish an ani-
Blake et al.
mal model for leprosy, investigators met many ob-
stacles. The appropriate animal would be naturally
susceptible to the disease in the same manner as hu-
man beings, would not be subject to immunosup-
pression, and would develop a spreading infection
with the bacteriologic and histopathologic charac-
teristics of leprosy in humans. Binford's attempts
with monkeys, chimpanzees, hogs, dogs, and fruit
bats were unsuccessful (cited in [60]), while Shepard's
mouse footpad experiments demonstrated charac-
teristic disease limited to the site of inoculation [61].
Using thymectomized, whole-body-irradiated mice,
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Rees et al. were able to increase the yield of bacilli
per footpad by as much as 100-fold [62].
Kirchheimer and Storrs first identified the nine-
banded armadillo (Dasypus novemcinctus) as a
model for leprosy research [60]. Its advantages are
readily apparent: it has a long life-span (about 12
years, compared with two years for the mouse),
which is compatible with the long incubation period
of leprosy; it has a body temperature of 30°C-36°C,
which is in keeping with the optimal temperature for
the growth of M leprae,· and it givesbirth to monozy-
gous quadruplets, which are ideal for long-term
genetic studies [63]. Moreover, when infected with
M. leprae, 800/0 of armadillos develop a disseminated
infection that closely resembles human disease: der-
mal nerve invasion, spread to uninoculated sites,
acid-fast bacilli in blood, great numbers of bacilli
in tissue, and a positive DOPA oxidase test [64]. The
organisms from human leprosy have been proven to
be identical to comparable organisms from a leprous
armadillo by DNA homology studies [65]. In addi-
tion, armadillo-derived lepromin is now a substitute
for human lepromin [66]. While the nine-banded ar-
madillo has become the focus of contemporary
leprosy research (table 3), the Venezuelan armadillo
[81] and the seven-banded armadillo [67, 68] have
also proven susceptible to infection with M leprae.
The armadillo is a member of the subclass Eu-
theria, the order Edentata, and the family Dasypod-
idae. Most of the nine genera are confined to South
America, but the naked-tailed armadillo reaches
Guatemala and the nine-banded armadillo reaches
North America [82]. The latter species appears to
have migrated from Mexico to Texasabout 150years
ago and has continued to migrate northward and
eastward ever since [83]. Armadillos were observed
in Louisiana before 1920, and their range has ex-
tended to southern Kansas and Missouri and east
through Mississippi, Alabama, and Georgia into
Nonhuman Sources of Leprosy 571

Table 3. Armadillos as sources of leprosy.

Refer-
Study Description Location Test method ence(s)
Experimental leprosy in Armadillos inoculated with Louisiana and Inoculation of Dasypus 60, 63, 64,
armadillos Mycobacterium leprae Venezuela novemcinctus, Dasypus 67-69
sabanicola, and Dasypus
hybridus
Cultivable AFB in armadillos Prevalence of cultivable AFB Colombia and Stain for AFB and culture 70-72
in healthy and leprous Belgium positive
armadillos
Natural leprosy in wild Seven armadillos with disease Louisiana Histopathology identical 30
armadillos indistinguishable from to that of M. leprae;

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Identification of natural
leprosy in wild armadillos
Survey of armadillo disease
in the wild (1977)
Survey, 1978
Survey, 1983
Survey, 1984
Survey, dead roadside
armadillos, 1984-1985
Isolated cases of armadillo
leprosy
Armadillo contact as risk
in leprosy
Cases of leprosy due to arma-
dillo exposure
Thorns as source of
armadillo infection
Armadillo sera containing
antibodies to M. leprae
leprosy culture negative
Histopathologic and micro- Louisiana Culture negative; DOPA 73,74
biologic studies; armadillo oxidase and pyridine
lepromin tested with 146 extraction positive;
lepromatous patients classic Mitsuda reaction
Positive: 47 of 459 armadil- Louisiana, Positive skin and ear 74,75
los in Louisiana, 1 of 88 in Texas, Mis- specimens, histopathol-
Texas; all negative in Mis- sissippi, and ogy, and lepromin
sissippi and Florida Florida reaction
Two of 20 armadillos positive Louisiana Culture negative, but his- 76
in French Acadiana topathology and pyridine
extraction test positive
Armadillos (21 of 457) posi- Texas Histopathology, base 65
tive along Texas Gulf Coast ratios, and DNA
homology positive
One of 96 armadillos positive Mexico Culture negative; histologic 77
and mouse footpad
studies positive
Positive: 10 (2070) of 494 Louisiana Histopathology of both 77A
ears; pyridine extraction
positive
One case each at CDC, Originally Histopathologic, mouse 43
San Diego Zoo from Texas footpad, and lepromin
studies positive
No association with contact Louisiana Indigenous leprosy cases 78
found compared with controls
Seven men (no other risk) Texas and Years of armadillo contact: 31-32A
developing leprosy South hunting, skinning, and
Carolina handling
Thorns embedded in 25% Louisiana Characteristic histo- 79
of infected ears pathology
Sera collected in 1961-1964 Louisiana Detection ofantibody by 80
positive for aritibody ELISA using PGL-I
antigen

NOTE. Abbreviations: AFB = acid-fast bacilli; DOPA = 3,4-dihydroxyphenylalanine; CDC = Centers for Disease Control;
PGL-I = phenolic glycolipid-I.

Florida. For the most part, the nine-banded ar-
madillo eats insects, grubs, dirt, and only occasion-
ally amphibians, reptiles, mammals, or bird eggs.
Covered by a carapace, it is free from ectoparasites
except for some ticks and fleas. It can be infected
with Trypanosoma cruzi, Borrelia, Rickettsia, and
helminths, particularly nematodes, including Travas-
sosia carinii, a thorny-headed worm unique to the
armadillo. Flukes and tapeworms can also infect the
armadillo [69].
Both Dasypus sabanicola and D. novemcinctus
have also been found to harbor cultivable acid-fast
bacteria: of 35 armadillos, 86070 contained "environ-
mental mycobacteria." Five of six ticks from ar-
572
madillos (Amblyommacajennense) were also posi-
tive for cultivable acid-fast bacteria. Cultivable
acid-fast bacteria were found in three of four ar-
madillos inoculated with M. leprae [70]. Noting the
widespread distribution of acid-fast bacilli in the en-
vironment of the armadillo, Munoz-Rivas states that
"in almost everything that they [armadillos] use as
alimentation [I] have been able to isolate saprophytic
mycobacteria" (translation, L. A. Blake) [70, 71].
Recently, Portaels et al. also isolated cultivable
mycobacteria from both healthy armadillos and ar-
madillos inoculated with M. leprae. These authors
found Mycobacterium avium-Mycobacterium intra-
cellulare-Mycobacterium scrofulaceum complex,
Mycobacterium gordonae, and Mycobacterium ter-
rae. In fact, tissues from M. leprae-infected arma-
dillos appeared to contain more cultivable acid-fast
bacilli than those from healthy animals; this find-
ing implied that the presence of M. leprae may favor
multiplication of other species. Of greater impact,
perhaps, was the discovery of three new, unclassi-
fied cultivable mycobacterial strains. These organ-
isms, designated armadillo-derived mycobacteria, are
distinct from other species isolated and have been
found only in a specific colony of inoculated ar-
madillos [72]. Armadillo-derived mycobacteria-
along with the human tissue mycobacteria of Bapat
[84] and Skinsnes et al. [85], the propionibacteria
of Barksdale ([86], cited in [87]), the corynebacteria
of Barksdale and Delville (cited in [87]), and leprosy-
derived corynebacteria [87A] - are found in combi-
nation with certain cases of M. leprae infection. They
may "share common antigens with M. leprae and
may shelter [it] in the tissues under the umbrella of
immune unresponsiveness associated with the dis-
ease" [87]. Since these observations have not been
confirmed, they are of uncertain significance.
Still other bacteria have had an impact on the ar-
madillo. In 1975 Walsh et al. discovered a natural
leprosy-like infection in seven armadillos at sites
17-39 miles from the Gulf South Research Institute
in New Iberia, Louisiana. Acid-fast bacilli were
found in skin, lymph nodes, spleen, liver, and der-
mal nerves, with heavily infiltrated macrophages.
The fact that the bacilli were not cultivable raised
questions about the identity of this organism vis-a-
vis M leprae [30]. Was this natural infection the same
as that caused experimentally by M. leprae, or was
it due to a different noncultivable acid-fast bacillus
with similar manifestations? If the infectious agent
was indeed M. leprae, was the source soil, water, hu-
Blake et al.
man leprous contact, or contact with experimentally
inoculated armadillos?
This discovery quickly prompted a survey of wild
armadillos in the southern United States. Examina-
tion of ear specimens indicated that 47 of 459
animals from 11 locations in Louisiana, two from
unknown locations in Louisiana, and one of 88 from
Texas had the natural infection. None of 178 animals
from Mississippi and none of 76 from Florida were
infected [75]. Prevalence rates were established for
some locations in Louisiana; however, differences in
the sample sizes at each location made comparisons
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difficult.
Further studies narrowed the identity of the or-
ganism to M. leprae. Binford et al. performed histo-
pathologic and microbiologic studies of the affected
tissues, including cultures for mycobacteria, pyridine
abolishment of acid-fastness, and the ability to oxi-
dize DOPA. (The last result is difficult to interpret
conclusively since normal armadillo tissue has the
ability to oxidize DOPA.) These tests revealed no dis-
tinctions between the mycobacteria and M. leprae
[73]. Similarly, Meyers et al. assayed lepromins pre-
pared from six armadillos with natural disease in
tests with 146leprosy patients and observed the clas-
sic pattern of Mitsuda reactions [74]. As M. leprae
is the only organism known to fulfill all of these
criteria, it appeared unlikely that the "natural dis-
ease" was caused by another bacillus.
Efforts to establish the range of this "natural dis-
ease" continued. In an independent study of wild
armadillos in French Acadiana (Louisiana) in 1978,
Smith et al. found two of 20 armadillos positive for
acid-fast bacteria that were indistinguishable from
M. leprae [76]. Later, armadillos along the TexasGulf
Coast were screened; positive animals were killed,
and specimens were cultured and studied histopatho-
logically. Base ratio and DNA homology determi-
nations indicated that these bacteria were identical
to M. leprae. Of 451 animals, 21 (4.6070) were positive
for natural infection [65]. Local prevalences varied
and increased along the coast toward Mexico, mir-
roring the distribution of endemic human leprosy [65,
88]. Isolated reports of natural cases have come from
the San Diego Zoo and from the Centers for Dis-
ease Control (CDC) in Atlanta [43], although both
of the armadillos involved were originally from
Texas. In Mexico one of 96 armadillos was posi-
tive for acid-fast bacteria that appeared to be
M. leprae [77].
These discoveries have generated public health
Nonhuman Sources of Leprosy
concerns. What does leprosy in armadillos have to
do with human leprosy? In 1977 Filice et al. com-
pared the armadillo contact of persons who had in-
digenous leprosy in Louisiana with that of matched
controls, finding no significant difference in the na-
ture or frequency of contact [78]. Yet while casual
contact may not prove significant, intense and
prolonged contact - as in the hunting, skinning, and
wrestling of infected armadillos - may predispose a
person, particularly one with breaks in the skin, to
infection transmitted via a leprous armadillo. The
acquisition of leprosy by seven men who had no risk
factors besides extensive armadillo contact supports
this argument [31-32A]. Indeed, contact with ar-
madillos has been considered a risk factor since 1976,
as indicated by the inclusion of this category on the
CDC surveillance form for leprosy [27].
Of late, more attention has been focused on the
origin of the disease in armadillos. One potential
source is the untreated lepromatous patient, who
most likely would transmit the disease in a rural area
where armadillos have access to contaminated cloth-
ing, dressings, or human remains. In marshy south-
ern Louisiana, where leprosy has been endemic for
over 150 years [89], the burial of bodies of lepers in
graves too shallow to prevent their being eaten as car-
rion by burrowing armadillos may have been a fac-
tor in exposure. On the other hand, armadillos in
all places can burrow, yet no armadillos in other
leprosy-endemic areas of Central and South America
appear to have been affected (with the exception of
the animal recently found in Mexico). This pattern
leads to the suspicion that some unique natural ele-
ment in Louisiana (soil, water, fauna) may be a con-
tributing environmental source of leprosy. Insects,
as the main component of the armadillo diet, may
be a source of infection, either through ingestion or
through surface bites [90]. In a recent preliminary
study, earthworms (a component of the armadillo's
diet) were taken from household "worm farms" ad-
jacent to the homes of three patients with leprosy
in northern Louisiana, an area where leprosy is not
endemic and where armadillos are common. No
acid-fast bacilli were found in the worms [91].
In a recent survey, 3.1010 of the Louisiana ar-
madillos sampled manifested acid-fast bacilli within
the nerves of the ear; these bacilli were identified as
M. /eprae. A more remarkable finding was that
25.3010 of the infected ear specimens had thorns im-
paled within them. In another animal, sections of
thorns were found in the nose. Although in this par-
573
ticular animal there was no evidence of systemic in-
fection, macrophages surrounding the thorn were re-
plete with acid-fast bacilli [79]. It is tempting to
ascribe a direct relationship between the illness of
these animals and their ear or nose thorns, as the
characteristic ear involvement lends credence to the
infectivity of the thorn. A base-line value for thorn
prevalence is necessary to establish a link in this en-
vironmental chain.
We do know that armadillos are not responsible
for introducing leprosy into Louisiana: leprosy was
reported there as early as 1766, and its presence
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resulted in the opening of a leprosy hospital in New
Orleans in 1785 [2]. Recent work with armadillo se-
rum collected between 1961 and 1964demonstrated
that at least 20010 of samples contained antibodies
to the species-specific PGL-I capsular antigen. This
finding indicates that M. /eprae was enzootic in ar-
madillos of southern Louisiana as early as 1961 and
that the original infection could not have occurred
by environmental contamination in experiments
starting in 1968 [80]. In precluding the possibility
that experimentally infected armadillos are the
source of leprosy in wild armadillos, this informa-
tion leaves investigators with uncertainty about the
origin(s) of leprosy in the armadillo and the possi-
ble role of the armadillo in human leprosy.
Conclusions
Close inspection of the literature on nonhuman
sources of leprosy makes it apparent that research-
ers are severely limited by certain characteristics of
the leprosy bacillus itself. First, a favorable culture
medium for the growth and unequivocal identifica-
tion of M /eprae is lacking. While the sphagnum
nutrient medium introduced by Kazda [37] may
prove to be a valuable toolin the future, at the pres-
ent time investigators are restricted to time-con-
suming and expensive inoculation of animals or
biochemical tests that can only be presumed to be
specific. The clumsiness of the available methods and
the relative inaccessibility of promising biochemi-
cal tests are major stumbling blocks in studies of this
sort. Unfortunately, this complicated state of affairs
undermines much of the careful research done ear-
lier in this century; we are forced to interpret it as
mere observation, not proof.
Second, other variables hark back to the enigmatic
nature of leprosy itself. It is a disease with a long
incubation period, a low attack rate, and a mecha-
574
nism of transmission that may vary from case to case.
In addition, the immune status of the host deter-
mines to a great extent whether or not infection will
occur and, indeed, what degree of infection will be
encountered. Because the necessary infective load is
still largely a matter of speculation, predictions of
infection are virtually impossible.
In light of so many unanswered questions about
leprosy, the introduction of yet another variable-
environmental sources - does not seem altogether
unjustified. Our critical review indicates that it is not
only possible but likely that the presence of the ba-
cillus in one or several nonhuman sources has been
a key factor in infection. Environmental sources are
suggested by many of the patterns of leprosy. The
disease frequently has a rural prevalence, is often as-
sociated with farming, and tends to occur in youn-
ger persons in rural than in urban settings [3]. Like-
wise, the numerical predominance of male patients
with lepromatous leprosy strongly favors an environ-
mental reservoir, because men traditionally have
more environmental contacts than women. M leprae
may possibly enter the body through sites of trauma
on the feet and legs; a soil or plant source could ac-
count for the observed distribution and could ex-
plain the often asymmetrical location of lesion sites.
In addition, environmental cofactors - and even
other environmental mycobacteria - could predis-
pose an individual who might otherwise not be sus-
ceptible to infection with M. leprae. The latter pos-
sibility is underscored by leprous armadillos in which
cultivable mycobacteria, including the unique
armadillo-derived mycobacteria, are present in
greater quantities than are found in nonleprous ar-
madillos.
Many of the above observations also apply to the
potential role of arthropod vectors in the transmis-
sion of leprosy, as environmental exposure would cer-
tainly increase exposure to insects. However, insect
populations respond dramatically to changes in hab-
itat, and one must consider that developments in the
past 100 years have significantly altered the role of
insects in any disease, save in countries with poverty
and squalor. Unlike the aforementioned environmen-
tal sources, insects have been proven to have the abil-
ity to pick up M. leprae from the blood, maintain
it, deposit it, and even infect mouse footpads with
it. Although their prevalence is highly variable from
country to country, insects may prove responsible for
a significant number of infections. This possibility
is particularly significant in the context of severemal-
Blake et al.
nutrition, in which a weakening of cell-mediated im-
munity enhances the risk of infection by intracellu-
lar pathogens such as M. leprae [92].
The armadillo is the most firmly established non-
human reservoir of leprosy; the animal sustains a
natural infection and, with especially intense con-
tact, probably can infect humans. It is suspected that
humans contract the disease from armadillos by way
of droplet inhalation or through breaks in the skin
and that infection can be transmitted to armadillos
from humans via similar routes; in effect, humans
and armadillos may pass the disease back and forth.
Downloaded from http://cid.oxfordjournals.org/ at East Carolina University on April 26, 2015
It is, however, equally possible that human beings
and armadillos share an environmental niche with
a third component that is infected with or harbors
M. leprae. Environmental mycobacteria-not only
M leprae- appear to contribute to infection and the
response to infection in armadillos.
The associations of leprosy and its causative or-
ganism with soil, water, vegetation, arthropods, and
armadillos are compelling. However, the broad dis-
tribution of leprosy, with accompanying wide vari-
ations in climate, population, and prevalence, defies
facile conclusions. Therefore, proof of one or several
environmental sources for specific clinical cases of
leprosy awaits either the application of currently
available techniques to identification of the specific
PGL-I capsular antigen or (as is more likely) the de-
velopment of a less labor-intensive and time-con-
suming method by which M. leprae isolation and
identification can be accomplished.
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