LEPROSY

Leprosy (Hansen’s disease) is a chronic granulomatous mycobacterial disease affecting skin

and nerve and is caused by Mycobacterium leprae .It is common in ancient world and is still
afflicting patients in many parts of world-mainly Asia and Africa. It is first observed by Hansen
in 1868.

It is a chronic infectious bacterial disease characterized by lesions of the peripheral nerve, skin,
and mucus membrane of the upper respiratory tract. It is a polymorphic infectious disease, the
manifestation of which is determined by the immune system of the host.

Morphology:
 M. leprae is first bacterial disease in humans, a slender, slightly curved or straight bacillus,
and shows considerable morphological variations. It is intracellular, pleomorphic, acid-
fast, pathogenic bacterium
 It is an aerobic bacillus.
 It multiplies slowly. On average, the disease incubation period is 5 years but
symptoms may occur within 1 year.
 It closely resembles Mycobacterium tuberculosis

Epidemiology: In 2018, there were 208,619 new cases of leprosy recorded, a slight decrease
from 2017. In 2015, 94% of the new leprosy cases were confined to 14 countries. India reported
the greatest number of new cases (60% of reported cases), followed by Brazil (13%)
and Indonesia .
Types:
High levels of CMI with elimination of leprosy bacilli produce tuberculoid leprosy, whereas
absent CMI results in lepromatous leprosy.
1. Paucibacillary –
 Tuberculoid: affects nerves in fingers and toes, and surrounding skin, hypo pigmented skin
macules and patches where skin sensations are lost because of damaged peripheral nerves.
Mycobacterium leprae are either absent from the lesion or occur in very small numbers. This
type of leprosy is most benign.

2. Multibacillary –
 Borderline: It has both types of effects, most common form. Skin lesions are more
numerous and irregular. Peripheral nerve involvement with weakness and loss of sensation.
is common.
 Lepromatous: Damages respiration, eyes, and skin. It is associated with symmetric
skin lesions, nodules, plaques, nasal congestion and nose bleeds, absence of epithelioid
cells in the lesions. Mycobacteria leprae are found in lesions in large numbers.

Modes of transmission:
1. Two routes of M. leprae from the human body often described are the skin and the nasal
mucosa.
2. The skin and the upper respiratory tract are most likely favors the respiratory route.
3. The bacillus is likely transmitted via droplets, from the nose and mouth, during close
and frequent contact with untreated cases.
Mechanism:
A Lepra bacillus enters into the body through respiratory route. The nerve damage occurs
from direct invasion by the M. leprae bacteria and a person's immune response resulting in
inflammation. M. leprae has been shown to bind to Schwann cells, which may lead to nerve
injury including demyelination and a loss of nerve function.

These are also found in macrophages, muscle cells and endothelial cells of blood vessels.
Bacilli start multiplying slowly within the cells and get liberated from destroyed cells and
then enter unaffected cells. As bacilli multiply, bacterial load increases in body and thus
infection is recognized by body immune system.

In the initial stages, small sensory and autonomic nerve fibers in the skin of a person with
leprosy are damaged. Further peripheral nerve damage may result in skin dryness, more
numbness, and muscle weaknesses or paralysis in the area affected.

Incubation period:
The average incubation period is 2 to 5 years for tuberculoid cases and 8 to 12 years for
lepromatous cases. People may begin to notice symptoms within the first year or up to 20 years
after infection.

Clinical features:
The most common symptoms include:
 Skin: The most common skin lesions are macules or plaques. Tuberculoid patients have a
few hypo pigmented lesions. In lepromatous leprosy, papules, nodules or diffuse infiltration
of the skin occur. Confluent lesions on the face can lead to a ‘leonine facies’.

 Anesthesia: In skin lesions, the small dermal sensory and autonomic nerve fibers are
damaged, causing localized sensory loss and loss of sweating. Anesthesia can occur in the
distribution of a large peripheral nerve, or in a ‘glove and stocking’ distribution.
 Nerve damage: Peripheral nerve trunks are affected at ‘sites of predilection’, including the
ulnar (elbow), median (wrist), radial (humerus, causing wrist drop), radial cutaneous (wrist),
common peroneal (knee), posterior tibial nerves and the sural nerves at the ankle; the facial
nerve as it crosses the zygomatic arch; and the great auricular nerve of the neck.
 Eye involvement: Blindness is a devastating complication for a patient with anaesthetic
hands and feet. Eyelid closure is impaired when the facial (7th) nerve is affected. Damage to
the trigeminal nerve causes anesthesia of the cornea and conjunctiva.

Chronic symptoms:
 Weakness of hands with claw fingers
 Foot drop
 Facial paralysis
 Lagopthalmos
 Lack of eyebrows and eyelashes
 Collapsed nose
 Perforated nasal septum
 Trophic ulcers

Other signs and symptoms include:

Runny nose; dry scalp; eye problems;; muscle weakness; reddish skin; smooth, shiny, diffuse
thickening of facial skin, ear, and hand; a flat nose from destruction of nasal cartilage; and
changes in phonation and other aspects of speech production. In addition, atrophy of the testes
and impotence may occur.

Leprosy reactions:
These are events superimposed on the cardinal features.
Type 1 (reversal) reactions: These occur in 30% of borderline patients (BT, BB, BL), and are
delayed hypersensitivity reactions. Skin lesions become erythematous; peripheral nerves
become tender and painful with sudden loss of nerve function. Reversal reactions may occur
spontaneously, after starting treatment or after completion of multidrug therapy.
Type 2 (erythema nodosum leprosum (ENL)) reactions: Partly caused by immune complex
deposition, these occur in BL and lepromatous patients who produce antibodies and have a high
antigen load. Patients develop malaise, fever and crops of small pink nodules on the face and
limbs. Iritis and episcleritis are common. Other signs are acute neuritis, lymphadenitis, orchitis,
bone pain, dactylitis, arthritis and proteinuria. ENL may continue intermittently for several
years.

Risk factors:
 Close contact with patients of leprosy
 People living in endemic areas
 Immunocompromised individuals
  Overcrowding
 Low socio economic status
Investigations:
 Polymerase chain reaction for detection of M. Lepra, DNA in tissue.
 Lepromin test-A sample of inactivated leprosy causing bacteria is injected just
under the skin ,usually on the forearm.
 Skin smears: Smears taken from the lesions, from ear lobules and eyebrows and are
stained using modified zeihl-neelsen method.
 Skin biopsy: histological examination may aid diagnosis.
Complications:
 Leprosy may cause the victim to lose limbs and digits but not directly.
 M. leprae attacks nerve endings and destroys the body’s ability to feel pain and injury.
 Fingers, toes, and limbs become shortened and deformed
Major goals of treatment:
 Early detection of treatment
 Appropriate treatment
 Adequate care for prevention of disabilities

Management:
Treatment:
Multidrug treatment (MDT) is required for all leprosy patients. . The treatment varies based
upon the type of leprosy. Medication should be continued for 6 months in acute cases and 1
year in chronic cases.
 Rifampicin (600mg) monthly, supervised is a potent bactericidal for M. leprae, but should
always be given with other drugs, as a single mutation can confer resistance.
 Dapsone (100mg) daily is bacteriostatic. It commonly causes mild hemolysis and, rarely,
anemia.
 Clofazimine (300mg) monthly, supervised is a red, fat-soluble crystalline dye that is
weakly bactericidal for M. leprae. Skin discoloration (red to purple-black) and ichthyosis are
troublesome side effects, particularly on pale skins.
 Newer drugs such as perfloxacin, ofloxacin, clarithromycin and minocycline are now
established second-line options.


Treatment of reactions:
Most reactions respond to high-dose oral prednisolone. Thalidomide may also be used, but
teratogenicity limits its use in women who may become pregnant. Hydrocortisone eye drops are
used for ocular symptoms.
Patient education and rehabilitation: Patients should be reassured that after 3 days of
chemotherapy they are not infectious and can lead a normal social life. Additional measures
include:
• Patients with anaesthetic hands or feet need to avoid and treat burns or other minor injuries.
• Good footwear is important.
• Ulceration: the cause of the injury should be identified, and the patient advised not to weight-
bear until the ulcer has healed.
• Physiotherapy: can help prevent contractures and muscle atrophy.

Prevention:
The WHO recommends that preventive medicine be given to people who are in close contact
with someone who has leprosy. The suggested preventive treatment is a single dose of
rifampicin (SDR) in adults and children over 2 years old who do not already have leprosy or
tuberculosis
 Early detection through survey and initiation of treatment
 Families of patients to be kept under surveillance
 Improvement in socio-economic conditions
 Vaccination with BCG partially protective for leprosy, single dose-50% protective.
Prophylaxis:
Tuberculous leprosy may self-heal, but lepromatous leprosy has high morbidity if untreated.
Within the endemic areas, WHO 2018 guidelines recommend single dose of rifampin for
adults and children >/= 2yrs.

QUESTIONAIRE:

1. Mycobacterium leprae are either absent from the lesion in

A) Tuberculoid Leprosy
B) Borderline
C) Lepromatous
D) Mid borderline
Answer: A

2. The average incubation period is

A) 2 years
B) 5 years
C) 6 years
D) 10 years
Answer: B

3. Peripheral nerve involvement with weakness and loss of sensation is common in

A) Lepromatous
B) Tuberculoid
C) Borderline
D) Mid borderline
Answer: C

4. The most common skin lesions in leprosy are

A) Pustules
B) Papules
C) Redness
D) Macules and plaques
Answer: D

5. Type 1 reversal reactions of leprosy occur in 30% of

A) Borderline patients
B) Tuberculoid patients
C) Lepromatous patients
D) Paucibacillary
Answer: A