 Chronic infection disease

 Mainly affects the

 skin,
 peripheral nerves,
 mucosa upper respiratory tract,
 reticulo endothelial system,
 eye,
 bone ,
 testis,
 except central nervous system.
 to reduce the rate of new cases
 with grade-2 disabilities worldwide by at
least 35%.
 This will be carried out by enforcing
activities to decrease the delay in diagnosing
the disease and
 actuate treatment with multidrug therapy.
 This will also have the impact of reducing
transmission of the disease in the community
expand Multi Drug Therapy (MDT)
services to all health facilities
ensure that all existing and new
cases are given appropriate MDT
regimens
encourage all patients take
treatment regularly and completely
promote awareness in the
community on leprosy so that
individuals with suspicious lesions
will report voluntarily for diagnosis
and treatment
set targets and time table for
activities and make all efforts to
achieve them
keep good records of all activities in
order to monitor the progress
towards elimination
 Mycobacterium leprae
 Curved rod shaped
 Acid Fast Bacilli
 Gram positive
 Intracellular
 Prefer a growth temperature of less than 37° C
 Can not be cultured
 Africa / Central Asia ---- World
 All ages ranging : early infancy to very old age
 15 – 25 years old >>
 Both sex : Males : Females = 2 : 1
 Very long period : 3 – 5 years
 1990 : 7 / 10,000 ----- 2000 : 1 / 10,000
 Contact person
- Respiratory tract
- Skin

- Immunity
- Virulence
- Physical
- Environment : - Biological
- Social
 M. leprae  can not be cultured

Bacteriological examination :
1. Diagnosis
2. To get a cross spectrum
3. Evaluations
4. Prognosis
 Skin lession
 Ear lobe
 Nasal secretions / Nose blows
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.
 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
 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.
 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
If shown one or more of the following cardinal
signs :
1. Hipopigmented or reddish skin lession with
definite loss of sensation
2. Involvement of the peripheral nerves, as
demonstrated by definite enlargement /
thickening peripheral nerves with loss of
sensation
3. Skin smear positive for Acid Fast Bacilli

If Not ----- Observe for 3 – 6 months

ANESTESI
ATROFI
ACHROMIA
ALOPECIA
ANHIDROSIS
Ulnar and median - Clawed hand
Posterior tibial - Plantar insensitivity
and clawed toes
Common peroneal -Foot drop
Radial cutaneous, facial, and
greater auricular nerves
 destruction of nasal cartilage
(lepromatous leprosy),
 ocular involvement
 and diffuse thickening of the skin.
 Advanced cases of leprosy involve the loss
of eyebrows and lashes, but these
deformities are less common today.
Measurement of the Bacterial Index :
1. Diagnosis
2. To get across the spectrum
3. Therapy evaluation
Average Number of Bacterial Index
Acid Fast Bacilli (BI)
1000 / field 6+
100 – 1000 / field 5+
10 – 100 / field 4+
1 – 10 / field 3+
1 – 10 / 10 fields 2+
1 – 10 / 100 fields 1+
0 / 100 fields 0
 The proportion or percentage of regularly
stained bacteria of the total scored
 Ridley ( 1971 ) :
- Regularly stained bacteria = Solidly
bacteria
- Irregularly stained bacteria =
Fragmented + Granular bacteria
 1. Response to treatment
 2. Drug resistance
 3. Determining the infectiousness of a
patient

Treatment --- M I  quickly

B I  slowly
Irregularly
Malabsorbtion
Drug resistance
1. Infectious / Non infectious
2. Possible – infectious
3. Possible – Disability
4. Duration of treatment
 SPECTRUM
Ridley & TT BT BB BL LL
Jopling

MADRID Indeter- Tuber- Border- Lepromatous

minate culoid line

WHO Paucy Bacillar Multi Bacillar

( 1988 ) <5 LESION >5LESION
Indeter- TT BT BB BL LL
minate
Infectious Infectious Infectious Infectious Infectious Infectious
(-) (-) (-)

Children 2–3 Satelit Punch Out

lesion lesion
Hipopig- Macules – Macules : Dimor- Symetrical Symetri-
mented / hipopig- hipopig- phous papul, cal papul,
pink : Face, mented mented / features nodules nodules
back, reddish and tend
buttock symmetry
Indeter- TT BT BB BL LL
minate
Loss of (+) (+) (+) Sensory Stocking
sensation loss, and gloves
(-) decreases anesthesia
sweating and
hair growth
Nerve (+) (+) (+) Nerve Nerve
swollen (-) damaged damaged

Lepromin (+) 4 (+) 3 (+) 1 -2 (-) (-)

(-)
Acid Fast (-) (+) / (+) 3 (+) 3 - 4 (+) 5 - 6
Bacilli (-) (-)
 Multi Drug Therapy :
- Prevention & treatment of resistance
- A shorter period of time for treatment
- To interrupt the transmission of the
infection
 Paucibacillary Single Lesion Leprosy
(one lesion)
 Paucibacillary Leprosy (2-5 skin lesion)
 Multibacillary Leprosy (More than 5 skin
lesion)
 CHILD ADULT

Rifampicin 300 mg Rifampicin 600 mg

Ofloxacin 200 mg Ofloxacin 400 mg

Minocycline 50 mg Minocycline 100 mg

Dosage : Single Dose R O M

 CHILD ADULT
Monthly Treatment : Monthly Treatment :
Day 1 : Day 1 :
Rifampicin 450 mg Rifampicin 600 mg
Dapsone 50 mg Dapsone 100 mg

Daily : Daily :
Day 2 – 28 Day 2 – 28
Dapsone 50 mg/daily Dapsone 100 mg/daily
Duration of treatment : 6 - 9 Months
 CHILD ADULT
Monthly treatment Monthly treatment
Day 1 : Day 1 :
Rifampicin 450 mg Rifampicin 600 mg
Clofazimine 150 mg Clofazimine 300 mg
Dapsone 50 mg Dapsone 100 mg

Daily 2 – 28 : Daily 2 – 28 :
Clofazimine 50 mg / daily Clofazimine 50 mg / daily
Dapsone 50 mg / daily Dapsone 100 mg / daily
Duration of treatment : 12 – 18 months
 During the course of leprosy,
immunologically mediated episodes of
acute or subacute inflammation known as
reactions may occur
 in up to 25% of patients with
paucibacillary leprosy and as much as
 40% in multibacillary leprosy.
 Clinical indications of a reaction are
 nerve pain,
 loss of sensation and
 loss of function.
 The reactions may rapidly cause severe and
irreversible nerve damage and must always be
treated promptly.
 If a patient does not respond to lepra reaction
treatment within 4 weeks or his/her condition
deteriorates at any time during lepra reaction
treatment,
 send that patient immediately to the nearest
specialist centre.
 During a lepra reaction, do not interrupt leprosy
multidrug therapy.
 Treatment with multidrug therapy reduces the
frequency and severity of lepra reactions
 Type 1 reaction : Reversal reaction
 Type 2 reaction :
Erythema Nodosum Leprosum
( E N L reactions )
 are associated with the development of M. leprae antigenic
determinants.
 They are delayed hypersensitivity reactions
 and may occur in both paucibacillary leprosy and multibacillary leprosy.
 high risk of permanent damage to the peripheral nerve trunks.
 If the reaction is mild and there is no evidence of neuritis (pain, loss of
sensation or function), the reaction should be treated with
 analgesics, such as acetylsalicylic acid or paracetamol.
 However, if there is nerve involvement,
 treat with analgesics and corticosteroids, such as oral prednisolone. The usual course
begins with 40 - 60 mg daily (up to a maximum of 1 mg/kg), and the reaction is
generally controlled within a few days. The dose is then gradually reduced weekly or
fortnightly and eventually stopped.
 Most reversal reactions and neuritis can be treated successfully under
field conditions with a standard 12-week course of prednisolone but some
authorities claim that corticosteroids need to be continued for much
longer periods of time
  1. Reversal reaction
Mild Severe
Skin - Lesion become reddish - Same & rarely new skin lesion
& swollen - Fever, malaise
Nerve - Enlarge, painfull (-) - Enlarge, painfull (+)
- Nerve damage (-) - Nerve damage, loss sensation
- < 6 weeks - > 6 weeks
Skin & - Lesion become reddish - Same
Nerve - Painful on peripheral - Ulceration
nerves - Swollen on hand & foot
- < 6 weeks - Nerve enlarge
-- > 6 weeks
 areassociated with circulation and tissue
deposition of immune complexes.
 They are an antibody response or immune
complex response to M. leprae antigenic
determinants which
 occur only in multibacillary leprosy.
 Therapy for type 2 reactions may include
 analgesics, such as acetylsalicylic acid or
paracetamol,
 and corticosteroids, such as oral prednisolone.
 In patients with severe type 2 reactions, who do not
respond to corticosteroids or in whom corticosteroids
are contraindicated,
 clofazimine at high doses or
 thalidomide may be used under close medical
supervision.
 Clofazimine often requires 4-6 weeks before an
effect is seen, and therefore must never be used as
the sole drug for treatment of severe type 2
reactions.
 However, it may be useful for reducing or
withdrawing corticosteroids from patients who have
become dependent on corticosteroids.
 The clofazimine dose for treatment of severe type 2
reactions is 300 mg daily, which should be given in 3
doses of 100 mg each.
 The clofazimine dose for treatment of severe type 2
reactions is 300 mg daily, which should be given in 3 doses
of 100 mg each.
 The total duration of this high dose of clofazimine should
not exceed 12 months.
 Thalidomide should be avoided in women of childbearing
age since it is a proven teratogen.
 If this is not possible, it is imperative that pregnancy is
excluded before this treatment is initiated.
 Effective contraception must be used during the 4 weeks
preceding and following treatment as well as during the
treatment period.
 Should pregnancy occur despite these precautions, there is
a high risk of severe malformation of the fetus.
 MILD SEVERE
Skin Skin nodules : Skin nodules >>
- Tender reddish - Painful
- Ulceration - Ulceration
- Fever & malaise
Nerve Enlarge Enlarge
Painful (-) Painful & swollen
Nerve damage (-) Nerve damage
Eye Not involvement Painful
Visual impairment
Testis Swollen, Painful (-) Painful, Enlarge
Skin, nerve, Same - Same
eye, testis - Very painful
- Fever
 Prednisone : 30 – 80 mg / daily and then
tappering off
 Continued M D T without interruption
 MILD REACTION :
- Immobilization
- Rest
 SEVERE REACTION :
Reffered to the nearest hospital
Lepromatous leprosy. Note the diffuse infiltration of the face with
leonine facies and madarosis.
 Sequele of leprosy. The patient has madurosis, a saddle nose and
blindness in the left eye. Courtesy of Evangeline Handog, M.D.