BLENDED LEARNING

‘LEPROSY’

DR MUNIRA F
ASSISTANT PROFESSOR
DEPARTMENT OF COMMUNITY MEDICINE
LEARNING OBJECTIVES:
• Introduction
• Causative agent
• Mode of transmission
• Classification with clinical features
INTRODUCTION:
• Also known as Hansen disease.
• One of the oldest disease.
• Remains as social stigma.
• Leprosy is a chronic, granulomatous, slowly progressive, destructive infection
primarily involving cooler parts of the body like skin and peripheral nerves but
capable of affecting any tissue or organ.
CAUSATIVE AGENT:
• Mycobacterium leprae
• Mycobacterium lepromatosis (diffuse form of leprosy in Mexico)
MODE OF TRANSMISSION:
• Respiratory route (major)
• Skin to skin contact
CLASSIFICATION:
• Ridley and Jopling classification
Tuberculoid leprosy (TT)
Borderline tuberculoid (BT)
Borderline leprosy (BL)
Borderline lepromatous (BL)
Lepromatous leprosy (LL)

• WHO classification
Paucibacillary leprosy
Multibacillary leprosy
WHO CLASSIFICATION:
PAUCIBACILLARY LEPROSY:
• A case of leprosy which fulfils all the below criteria:
1 – 5 skin lesions
No nerve involvement
Slit-skin smear negative

MULTIBACILLARY LEPROSY
• A case of leprosy which fulfils any of the below criteria:
>5 sin lesions
Nerve involvement
Slit-skin smear positive
RIDLEY – JOPLING CLASSIFICATION:

RIDLEY- JOPLING
CLASSIFICATION

Bacteriologic Clinical
Immunologic Histopathologic
1. Acid fast 1. Skin lesions
1. CMI 1. Granuloma
bacilli 2. Nerve
2. Lepromin involvement 2. Status of
2. Slit-skin
test macrophages
smear
TRAITS TUBERCULOID LEPROSY LEPROMATOUS LEPROSY

CMI Good Poor

Lepromin test Positive Negative

Acid fast bacilli Few Numerous

Slit-skin smear Negative Positive

Skin lesions 1-3, asymmetric with well defined Innumerable, symmetric with ill-
margins defined margins

Nerve involvement 1 nerve thickened Multiple symmetric nerve

involvement

Granuloma Present Absent

Status of macrophages Epithelioid type Foamy type

TUBERCULOID LEPROSY:
• No of skin lesions: 1-3
• Morphology of lesions: Annular plaque with central clearing and well defined
raised margin (saucer right way up appearance)
• Granuloma formation destroys nerves, sweat glands and hair
 Loss of nerve – anaesthesia
 Loss of hair – alopecia
 Loss of sweat glands – anhidrosis
BORDERLINE TUBERCULOID LEPROSY:
• Most common type in India
• No of skin lesions: 3-10.
• Satellite lesions are seen.
BORDERLINE LEPROSY:
• Most unstable form
• No of skin lesions: 10-30
• Polymorphic skin lesions (size and shape) geographic map appearance seen
• Dimorphous skin lesions
 Inner border – punched out (Swiss cheese appearance) (well defined)
 Outer border – sloping outwards (inverted saucer appearance) (ill defined)
BORDERLINE LEPROMATOUS:
• Skin lesions: numerous uncountable, bilateral and almost symmetrical
• Nerve involvement: bilateral asymmetric nerve thickening
• Onion skin appearance on histology
• Dimorphous skin lesions
 Inner border – punched out (Swiss cheese appearance) (well defined)
 Outer border – sloping outwards (inverted saucer appearance) (ill defined)
LEPROMATOUS LEPROSY:
• Systemic disease with extensive cutaneous, nerve and internal organs involvement
• Symmetrical bilateral skin lesions consisting of ill-defined macules,
papulonodules, diffuse infiltration and thickening of skin
• Symmetrical bilateral nerve thickenings

EARLIEST FEATURES LATE FEATURES

• Epistaxis • Leonine facies
• Nasal crusting • Buddha ears
• Pedal edema • Saddle nose
• Gynaecomastia
• Madrosis
• Glove and stocking peripheral
neuropathy
DEFORMITIES IN LEPROSY:
• Madrosis
• Saddle nose deformity
• Claw hand
• Foot drop
• Lagophthalmos
• Trophic ulcers
INDETERMINATE LEPROSY:
• Early form of leprosy
• CMI – Not yet determined
• Mostly patients self-heal or can progress to TT, BT, BL, LL
• Solitary, ill-defined, hypopigmented patch or macule seen
• Normal sensations
• Peripheral nerves not enlarged
• Granuloma is absent
HISTOID LEPROSY:
• Type of lepromatous leprosy with dapsone resistance
• More common in earlier times when only dapsone monotherapy used to be given
• Shiny papules and nodules with intervening normal skin
• Skin biopsy shows spindle shaped foamy cells
PURE NEURITIC DISEASE:
• Skin lesions are absent
• Investigation of choice: Nerve biopsy
Only sensory nerves are biopsied
Ulnar nerve is never used since it’s a motor nerve
Upper limb: Radial cutaneous nerve
Lower limb: Sural nerve
LEPROSY DIAGNOSIS FOR MCQS:
TT BT BB BL LL
• Single lesion • Satellite lesions • Punced out/ • Multiple • Multiple lesions
• Single thick • Few non- Swiss cheese/ uncountable • Perfectly
nerve symmetrical inverted saucer lesions symmetrical
• Well-defined nerve lesions • Almost lesions
borders thickenings and • Multiple symmetrical • Glove and
non-symmetrical countable lesions lesions stocking
patches • Lesions with • Multiple anaesthesia
well-defined bilaterally • No hypo-
inner border and thickened nerves pigmentation
ill-defined outer • Punched out/ • Normal
border Swiss cheese/ sensations on
inverted saucer patches in early
lesions stages
• Ear lobe
infiltration
• Trophic ulcers
MCQ CORNER:
• 100% patients have nerve involvement
• Order of sensation loss- Hot and cold differentiation> cold> hot> light touch>
pain> deep touch
• Earliest sensation to loss is temperature
• Leprosy generally does not involve CNS
• Commonest nerve involved – Ulnar nerve
• Proprioception is not affected in leprosy