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LEPROSY

LEPROSY. Leprosy I Introduction Epidemiology Bacteriology Classification Clinical features. Leprosy II Reactions Diagnosis Treatment Rehabilitation. Introduction. Chronic granulomatous disease Caused by Mycobacterium leprae Mainly involves the peripheral nerves and skin

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LEPROSY

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  1. LEPROSY

  2. Leprosy I Introduction Epidemiology Bacteriology Classification Clinical features Leprosy II Reactions Diagnosis Treatment Rehabilitation

  3. Introduction • Chronic granulomatous disease • Caused by Mycobacterium leprae • Mainly involves the peripheral nerves and skin • Other organs may involve: Mucosa of mouth Upper respiratory tract Eyes Bones Testes etc

  4. Historical aspect of leprosy • Oldest disease known to mankind • Word leper comes from Greek word “scaling” • Earliest description from India in 600BC • Kustha Roga & attributed punishment or curse of God • M. leprae discovered in 1873 by Armauer Hansen • Referred as Hansen’s disease

  5. Epidemiology

  6. Distribution • Prevalence • Wide distribution world-wide • Out of 122 countries, only 2 countries still have to reach the elimination goal Brazil and East Timor

  7. Leprosy status in districtsMarch 2010 59 Districts with Prevalence rate less than 1 per 10,000 16 Districts with PR more than 1 per 10,000

  8. Cases under treatment at the end of the year Year 2004-2010

  9. Bacteriology

  10. Lepra bacilli • Obligate intracellular Gram positive and acid fast bacilli • Short, thick, pink stained rods • Size: 5 X 0.5  • Arrangement: Single or in cigar-shaped bundles or in “globi” • Affinity for Schwan cells & cells of R-E system • Cannot grow in vitro but can grow in • mice and • nine banded armadillos

  11. The Leprosy Bacteria

  12. Reservoir of infection • Main reservoir: Human being • Lepromatous case> Non lepromatous cases • Animal reservoirs • 9-banded armadillos • Chimpanzees • Mangabey monkeys

  13. Portal of exit • Major portal of exit: Nose • LL cases harbour millions of M. leprae in their nasal mucosa • Ulcerated or broken skin of bacteriologically positive cases

  14. Mode of transmission • Transmission by inhalation • Droplet infection • Transmission by contact • Skin to skin contact with infectious cases • Skin contact with soil & fomites

  15. Incubation period • Long incubation period • Ranged: 6 months-40 years or more • Average: 2-5 years

  16. Environmental factors • Humidity favors survival of M. leprae in environment • M. leprae remain viable in • Dried nasal secretions for 9 days • Moist soil at room temperature for 46 days • Overcrowding & lack of ventilation within households

  17. Social factors • Often called a “social disease” • Social factors: • Poverty • Poverty related circumstances • Overcrowding • Poor housing • Lack of personal hygiene

  18. CLASSIFICATION OF LEPROSY

  19. IMPORTANCE OF CLASSIFICATION Identify the infectious cases – Epidemiological importance - Principal targets for treatment Identify the patients likely to develop the deformities and determine the prognosis Frame the line of treatment Helpful in planning and evaluation of leprosy control activities

  20. Ridley-Jopling 1966 (Research purposes) Most widely accepted Based on clinical, bacteriological, immunological and histopathological parameters, which divide the leprosy into five recognizable groups Exhibits a spectral disease with varied clinical characteristics due to varied host immune response to bacilli

  21. RIDLEY-JOPLING Tuberculoid (TT) Borderline Tuberculoid (BT) Borderline Borderline (BB) Borderline Lepromatous (BL) Lepromatous (LL)

  22. Indeterminate leprosy

  23. Immunity in leprosy LL - multibacillary state with multiple lesions due to low immune response (+) TT -paucibacillary state, few lesions due to high immune response (-) BLHD LLHD BBHD BTHD TTHD

  24. Contd.. Borderline forms (BB, BT and BL) lie between these two poles and are immunologically unstable, tending to move towards one of the polar forms

  25. Immunology & bacteriology in leprosy (spectrum) (+++) (+++) Bacilli Immunity (++) (++) Bacilli Immunity (+) (+) (-) (-) LLHD BLHD BBHD BTHD TTHD

  26. WHO Classification

  27. W H O classification(For chemotherapy – M. leprae) Paucibacillary Multibacillary Mid borderline – BB Borderline Lepromatous – BL Lepromatous – LL All smear positive cases Indeterminate - I Tuberculoid – TT Borderline Tuberculoid – BT If any of these have positive bacterial index they should be classified as multibacillary for multidrug therapy

  28. Clinical Feature

  29. Indeterminate Leprosy • Earliest & transitory stage • Hypopigmented macule with indistinct margins

  30. Indeterminate Leprosy If untreated may progress towards tuberculoid, borderline or lepromatous leprosy Spontaneous regression may occur Usually negative for skin smear for AFB

  31. TUBERCULOID LEPROSY Single or a few lesions Asymmetrically distributed on trunk and limbs Sharply defined, dry, erythematous or hypopigmented, anesthetic macules or plaques One or two nerves may be enlarged near the skin lesion SS for AFB: Negative Lepromin test may be strongly positive

  32. Tuberculoid Leprosy

  33. Borderline Tuberculoid Single or multiple, asymmetrically distributed Macules or plaques of variable sizes with well-defined margins & satellite lesions Peripheral nerves enlarged asymmetrically Sensation: hyposthesia SS for AFB: may be seen Lepromin test may be weakly positive

  34. Borderline tuberculoid

  35. Borderline Borderline Multiple erythematous macules & plaques Various sizes and shapes with punched out centre and ill defined slopping outer margin Tend to be symmetrical Nerves may be asymmetrically enlarged Sensation:+/- SS for AFB: seen +/- Lepromin test-usually negative, may be doubtful

  36. Borderline Borderline

  37. Borderline Lepromatous Numerous, symmetrically distributed lesions Hypopigmented or erythematous irregularly shaped maculopapules, infiltrative nodules, or plaques, with smooth surfaces & ill defined borders, sloping outwards Nerves may be symmetrically or asymmetrically enlarged Sensation:+/- SS for AFB: numerous seen Lepromin test -negative

  38. Borderline Lepromatous

  39. Lepromatous Leprosy Numerous macules, plaques, nodules or diffusely infiltrated lesions, symmetrically distributed on face, trunk and extremities with ill-defined margin which may be slightly hypopigmented or erythematous Symmetrical nerve enlargement is seen Sensation: normal SS for AFB: numerous seen Lepromin test - negative

  40. Lepromatous Leprosy

  41. Ear lobes thickens

  42. diffuse thickening of the skin, with loss of hair (eyebrows and eyelashes). saddle nose deformity leonine facies

  43. General Findings • Eye The anterior chamber can be invaded in LL with resultant glaucoma and cataract formation. Iritis/Iridocyclitis • Testes May be involved in LL with resultant hypogonadism. • Systemic involvement – Respiratory, Bones, Kidneys, Lymph glands, etc.

  44. Nerve involvement in Leprosy

  45. M. Leprae : superficial nerve involvement W Britton

  46. Nerve Involvement • Neural involvement leads to muscle weakness, muscle atrophy, severe neuritic pain, and contractures of the hands and feet. • Ulnar nerve commonly involved • Examination for sensations of hot and cold , pain and fine touch

  47. Nerve palpation

  48. Face Facial Nerve  Lagophthalmos  Facial droop Trigeminal Nerve  Corneal anaesthesia

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