2. CONTENTS
History
Transmission of leprosy
Etiopathogenesis
Global and national scenario of
leprosy
Immunity and leprosy
Microbiology of M.Leprae
Classification of leprosy
Clinical spectrum
Systemic involvement in leprosy
Differential diagnosis
Diagnosis
Treatment
Lepra reactions
Deformities
Physiotherapy
Prevention
Rehabilitation in leprosy
MCQs
Photoquiz
3. History
Oldest infection known to mankind
India considered as point of origin of leprosy
First written reference appeared in Egyptian document written around
1550 BC
Dr Gerhard Henrik Armauer Hansen first described M.leprae to be the
causative organism in 1873.
Synonyms: Hansen’s disease, ‘Kushtha roga’
Definition :
Leprosy is a chronic systemic disease caused by Mycobacterium leprae
manifesting as development of specific granulomatous or neurotrophic
lesions in the skin, mucous membrane, eyes nerves, bones and viscera.
4. Transmission of Leprosy
Respiratory route : inhalation of bacilli-laden droplets
Cutaneous : skin to skin contact
GIT : ingestion of food
In utero transmission
Transmission through breast milk
Intradermal : inoculation by tattoos
Incubation period : 5-7 years (on average)
Not Yet Proven
5. Epidemiological Factors
Occurs at all age groups
Peak age of onset : Between 20-30 years
Males > Females (M:F: 2:1) (male predominance seen in adults, in
children gender distribution is nearly equal)
Less common in children and women
Commonest type of leprosy in children : Borderline tuberculoid
Occurrence of disease depends on immune status
Genetic susceptibility reported
Migration from rural to urban areas: increase in cases
Overcrowding, lack of personal hygiene, humidity favor disease
transmission
6. Global & National Scenario of Leprosy
Registered prevalence globally(2009) : 213036
Total cases detected in India (2011-12) : 1.27 lakh
Annual case detection rate in India : 10.35 per one lakh population
Increased no of new case detected (2011-12): Orissa, Gujarat,
Maharashtra, Madhya Pradesh, Andhra Pradesh
7. Immunity and Leprosy
Host resistance
Excellent
Good
Fair
Poor
Very poor
Clinical manifestation
No infection
Subclinical infection with spontaneous
regression
Indeterminate, pure neuritic,
tuberculoid
Mid-borderline,
borderline-lepromatous
Lepromatous
8. Immunopathogenesis of leprosy
Entry of M.Leprae in the body via nose
Invasion
Multiplication in dermal lymphatics and
vascular endothelial cells
Hematogenous spread
Invasion of M.Leprae into nerves
Immunological response
9. Mycobacterium Leprae
Obligate, non motile, nonspore forming microaerophilic intracellular,
acid-fast bacillus that forms curved or straight rods
Components include : Cell wall, cell membrane, cytoplasm and capsule
Affinity for skin, nerves and muscle tissue
Found in macrophages, histiocytes and Schwann cells
Non cultivable
Grown in animal models(armadillo and mice)
Closely resembles M. Tuberculosis, but less acid-fast.
Multiplies (generation time) in 11-13 days
13. Tuberculoid (TT)
Single or few (upto 3), large,dry, asymmetrical,
erythematous / hypopigmented patches with
well-defined margins.
Sweating – Lost
Sensations – Absent
Nerves - Thickened,
presence of feeding
nerves, abscesses
Skin smears – Negative
Lepromin test - Strongly positive
Course-Polar TT stable and sub polar TT may
downgrade.
14. Borderline Leprosy
Common type of leprosy
Subdivided into BT, BB & BL.
Course - Unstable with variable prognosis, may progress to sub-polar
LL leprosy.
Most prone to reactions.
Lepromin test -Negative, weakly positive in BT.
15. Borderline Tuberculoid (BT)
Few(upto 10),large, asymmetric,
hypopigmented or skin coloured macules,
plaques with ill defined margins
Surface-Dry with hair loss
Presence of satellite lesion near the
advancing margin of patch
Sensory impairment - Marked
Nerve involvement-Irregular and
asymmetrical
Deformities are common
Lepromin test-Weakly positive Satellite lesion
17. Midborderline leprosy (BB)
Unstable form, reactions frequent
Multiple and symmetric lesions
Lesions range from papules, macules
and plaques
Plaques show well demarcated
edges with characteristic punched
out centre (inverted saucer shaped)
Face may show infiltration with
nodules on ears
Sensory impairment - Moderate.
Nerve involvement-Many nerves
involved and asymmetrical
18. Borderline lepromatous leprosy (BL)
This type classically start as macule,
widespread and symmetrical, later
become infiltrated centrally
Papules, nodules and plaques with
sloping edges
Sensory impairment- Variable
(more in centre)
Nerve involvement - Widespread and
asymmetrical
Glove & stocking hypoaesthesia occurs late
Lepromin reaction-Negative
Prognosis-Variable
19. Lepromatous leprosy
Lesions symmetrically distributed, small, multiple, shiny and waxy.
Macular, infiltrated, nodular, diffuse or ulcerative
Macules-Small, widespread, ill defined margins
Nodules- Arise from macules or infiltrated lesions
Sensory impairment-Normal or mild
Leonine facies- Infiltration of skin with nodules, loss of eyebrows and
eyelashes.
Nerve involvement -Symmetrical, not markedly enlarged, fibrotic and
shrunken in late stages.
Glove and stocking anaesthesia
Lepromin test - Negative
21. Indeterminate leprosy
Commonest presentation in children
(20-80%)
Flat erythematous or hypopigmented,
asymmetrical, macules varying in number,
size and location with vague margins
Common sites : Face, limbs, thighs
Sensation - Normal or slightly impaired
Peripheral nerves - Normal
Skin smears - Negative
Lepromin test - Unpredictable and variable
Course - Usually self limiting, may progress
to other forms of leprosy.
22. Pure Neuritic leprosy
Commonly reported from India and
Nepal
Male preponderance seen
Sensory loss without skin lesion
Neuritic manifestations -Tingling,
heaviness and numbness, paresis,
hypotonia, atrophy, claw hand and toes,
wrist-drop, foot-drop.
Other changes-Anhidrotic, dry glossy
skin, blisters, neuropathic ulcers,
decalcification, bone resorption
Dry skin in leprosy
23. Lepromin test -Slightly positive
Course-Spontaneous regression or progression to TT leprosy
Silent neuritis (silent neuropathy)
Sensory or motor impairment without skin signs of reversal reaction
or ENL, tenderness, paresthesia or numbness
Pure Neuritic leprosy
24. Special forms of Leprosy
Lucio Leprosy/Lepra Bonita’/Beautiful leprosy
Rare form of lepromatous leprosy, described in Mexico. Diffuse
widespread infiltration of skin, loss of body hair, loss of eyebrows &
eyelashes, and widespread sensory loss.
Histoid leprosy
Seen in LL, but also in borderline and indeterminate cases.
Seen in patients taking irregular or inadequate treatment and in drug
resistant cases.
Nodules are firm, reddish or skin colored, dome shaped with shiny
skin.
Skin smears- Many bacilli seen.
Lazarine leprosy
Diffuse ulceration seen as a part of lepra reaction in undernourished
patients.
37. Differential diagnosis of neurological conditions
Sensory impairment with or without muscle wasting
Peripheral neuropathy
Diabetic neuropathy
Primary amyloidosis of peripheral nerves
Congenital sensory neuropathy
Syringomyelia
Tabes dorsalis
Thoracic outlet syndrome
Alcoholic neuropathy
Hereditary motor and sensory neuropathy
38. Diagnosis
Cardinal signs of leprosy
Anesthetic skin lesions
Nerve enlargement
Demonstration of M.Leprae
Only one of these three features needed to make diagnosis
40. Clinical Examination
Symmetrical appearance
Cutaneous nerve twig over the patch
Earlobe infiltration
Sensory impairment
Motor examination
Nerve examination
Trophic ulcers
Gynecomastia
Loss of hair / sweating
41. Clinical Examination
Sensory
Touch : Tested with wisp of cotton
Temperature : Tested with two test tubes
one containing hot water and other cold
Pain : Tested by pin prick
Semmes-Weinstein monofilament testing
Corneal reflex : Tested with a wisp of
sterile cotton wool
Motor
Testing of motor power- Done clinically
Electro-diagnosis - Employed in very early cases. Electrical stimulator
using faradic and galvanic current used to test muscle power
Monofilaments
42. Nerve Examination
Check for enlargement, tenderness,nodularity and
abscess and scoring system
Scoring system for enlarged nerves
Normal 0
Enlarged +
Moderately enlarged ++
Very much enlarged +++
44. Investigations for M. Leprae
Bacteriological examination
Skin smears :
Made by slit and scrape method from the most active looking edge of skin
lesion and stained with Ziehl-Neelsen method.
Reading of smears :
Bacteriological index - Indicates density of leprosy bacilli (live & dead) in the
smears and ranges from 0 to 6+
Morphological index - It is the percentage of presumably living bacilli in
relation to total number of bacilli in the smear
45. Other Investigations
Histopathological examination
Nerve biopsy
Sweat function test
Nasal mucosal smears
Nerve biopsy
Histamine tests
Lepromin test
FNAC
Animal Models : Armadillo, Thymectomised, irradiated nude mice, Korean
chipmunk etc.
46. Newer Investigations
Serological assays: FLA-ABS, RIA, ELISA
PGL, PCR
Other techniques: Chemical, Immunological, Molecular biological,
Bioluminescent techniques, Strain specific probes
Indications :
To confirm diagnosis in c/o inconclusive histopathological/smear reports.
To distinguish between reaction and relapse
To demonstrate M. leprae or its components
To elicit strain differentiation for molecular epidemiology
To detect drug susceptibility or resistance
48. Blister packets for MDT
Easy to use, handy and of convenient size
Provide complete treatment
Improve clinical attendance
Drugs are better protected against moisture, heat and accidental damage
Ensures quicker dispensing of the drugs
Can be dispensed by non medical person
53. Lepra Reactions
Acute episodes or bouts of exacerbations occurring in course of chronic
disease
It is a sudden tissue response resulting from liberation of bacilli or their
products into the tissues, manifestations of which are local or systemic
Sudden increase in activity of existing lesions, appearance of fresh lesions
with or without constitutional symptoms
Type I reaction - All borderline cases (BT, BB,BL)
Type II reaction - LL and sometimes BL cases
55. Type I Reaction
Type IV hypersensitivity reaction
Sub - types
• Upgrading (Reversal)
• Downgrading
Existing lesions worsen / New lesions may appear (have typical
characteristic of TT leprosy)
Lesions become erythematosus and / or edematous and may ulcerate
Neuritis / Nerve abscesses
Systemic disturbances - Unusual
56. Type I Reaction
Diagnosis : Clinical, histopathology (epitheloid cell granuloma, dermal
edema, plasma cells and foreign body giant cells)
Complications : Neuritis, dactylitis, edema of hands/ feet,
corneal anesthesia, conjunctivitis, sudden occurrence of claw hand, foot-
drop, facial palsy
58. Type II Reaction (ENL-erythema nodosum leprosum)
Occurs in BL and LL cases
Type III hypersensitivity reaction
Crops of tender, warm, recurrent, evanescent, erythematous nodules
distributed bilaterally symmetrically located on thighs ,legs and face
Vesicular lesions can occur which break down to form ulcers (erythema
necroticans)
ENL precedes fever, malaise, headache and joint pains
Other manifestations : Rhinitis, epistaxis, Iridocyclitis, episcleritis,
dactylitis, epididymo-orchitis, arthritis, neuritis, bone pain and
lymphadenitis
Diagnosis : Clinical, slit skin smears show broken bacilli, biopsy (vasculitis)
61. Type 3 reaction (Lucio phenomenon)
Rare form of reaction observed only in Lucio leprosy
Acute ,severe, necrotizing vasculitis occurring in patients of Mexican
ancestry
Presents as painful erythematosus patches that become necrotic and
ulcerated
Treatment of Lepra reactions
Principles of treatment
Early initiation of treatment for reaction
Continuation / initiation of MDT
Removal of precipitating factor
Rest, physical and mental
63. Treatment Modalities
Supportive management
Surgical decompression of nerves, splints / padding, treatment of steroids
/ atropine eye drops for iridocyclitis, steroids / scrotal support for
epipdidymoorchitis
Newer drugs for ENL :
Leukotriene inhibitors, thalidomide derivatives, infliximab
64. Deformities/Disabilities in leprosy
Deformity : Visible alteration in the appearance which results in
disability.
Disability : Restriction or lack of ability to perform an activity
considered normal for a human.
Primary : Are caused by the tissue reaction to infection with M.Lepra
e.g. leonine facies, flat-nose, claw hand.
Secondary : Occur as a result of damage to the anesthetic parts of
the body e.g. planter ulcers, corneal ulcers.
65. Grading of Deformities/Disabilities : WHO disability grading
Grade 0 :
No anaesthesia, no visible deformity or damage in hands and feet, or
no problems in eye or no visual loss.
Grade 1 :
Anaesthesia present, but no visible deformity or damage, eye
problems due to leprosy present but vision not severely affected (6/60
or better) and can count fingers at 6 metres.
Grade 2 :
Visible deformity or damage present in hands or feet , and severe
visual impairment (vision worse than 6/60)i.e unable to count fingers
at 6 metres or lagophthalmos or iridocyclitis or corneal opacities.
66. Deformities
Primary Deformities
Leonine facies
Loss of eyebrows and eyelashes
Depressed nose
Gynaecomastia
Palatal perforation
Secondary deformities
Corneal ulcers and opacities
Plantar ulcers
Palmar ulcers and ulcers on tips of fingers
Resorption
Charcot joints
Plantar ulcer
67. Deformities : Nerve Damage
Claw hand (ulnar, median)
Clawing of the toes (posterior tibial)
Wrist-drop (radial)
Foot-drop (lateral popliteal)
Lagophthalmos, facial palsy (facial)
68. Trophic Ulcer : Stages
Threatened ulcer : Process of tissue damage starts associated with
inflammation
Presents as edema and warmth in region of metatarsal head with
associated deep tenderness and increase in inter digital gap
Concealed ulcer : Damage to subcutaneous tissue presents as
necrosis and blisters at the site of damage
Open ulceration : Skin breaks down and tissue damage site is
exposed to form frank ulcer
Types of ulcers :
• Acute ulcer/ Chronic ulcer
• Complicated/uncomplicated ulcer
69. Prevention of Deformities
Adequate treatment of leprosy patient
Early detection of nerve damage
Prevention of nerve damage
Protection of anesthetic hands from injury
Care of hands with weakness/paralysis
Use of protective footwear
Adequate hydration of skin
Physiotherapy
70. Management of Deformities
Education of patient regarding prevention of injuries
Daily examination of hands and feet and prompt treatment for minor
injuries
Using adapted tools and appliances after training
Reconstructive surgery
Rehabilitation
71. Physiotherapy
Oil massage/Wax Therapy-Uses
To make the skin soft and supple and loosen stiff joints
As a preliminary to exercises
To strengthen muscles and keep joints mobile
To reduce pain in acute neuritis
To stimulate innervated sweat glands to increase blood flow
Exercises : Active and assisted exercise : To increase the strength of muscles
and retain their tone
Electric stimulation – Uses
To maintain the tone of denervated muscle
Helpful in breaking post operative adhesions
Before tendon surgery could be used as a means of documenting nerve
damage and the progress of the nerve recovery with treatment.
72. Splints
Indication
Acute neuritis
Mobile deformities(to prevent fixed deformities),
Fixed deformities(to correct the deformities).
Various splints
For radial neuritis-Static or dynamic wrist drop splint
For mobile deformity- Static or dynamic splint
For fixed deformity-Gutter splints, finger loops etc.
Splints for various deformities
Hand deformities : Gutter splints, finger loop splints, opponens splints and
adductor bands
Foot deformity : “Y” strap with spring, single elastic strap
73. Prevention and Control of leprosy
Prevention of leprosy
Early detection through survey and initiation of treatment
Families of patients to be kept under surveillance
Immunoprophylaxis -Use of leprosy vaccines
Improvement in socio-economic conditions
Leprosy control
Three activities of a leprosy control unit
• Case detection
• Case holding, including treatment
• Health education of public and patients
74. Prevention and Control of leprosy
Leprosy Organizations
UNICEF LEPRA, DANIDA, SIDA, CIDA, Leprosy mission, American
leprosy mission (ALM), German leprosy relief association(GLRA),
LEPRA, Netherland leprosy relief (NLR)
Leprosy control Programmes
National leprosy control programme (NLCP) 1954
Triad of Survey, Education and Treatment (S.E.T).
National leprosy eradication programme (NLEP) 1982
75. Prevention and Control of leprosy
National Leprosy Eradication Programme (NLEP), 1982
Eradicate leprosy from the country by 2000.
‘Vertical’ health programme- In areas where prevalence of leprosy is
more than 5 per 1000.
‘Horizontal’ programme- In areas where the prevalence rate is less
than 5 per 1000.
Three main units for programme operation :
Basic tier : Survey, education and treatment unit, leprosy control unit
and urban leprosy control unit.
Second tier : District/zonal leprosy office.
Third tier : Leprosy division of the state Directorate of the health
services.
76. Rehabilitation in Leprosy
Rehabilitation :
• Physical and mental restoration of patients to normal activities, so
that they are able to assume their place in the home, society and
industry.
• Treatment of physical disability
• Education of patient, family and public
• Rehabilitation in special homes or institutional rehabilitation
• Community based rehabilitation
77. Thank You!
This presentation is a part of iadvl- digital
lecture series. Thanking iadvl and team for
very informative lecture
Presented by-
Dr. Harshit Bhachech
MBBS,DDVL.
Safalya Skin Clinic, Naroda