Grows in animal= mouse / armadillos but not in artificial medium
Source- all active cases. Esp lepromatous leprosy
Portal of exit- nose. Also ulcerated skin
Highly infections. Low pathogenic
Attack rate- 4.4 to 12%
symptomatic in 5 yrs
Epidemiological determinants- host
Any age. Both sexes. 2.5yr baby too (active and spreading)
Prevalence pool/ migration
Inactivation of the disease
Immunity – cell mediated
Genetic factors- HLA linked genes influence the type of response
Epidemiological determinants- environment
Presence of infectious cases
Overcrowding and lack of ventilation
Mode of transmission
? Insect vectors/ tattooing needles
Incubation period 3- 5 yrs for lepromatous and less for Tuberculoid leprosy
Indian Classification Indeterminate 1-2 patches. Sensory impairment Bact negative Tuberculoid 1-2 well defined flat/ raised/hypo pig/ erythematous Anaesthetic Bact negative Borderline 4 or more lesions others same as above. Usually progresses to lepromatous anaesthetic positive Lepromatous Diffuse infiltration or numerous other types anaesthetic positive Pure neuritic No skin lesion Has only nerve involvement negative
Bacterial Index number of bacilli in oil immersion fields (OIF) in an average microscope Help in monitoring Bacterial Index= total of indices / number of sites examined Total number of + in 7 sites -4 skin lesions, 1 nasal swab, both ear lobes Pauci bacillary 2 Multibacillary>2 0 No bacilli 100 OIF 1+ 1 or<1 in each mic field 2+ Bacilli found in all the fields 3+ Many bacilli in all the fields
Solid -fragmented- granular percentage
Indicator of patient's response to treatment during the first few months- -
200 pink stained free standing bacilli have to be counted
Total of Mis for all sites / number of sites+ average MI for the body.
Solid rods: Uniform staining of entire organism/ parallel sides, rounded end length 5 times the width - Viable
Solid -fragmented- granular are given separately
Better indicator of response
Foot pad culture
Inoculate material into foot pads of mice
Demonstrate its multiplication
10 times more sensitive than slit skin smears- 6-9 mths
Macrophage culture: 3-4 wks
Helpful to detect drug resistance
Evaluate potency of anti leprosy drugs
Viability of baciili during treatment
Detecting at an early stage peripheral nerve damage due to leprosy
Inject 0.1 ml of 1:1000 solution of histamine phosphate or chlorhydrate in hypo pigmented patches or anaesthetic patches flare response is lost
For detecting cell mediated immunity
Tests for humoral antibodies
CMI Tests : Lepromin Test
Lepromin is a suspension of killed M leprae obtained from infected human or armadillo tissue. Mitsuda / Dharmendra
Inject Lepromin O.1 ml inner aspect of forearm .
Following intradermal inoculation, Read linke for PPD
early ( 48 h, Fernandez) reactions and late ( 3-4 wk, Mitsuda) reactions may be seen.10 mm mild 15-20 mod >20 strong
The Mitsuda reaction, a granulomatous response to the antigen, is more consistent. 3-4 weeks. Patients with TT or BT leprosy have strong positive (>10 mm) responses,
PATIENTS WITH L L DISEASE DO NOT RESPOND .
The test is not useful in the diagnosis of leprosy because most of the population in both areas of endemic and nonendemic disease are Mitsuda positive.
The lepromin test is a guide to the cell-mediated immunity of the individual.
CMI= cell mediated immunity
lymphocyte transformation test (LTT) and
lymphocyte migration inhibition test (LMIT).
Response decreases steadily in the progression from subpolar TT to subpolar LL leprosy
Leprosy Control Medical measures
Estimation of problem
Early case detection
Multi drug therapy
Deformities health education
Leprosy control ( contd)
To interrupt transmission reduce incidence
To treat patients.. cure.. rehab
To prevent formation of associated deformities
Estimation of the problem
Random sample surveys
Prevalence among all school age children x 4 = average prevalence in the community
II.Early case detection
Aim: identify and register all cases
Involve primary health care workers
Active community participation
Contact survey- household
if 1 per 1000 Group survey ..school/slum/military
if prevalence is10 or more per 1000 : Mass surveys House to house
Records; standardised:. Use WHO format
III Multi Drug therapy- MDT
Mainstay of control
Drug resistance leprosy due to monotherapy
Relapse of disease
Therefore MDT. Shorter treatment
To interrupt transmission by sterilizing infectious patients as rapidly as possible by bactericidal drugs
To ensure early detection and treatment of cases to prevent deformities
To prevent drug resistance
Case of leprosy- person showing clinical signs with or without bacteriological confirmation, and who has not completed MDT
Pauci bacillary : A person with 1-5 skin lesions and/or only 1 nerve involvement
Multi bacillary ; A person having 6 or more skin lesions and /or more than1 nerve involvement
Adequate treatment: completion of regimen of multi drug therapy –
6 mthly doses within 9 mths for paucibacillary and
12 mthly doses within 18 mths for multi bacillary
Regular treatment : Received MDT for at least 2/3 rd of the months in any interval of time
Newly diagnosed case- Diagnosed as a leprosy case and who has not taken MDT in the past
Defaulter case : A leprosy patient on MDT who has not collected treatment for 12 consecutive months
Relapsed case: successfully completed an adequate course of MDT and who subsequently develops new signs and symptoms of the disease, within during the surveillance period or thereafter.
Principles of treatment
Stop the infection with chemotherapy
Educate the patient about leprosy
Support patient socially and psychologically
Drugs Name Description Rifampicin Bactericidal -Hepatotoxic -Observe patient 1 hr after giving the drug 600mg -3 days1500 stat dose Dapsone DDS Mild bactericidal.in 90 days make non infective Haemolytic anemia, meth hb DDS syndrome 1-2 mg/kg; 100 mg OD Clofazimine CLF Anti leprosy anti inflamm. Expensive. Red colouration 300 mg once a mth Ethionamide/ protionamide Bactericidal more expensive and toxic than DDS. Use if CLF is un acceptable Quinalone-ofloxacin Bactericidal. GI side effects minocycline Inhibits bact protein synthesis CI children pregnancy Clarithomycin Bactericidal. useful In LL
WHO Recommended regimens Adults monthly / daily / both
Rifampicin-600mg monthly under supervision x 12 mths
DDS 100 mg OD x 12 mths
CLF 300 mg mthly supervised and 50 mg OD- for 12 mths
Rifampicin-600mg monthly x 6 months supervised
DDS 100 mg OD x 6 mths
WHO Recommended regimens Children
Rifampicin-450mg mthly under supervision x 12 mths
DDS 50 mg OD x 12 mths
CLF 150 mg mthly supervised and 50 mg alt days for 12 mths
Rifampicin-450mg x 6 mths supervised
DDS 50 mg OD x 6 mths
Not registered as new cases
Start a new course if she has red raised lesion/ new skin lesion/ new nerve involvement/ lepra nodules/ ENL or reversal reaction
Drugs Shd be continued in pregnancy
Can be given to HIV positive persons
Immunologically mediated episodes. Involve nerves. Can cause deformities if not treated
Reversal – Type 1 Delayed Hypersensitivity reaction CMI. Usually in borderline BT BL BB cases .
Erythema nodosum leprosum- Type II (mild/severe) Immune complex deposition. BL and LL patients
Nodules, neuritis,High fever, ulcers and pustular, involve other organs-eye, testis, lymph node joints
More with mono therapy than MDT
Treat with Prednisolone 12 weeks only. CLF
TYPE 1 Reversal reaction TYPE 2 ENL Relapse Time interval Occurs with chemo and within 6 mths of stopping treatment Only when chemo is discontinued after abt 5 mths Onset Abrupt Slow Insidious Old lesions Edematous, erythematous tender Not tender New lesions Several appear Minimal Ulceration May possible Nerve involvement Multiple+ painful and tender.Loss of nerve function Single nerve. Painless Gen condn May have fever jt pains. malaise Not usual Response to steroids Rapid Nil. Use Clofazamine
To detect long term success and detect relapse
Pauci bacillary: Once an year x 2 yrs
Multi bacillary : Once an year x 5 yrs
BCG vaccine – varying results 23-30-80%
DDS : 1-4 mg/kg for child contacts
Given 3 yrs or till index case becomes bact Neg.
ICRC – effective for 8 yrs
Acdapsone : Inj once in 10 wks long term or short term 7 mths
Disease process- eye brows, facial
Paralysis of muscles due to nerve damage-lag ophth, claw hand, foot drop
Injuries infection of hands and feet- mutilation, corneal ulcer
Hands and feet Eyes Grade 0 No anaesthesia. No visible deformity No eye problem / vision defect Grade I Anaesthesia+ No visible deformity eye problem present vision defect absent Grade II Visible deformity/ damage Severe visual impairment, lag ophthalmos, iridocyclitis and corneal opacity
Prevent these by lots of care …
Health education- patient / family / public
Treat by prosthesis/ surgery
Protect people at risk
Hypopigmented patch with loss of sensation could be leprosy
Like any disease Leprosy is caused by germs
Leprosy is non hereditary
80% do not spread to others
It is completely curable
Early detection and sustained treatment
Become non infectious soon after treatment is commenced
Need kindness and empathy
Not a poor man’s disease
Community support is essential for eradication
17 states have achieved Leprosy elimination
7 more are nearing this
Child proportion is 13.77%
Multi bacillary 39.3%
Visible deformities 1.44%
Anti leprosy activities in India
Hindu kushth Nivaran Sangh
German leprosy Relief association
JALMA central institute in Agra
Central leprosy teaching and research institute Chenglepet
Goals of Physical Therapy for Non-Surgical patients Of Leprosy Disease
The major aim is to prevent or reduce complication, deformity and disability in body through Physical Therapy.
The ways of reaching these Goals are-
By teaching the patient.
By treating and helping the patient.
What the disease of leprosy is?
The possible complications and deformities resulting from leprosy.
prevention of complication, deformities and disabilities.
Treating and Helping:
To respect themselves enough to take medication regularly and to take care of complications.
To protect their own anesthetic hands, feet and eyes.
To keep their skin soft and supple.
To keep their joint flexible.
To preserve all possible movements of hands and feet.
To keep their muscles strong.
To use their hands, feet and eyes safely, in daily work.
Goals of Physical Therapy for Surgical patients Of Leprosy Disease
To protect and prevent further damage and deformity.
To improve and restore function.
To improve appearance of hands, feet, face and eyes.
Surgical Techniques used in Leprosy Disease:
Tendon Transfer : Moving the distal end of the tendon to a new place so that contraction of muscle belly will produce a needed movements used to replace paralysed muscles. Example- Transfer of fore-arm muscle to make finger movements.
Tendon Lengthening : Lengthening the tendon of a muscle to permit more movement and reduce contracture. Example- Tendo Calcaneus lengthening.
Capsulotomy : To loosen tight joint capsule often done with tendon lengthening and tendon transfer to improve range of motions. Tighten the loose joint capsule using suture.
Arthrodesis : Elimination of unstable and deformed joints.
Tenodesis : Attach a piece of tendon across the joint to reduce the movement. The tendon then act as ligament. Example- Tenodesis of MCP joint to prevent hyperextension.
Physical Therapy Goals:
To increase and regain range of motion.
Improve muscle strength particularly in muscles to be transferred.
Clean supple skin in areas of surgery.
Teach home self care.
Protect tissue during wearing.
Muscle re-education after tendon transfer.
Safe use of any new restored skill in work.
Physical Therapy Technique:
For increasing/regaining ROM : ROM can be increased by soaking the skin or part in warm water and then performing passive movement to the part affected.
To improve strength specially in tendon transfer : Active exercise in all part in which surgery is performed.
Clean supple skin : It is provided by soaking the part in soap water, rubbing off thick skin, oiling, self massage and protecting the part from infection.
Home care : teaching skin, hand, foot and eye care to groups and individuals and teaching the patients actual home care.
Protect tissue during healing : Rest, body position and POP cast.
Prevent/Reduce swelling : Elevation, active and passive exercise.
Muscle Re-education after tendon transfer : Teaching new restored skills in movements provided by tendon transfer.
Self restored skills in daily work : Teaching patient ot use any new skill safely in specific task. Providing hand, eye and foot protection.