Cutaneous Leprosy

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Skin manifestations&therapy of leprosy

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Cutaneous Leprosy

  1. 1. Cutaneous leprosy <ul><li>Leprosy is a chronic granulomatous disease, caused by Mycobacterium leprae, which affects principally the skin and peripheral nervous system </li></ul><ul><li>Animal reservoirs of leprosy : 9-banded armadillos & chimpanzees </li></ul>
  2. 2. Pathophysiology: <ul><li>The areas most commonly affected by leprosy are the superficial peripheral nerves , skin, mucous membranes of the upper respiratory tract, anterior chamber of the eyes , and testes. These areas tend to be cooler parts of the body . </li></ul><ul><li>Tissue damage is caused by the degree to which cell-mediated immunity is expressed, the extent of bacillary spread and multiplication , the immunologic complications (ie, lepra reactions), and the nerve damage and its sequelae </li></ul>
  3. 3. <ul><li>M leprae is an obligate intracellular acid-fast bacillus with a unique ability to enter nerves. </li></ul><ul><li>The incubation period ranges from 6 months to 40 years or longer. The average incubation period is 2-3 years . </li></ul>
  4. 4. Medical Diagnosis of Leprosy <ul><li>The disease is usually diagnosed on the basis of : anesthesia of a skin lesion , thickened nerves , and typical skin lesions . </li></ul><ul><li>Prodromal symptoms are generally so slight that the disease is not recognized until a cutaneous eruption is present. </li></ul><ul><li>Temperature is the first sensation that is lost </li></ul><ul><li>The next sensation lost is light touch , then pain, and finally deep pressure . </li></ul><ul><li>A hypopigmented macule : the first cutaneous lesion. From this stage, most lesions evolve into the lepromatous, tuberculoid or borderline types. </li></ul>
  5. 5. Indeterminate leprosy (IL) <ul><ul><li>This early form causes one to a few hypopigmented, or sometimes erythematous, macules. Sensory loss is unusual. </li></ul></ul><ul><ul><li>Most cases evolve from this state into one of the other forms, depending on the patient's immunity to the disease. </li></ul></ul><ul><ul><li>Those with strong immunity may become cured of disease. </li></ul></ul><ul><ul><li>May persist in this indeterminate form. </li></ul></ul><ul><ul><li>In those with weaker immunity, the disease progresses to one of the other forms. </li></ul></ul>
  6. 10. Tuberculoid leprosy (TT) <ul><li>Skin lesions :few in number. Usually, one erythematous large plaque is present, with well-defined borders that are elevated and slope down into an atrophic center. </li></ul><ul><li>Another presentation involves a large asymmetric hypopigmented macule. </li></ul><ul><li>Neural involvement is common in TT; it leads to tender, thickened nerves </li></ul>
  7. 12. Borderline tuberculoid leprosy (BT) <ul><ul><li>Lesions in this form are similar to those in the tuberculoid form, but they are smaller and more numerous . The nerves are less enlarged, </li></ul></ul><ul><ul><li>Disease can remain in this stage, convert back to the tuberculoid form, or progress. </li></ul></ul>
  8. 13. Borderline borderline leprosy (BB) <ul><ul><li>Cutaneous : numerous , red, irregularly shaped plaques that are less well defined . Their distribution may mimic those of the lepromatous type, but they are more asymmetric . </li></ul></ul><ul><ul><li>Anesthesia : moderate . </li></ul></ul><ul><ul><li>Regional adenopathy may be present. </li></ul></ul><ul><ul><li>Disease may remain in this stage, improve or worsen. </li></ul></ul>
  9. 14. Borderline lepromatous leprosy (BL) <ul><ul><li>Lesions : numerous and consist of macules , papules , plaques , and nodules . </li></ul></ul><ul><ul><li>. Anesthesia : often absent . </li></ul></ul><ul><ul><li>As with the other forms of borderline leprosy, the disease may remain in this stage, improve, or regress. </li></ul></ul>
  10. 15. Lepromatous leprosy (LL) <ul><li>Early cutaneous lesions : pale macules . Later, infiltrations are present, with numerous bacilli. Macular lesions : small , diffuse , and symmetric . </li></ul><ul><li>The lateral eyebrows are affected by alopecia </li></ul><ul><li>Lepromatous infiltrations : diffuse, nodules (called lepromas), or plaques. The diffuse type results in the appearance of a leonine facies. </li></ul><ul><li>Lymphadenopathy ,hepatomegaly Stridor ,hoarseness ,osteomyelitis &Brawny edema . </li></ul>
  11. 17. Skin Biopsy <ul><li>Epidermis </li></ul><ul><li>Collections of Foamy macrophages in the upper dermis. </li></ul><ul><li>Around adnexa </li></ul>
  12. 18. Case : Clinical details <ul><li>An 8 year old boy presented to clinic with a right Bell’s palsy. </li></ul><ul><li>In addition it was noted that he had multiple hypo-aesthetic pale patches on the skin. </li></ul>
  13. 19. Mouth Drooping corner of mouth Reduced nasolabial fold
  14. 20. Right arm Slightly nodular hypopigmented rash
  15. 21. Left leg Slightly nodular hypopigmented rash
  16. 22. Case <ul><li>A 29 year old man was screened for skin lesions after his father was found to have leprosy </li></ul>
  17. 23. Left cheek Raised erythematous plaque over left cheek
  18. 24. Lab. Studies: <ul><li>Tissue smear test: An incision is made in the skin, to obtain fluid from a lesion. The fluid is placed on a glass slide and stained by using the Ziehl-Neelson acid-fast method to look for organisms.The bacterial index (BI) is then determined </li></ul><ul><ul><li>Skin biopsy : for morphologic features and the presence of acid-fast bacilli. </li></ul></ul><ul><ul><li>Sensory testing : Tactile and temperature sensations should be tested. </li></ul></ul>
  19. 25. Lab. Studies: <ul><li>Lepromin testing </li></ul><ul><ul><li>It indicates host resistance to M leprae. and does not not confirm the diagnosis, but they are useful in determining the type of leprosy. </li></ul></ul><ul><ul><li>A positive finding indicates cell-mediated immunity,. A negative finding suggests a lack of resistance to disease. </li></ul></ul><ul><ul><li>To perform this test, bacillary suspension is injected into the forearm. When the reaction is assessed at 48 hours , it is called the Fernandez reaction When the reaction is read at 3-4 weeks , it is called the Mitsuda reaction . </li></ul></ul>
  20. 26. Reactions in Leprosy
  21. 31. Medical Classification of leprosy <ul><li>Paucibacillary or PB leprosy .: patients can be cured by </li></ul><ul><li>treating the patient with two drugs for six months. </li></ul><ul><li>Multibacillary or MB leprosy : patients can be cured by treating the patient with three drugs for twelve months. </li></ul><ul><li>How to tell if someone has PB or MB leprosy? </li></ul><ul><li>Count the skin patches </li></ul><ul><li>• If you find five patches or less, classify the patient as PB. </li></ul><ul><li>• If you find more than five patches, classify the patient as MB. </li></ul><ul><li>When a skin smear is taken </li></ul><ul><li>• If the skin smear is negative and the patient has five patches or less, classify the patient as PB. </li></ul><ul><li>• If the skin smear is positive, classify the patient as MB, whatever the number of skin patches. </li></ul>
  22. 33. Therapy of Leprosy Multiple Drug Therapy ( MDT )
  23. 36. Therapy for lepra reactions <ul><li>Early diagnosis and the timely initiation of anti-inflammatory measures. </li></ul><ul><li>The possible precipitating factor should be removed MDT should be continued in full dosage without interruption. </li></ul><ul><li>The principles of treatment : Rest, both physical and mental, with appropriate sedation. </li></ul><ul><li>Analgesics and anti-inflammatory drugs: </li></ul><ul><li>Aspirin (acetylsalicylic acid) and corticosteroids </li></ul>
  24. 37. Therapy with corticosteroids <ul><li>Type 1 lepra reaction : Prednisolone should be started with a single daily dose of 40–60 mg (maximum 1mg/kg body weight) according to severity. </li></ul><ul><li>In severe Type 2 lepra reaction : prednisolone should be started at a dose of 20–40 mg/day. </li></ul><ul><li>Clofazimine : given in doses up to 300 mg daily for one month, and then gradually reduced . </li></ul>
  25. 38. THANK YOU

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