LEPROSY <ul><li>Ali M. Gargoom </li></ul><ul><li>MB,ChB. MSc. MD  </li></ul><ul><li>Assistant  Professor  </li></ul><ul><l...
 
An ancient,  chronic infectious  disease  caused  by  Mycobacterium leprae  .  It  principally  affects  the skin and   pe...
M. leprae is discovered by  Hansen from Norway in 1873
BACTERILOGY <ul><li>They  are straight or slightly curved rod-like bacilli.  </li></ul><ul><li>It measure about ( 3 x 0.5 ...
The nine - banded armadillo
BACTERILOGY  (cont.) <ul><li>Replicate very slow (every 12 days once). </li></ul><ul><li>Has an affinity for macrophages &...
Mode of transmission   The exact rout of transmission is not fully known . <ul><li>The spread of leprosy is believed to be...
Other modes of transmissions <ul><li>Contact through the skin (rare).  </li></ul><ul><li>Arthropod-born infection (rare). ...
Epidemiology   <ul><li>Leprosy is a disease of developing countries but affects all races. </li></ul><ul><li>Registered ca...
Epidemiology (cont.) <ul><li>The incubation period range from 2 -5 years. </li></ul><ul><li>Males appear to be twice commo...
Global Trend in Registered Cases
Predisposing or risk factors <ul><li>Residence in an endemic area. </li></ul><ul><li>Having a blood relative with leprosy....
Classification & Clinical Presentation Jopling  Classification Based on Host Immunity TT BL LL BT BB BL
Classification & Clinical Presentation  WHO Classification Based on Bacterial Load Paucibacillary Multibacillary Slit Skin...
LEPROSY Paucibacillary (PB) Multibacillary  (MB) Indeterminate Leprosy (IL) Tuberculoid Leprosy (TL) Borderline Tuberculoi...
CLINICAL PICTURE  Indeterminate  Leprosy Tuberculoid  Leprosy  Borderline Leprosy BT  BB  BL Lepromatous Leprosy
TT BT BB BL LL Skin Lesions No. of Bacilli  Slit skin test Immunity  Clinical spectrum of leprosy
Indeterminate  Leprosy (IL) <ul><li>Usually single (multiple) macule / patche. </li></ul><ul><li>Hypopigmented or faintly ...
Indeterminate leprosy :Hypopigmented patch, sensation normal, no palpable peripheral nerve and slit skin smear negative.
Tuberculoid  Leprosy  (TL)  <ul><li>Usually single but may be few ( < 5). </li></ul><ul><li>Hypopigmented / erythematous  ...
Tuberculoid leprosy: Two hypopigmented patches, hypoasthetic well defined borders, palpable peripheral nerve and SSS negat...
Tuberculoid  Leprosy:  Annular, erythematous, anasthetic  patch with well  defined and raised borders and  SSS Negative.
 
Borderline Leprosy  (BL) (BT,BB,BL)   <ul><li>Few / many  asymmetrical patches. </li></ul><ul><li>Partly well-defined bord...
Note: Sometimes patients may have  BT/BB or  BB/BL or BL/LL BL BB BT Many  Some  Few (<5)   Lesion no.  Roughly  Less Well...
Borderline Tuberculoid Leprosy: Well-defined large anaesthetic patches with satellite lesions. SSS Negative.
Borderline Borderline Leprosy: Less defined, asymmetrically distributed hypoaesthetic patches. SSS positive.
Borderline Lepromatous Leprosy: Numerous,  hypoaesthetic  almost  symmetrically distributed patches . SSS positive.
Lepromatous Leprosy  (LL) <ul><li>Very numerous ill defined lesions. </li></ul><ul><li>(macules, patches, papules,and nodu...
 
 
Lepromatous Leprosy: Leonine Face
Diagnosis of Leprosy <ul><li>Clinical Examination. </li></ul><ul><li>Slit Skin Smear. </li></ul><ul><li>Skin  Biopsy. </li...
1.Clinical examination: <ul><li>What are the cardinal skin signs of leprosy ? </li></ul><ul><li>Hypopigmented or erythemat...
2.Slit Skin Smear <ul><li>Simple and  valuable  test. </li></ul><ul><li>It is needed for diagnosis. </li></ul><ul><li>Moni...
Slit Skin Smear (method). <ul><li>Pinch the site tight. </li></ul><ul><li>Incise. </li></ul><ul><li>Scrape & collect mater...
Slit Skin Smear (site). <ul><li>Ear lobe. </li></ul><ul><li>Forehead. </li></ul><ul><li>Gluteal region. </li></ul><ul><li>...
Slit Skin Smear  (Reporting the smear). Bacteriological index 0 – no bacilli in 100 fields 1+: 1-10 bacilli in 100 fields ...
Skin Biopsy
Tuberculoid Leprosy (TT). <ul><li>Histologically TT resemble tuberculosis. </li></ul><ul><li>Characterized by tuberculoid ...
Lepromatous Leprosy (LL) <ul><li>Characterized by diffuse infiltration of foamy macrophages in the dermis. </li></ul><ul><...
<ul><li>TREATMENT  </li></ul>
<ul><li>LEPROSY IS A CURABLE DISEASE </li></ul><ul><li>Leprosy treatment is simple, available free & the drugs are supplie...
Drugs used in Leprosy treatment <ul><li>What are the three commonly used drugs? </li></ul><ul><li>Dapson. </li></ul><ul><l...
<ul><li>Rifampicin is highly bactericidal  99.999% of bacilli will be  killed within 3 monthly doses. </li></ul><ul><li>Da...
MDT for PB leprosy 6 months Monthly dose   Rifampicin 600mg Dapsone 100 mg  Daily dose Dapsone 100 mg
Multidrug Therapy (MDT) for Paucibacillary Leprosy (PB)
MDT for MB leprosy 24 months Monthly dose Rifampicin  600mg Clofazimine 300 mg Dapsone  100 mg Daily dose Dapsone  100mg  ...
Multidrug Therapy (MDT) for Multibacillary Leprosy (MB)
Multi Drug Therapy 24 months   6 months
COMLICATIONS  OF  LEPROSY
COMLICATIONS OF LEPROSY <ul><li>Reactions. </li></ul><ul><li>Complications of peripheral nerves. </li></ul><ul><li>Complic...
It’s a  sudden  change in  the  clinical  picture of  the  disease  because  of  conflict  between the bacilli  and  the  ...
TYPES  OF LEPRA REACTIONS <ul><li>Type I </li></ul><ul><li>Change in host CMI  </li></ul><ul><li>Seen in borderlines </li>...
Type I Lepra Reaction (Reversal Reaction) <ul><li>Seen in  BT, BB & BL. </li></ul><ul><li>Sudden onset. </li></ul><ul><li>...
Type II Lepra Reaction (ENL) <ul><li>Acute onset of constitutional symptoms. </li></ul><ul><li>Appearance  of ENL-like ski...
Erythema Nodosum Leprosum  (ENL) <ul><li>Erythematous. </li></ul><ul><li>Tender . </li></ul><ul><li>Subcutaneous. </li></u...
COMPLICATIONS  OF  PERIPHERAL NERVES
Peripheral nerves Sensory  Motor Autonomic  Hypoaestesia / anaestesia Muscle  paralysis Lack of sweating & sebum Ulcers Ul...
 
 
 
COMPLICATIONS  OF   EYE
Involvment of  the ophthalmic division of the (5 th .)  trigeminal  nerve   Corneal sensation imparment Patients ignore in...
 
 
Complications Of  Bones   <ul><li>Bone damage in Leprosy is confined to bones of hand , feet  &  skull. </li></ul>
 
In the skull   two pathognomonic changes occurs 1- Atrophy of anterior nasal spine. Nasal collapse 2- Atrophy of maxillary...
 
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Leprosy for undergraduate medical students

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Ali Gargoom
Assistant Professor of Dermatology
Faculty of Medicine
Benghazi-University
Benghazi-Libya

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Leprosy for undergraduate medical students

  1. 1. LEPROSY <ul><li>Ali M. Gargoom </li></ul><ul><li>MB,ChB. MSc. MD </li></ul><ul><li>Assistant Professor </li></ul><ul><li>Department of Dermatology </li></ul><ul><li>Faculty of Medicine. </li></ul><ul><li>Benghazi University </li></ul>
  2. 3. An ancient, chronic infectious disease caused by Mycobacterium leprae . It principally affects the skin and peripheral nerves. Leprosy ( Hansen’s disease )
  3. 4. M. leprae is discovered by Hansen from Norway in 1873
  4. 5. BACTERILOGY <ul><li>They are straight or slightly curved rod-like bacilli. </li></ul><ul><li>It measure about ( 3 x 0.5 micrometer) . </li></ul><ul><li>Weakly Gram +ve & stained by Ziehl-Neelsen method. </li></ul><ul><li>M. leprae is an obligate intracellular acid-fast bacillus. </li></ul><ul><li>Has never been grown in artificial media. </li></ul><ul><li>It grow in nine - banded armadillo. </li></ul>
  5. 6. The nine - banded armadillo
  6. 7. BACTERILOGY (cont.) <ul><li>Replicate very slow (every 12 days once). </li></ul><ul><li>Has an affinity for macrophages & Schwann cell. </li></ul><ul><li>It grows best at 27-30 C, hence its predilection for cooler areas of the body. </li></ul><ul><li>Skin, peripheral nerves, anterior chamber of the eye, upper respiratory tract & testes. </li></ul>
  7. 8. Mode of transmission The exact rout of transmission is not fully known . <ul><li>The spread of leprosy is believed to be via nasal discharge (Droplets infection). </li></ul><ul><li>Every 1 cc of nasal secretion contains 1- 2millions lepra bacilli </li></ul>
  8. 9. Other modes of transmissions <ul><li>Contact through the skin (rare). </li></ul><ul><li>Arthropod-born infection (rare). </li></ul><ul><li>Through placenta and milk. </li></ul><ul><li>Leprosy is not STD or directly inherited. </li></ul>
  9. 10. Epidemiology <ul><li>Leprosy is a disease of developing countries but affects all races. </li></ul><ul><li>Registered cases of leprosy have fallen from 5.4 millions worldwide in 1985 to below one million in 1998. </li></ul><ul><li>80% of the worldwide cases are found in five countries, namely India, Mynamar, Indonesia, Brazil and Nigeria. </li></ul>
  10. 11. Epidemiology (cont.) <ul><li>The incubation period range from 2 -5 years. </li></ul><ul><li>Males appear to be twice common than females. </li></ul><ul><li>Bimodal age (10-14years & 35-44 years). </li></ul><ul><li>Children are more susceptible to disease. </li></ul><ul><li>Genetic factors, e.g. HLA markers may determine the type of leprosy which the patient develops . </li></ul>
  11. 12. Global Trend in Registered Cases
  12. 13. Predisposing or risk factors <ul><li>Residence in an endemic area. </li></ul><ul><li>Having a blood relative with leprosy. </li></ul><ul><li>Poverty (malnutrition). </li></ul><ul><li>Contact with affected armadillo. </li></ul>
  13. 14. Classification & Clinical Presentation Jopling Classification Based on Host Immunity TT BL LL BT BB BL
  14. 15. Classification & Clinical Presentation WHO Classification Based on Bacterial Load Paucibacillary Multibacillary Slit Skin Smear Positive Negative
  15. 16. LEPROSY Paucibacillary (PB) Multibacillary (MB) Indeterminate Leprosy (IL) Tuberculoid Leprosy (TL) Borderline Tuberculoid (BT) Borderline Borderline (BB) Borderline Lepromatous(BL) Lepromatous Leprosy (LL)
  16. 17. CLINICAL PICTURE Indeterminate Leprosy Tuberculoid Leprosy Borderline Leprosy BT BB BL Lepromatous Leprosy
  17. 18. TT BT BB BL LL Skin Lesions No. of Bacilli Slit skin test Immunity Clinical spectrum of leprosy
  18. 19. Indeterminate Leprosy (IL) <ul><li>Usually single (multiple) macule / patche. </li></ul><ul><li>Hypopigmented or faintly erythematous. </li></ul><ul><li>Sensation normal but sometimes imparied. </li></ul><ul><li>The peripheral nerves normal. </li></ul><ul><li>Slit skin smear negative. </li></ul>
  19. 20. Indeterminate leprosy :Hypopigmented patch, sensation normal, no palpable peripheral nerve and slit skin smear negative.
  20. 21. Tuberculoid Leprosy (TL) <ul><li>Usually single but may be few ( < 5). </li></ul><ul><li>Hypopigmented / erythematous plaque. </li></ul><ul><li>Varying in size from few MM to several CM . </li></ul><ul><li>Well defined borders. </li></ul><ul><li>Sensation markedly imparied. </li></ul><ul><li>Enlarged peripheral nerve. </li></ul><ul><li>Slit skin smear negative </li></ul>
  21. 22. Tuberculoid leprosy: Two hypopigmented patches, hypoasthetic well defined borders, palpable peripheral nerve and SSS negative.
  22. 23. Tuberculoid Leprosy: Annular, erythematous, anasthetic patch with well defined and raised borders and SSS Negative.
  23. 25. Borderline Leprosy (BL) (BT,BB,BL) <ul><li>Few / many asymmetrical patches. </li></ul><ul><li>Partly well-defined borders. </li></ul><ul><li>Sensory impairments range from slight to marked. </li></ul><ul><li>Slit skin smear usually positive. </li></ul><ul><li>P. nerves asymmetrically enlarged. </li></ul>
  24. 26. Note: Sometimes patients may have BT/BB or BB/BL or BL/LL BL BB BT Many Some Few (<5) Lesion no. Roughly Less Well Lesions borders Slight Moderate Marked Sensory impairment Roughly symmetrical Asymmetrical Asymmetrical Distribution of skin lesions Less asymmetrical Asymmetrical Asymmetrical Peripheral nerves Multibacillary Multibacillary Paucibacillary Type of leprosy 4+ 2+ / 3+ - / 1+ Slit skin smear
  25. 27. Borderline Tuberculoid Leprosy: Well-defined large anaesthetic patches with satellite lesions. SSS Negative.
  26. 28. Borderline Borderline Leprosy: Less defined, asymmetrically distributed hypoaesthetic patches. SSS positive.
  27. 29. Borderline Lepromatous Leprosy: Numerous, hypoaesthetic almost symmetrically distributed patches . SSS positive.
  28. 30. Lepromatous Leprosy (LL) <ul><li>Very numerous ill defined lesions. </li></ul><ul><li>(macules, patches, papules,and nodules). </li></ul><ul><li>Symmetrically distributed allover the body </li></ul><ul><li>Loss of eyebrows and eyelashes. </li></ul><ul><li>Leonina facies. </li></ul><ul><li>No sensory impairments in lesions . </li></ul><ul><li>Peripheral nerves symmetrically enlarged. </li></ul><ul><li>Slit skin smear always positive. </li></ul>
  29. 33. Lepromatous Leprosy: Leonine Face
  30. 34. Diagnosis of Leprosy <ul><li>Clinical Examination. </li></ul><ul><li>Slit Skin Smear. </li></ul><ul><li>Skin Biopsy. </li></ul>
  31. 35. 1.Clinical examination: <ul><li>What are the cardinal skin signs of leprosy ? </li></ul><ul><li>Hypopigmented or erythematus patch / plaque </li></ul><ul><li>2. Complete / partial loss of sensation. </li></ul><ul><li>3. Thickening of peripheral nerves. </li></ul>
  32. 36. 2.Slit Skin Smear <ul><li>Simple and valuable test. </li></ul><ul><li>It is needed for diagnosis. </li></ul><ul><li>Monitor the progress of the treatment. </li></ul>
  33. 37. Slit Skin Smear (method). <ul><li>Pinch the site tight. </li></ul><ul><li>Incise. </li></ul><ul><li>Scrape & collect material </li></ul><ul><li>Smear on a slide. </li></ul><ul><li>Air dry & fix. </li></ul><ul><li>Stain (Z-N method) </li></ul>
  34. 38. Slit Skin Smear (site). <ul><li>Ear lobe. </li></ul><ul><li>Forehead. </li></ul><ul><li>Gluteal region. </li></ul><ul><li>Active edge of patch. </li></ul>
  35. 39. Slit Skin Smear (Reporting the smear). Bacteriological index 0 – no bacilli in 100 fields 1+: 1-10 bacilli in 100 fields 2+: 1-10 bacilli in 10 fields 3+: 1-10 bacilli in 1 field 4+: 10-100 bacilli in 1 field 5+: 100-1000 in 1 field 6+: >1000 bacilli field (globi). Morphological index The percentage of living bacilli to the total number of bacilli in the smear.
  36. 40. Skin Biopsy
  37. 41. Tuberculoid Leprosy (TT). <ul><li>Histologically TT resemble tuberculosis. </li></ul><ul><li>Characterized by tuberculoid granuloma, made up of epitheloid cell in the center surrounded by abundant Langhans giant cells, lymphocytes and foci of caseating necrosis. </li></ul><ul><li>No acid-fast bacilli </li></ul>
  38. 42. Lepromatous Leprosy (LL) <ul><li>Characterized by diffuse infiltration of foamy macrophages in the dermis. </li></ul><ul><li>Acid-fast bacill are present inside these foamy cells eighter singly or in globi. </li></ul><ul><li>There is free subepidermal zone (grenz zone). </li></ul><ul><li>Lymphocytes are scanty and giant cells typically absent. </li></ul>
  39. 43. <ul><li>TREATMENT </li></ul>
  40. 44. <ul><li>LEPROSY IS A CURABLE DISEASE </li></ul><ul><li>Leprosy treatment is simple, available free & the drugs are supplied in backs that contain correct dose for 4 weeks. </li></ul><ul><li>All you have to do is decide which course of treatment the patient needs and make sure that he take it regularly . </li></ul>
  41. 45. Drugs used in Leprosy treatment <ul><li>What are the three commonly used drugs? </li></ul><ul><li>Dapson. </li></ul><ul><li>Rifampicine. </li></ul><ul><li>Clofazimine . </li></ul><ul><li>The combination of these three drugs is </li></ul><ul><li>known as Multi Drug Therapy (MDT) </li></ul>
  42. 46. <ul><li>Rifampicin is highly bactericidal 99.999% of bacilli will be killed within 3 monthly doses. </li></ul><ul><li>Dapsone & clofazimine are weekly bactericidal, but in combination will </li></ul><ul><li>kill 99.999% of bacilli within 3 months. </li></ul><ul><li>MDT (Chemotherapy) renders Leprosy patients non-infectious. </li></ul>
  43. 47. MDT for PB leprosy 6 months Monthly dose Rifampicin 600mg Dapsone 100 mg Daily dose Dapsone 100 mg
  44. 48. Multidrug Therapy (MDT) for Paucibacillary Leprosy (PB)
  45. 49. MDT for MB leprosy 24 months Monthly dose Rifampicin 600mg Clofazimine 300 mg Dapsone 100 mg Daily dose Dapsone 100mg Clofazimine 50 mg
  46. 50. Multidrug Therapy (MDT) for Multibacillary Leprosy (MB)
  47. 51. Multi Drug Therapy 24 months 6 months
  48. 52. COMLICATIONS OF LEPROSY
  49. 53. COMLICATIONS OF LEPROSY <ul><li>Reactions. </li></ul><ul><li>Complications of peripheral nerves. </li></ul><ul><li>Complications of eyes </li></ul><ul><li>Complication of bones </li></ul>
  50. 54. It’s a sudden change in the clinical picture of the disease because of conflict between the bacilli and the immune system of the host. <ul><li>What are the precipitating factors ? </li></ul><ul><li>Effective treatment. </li></ul><ul><li>Intercurrent infection. </li></ul><ul><li>Physical stress. </li></ul><ul><li>Surgical operation. </li></ul><ul><li>Pregnancy. </li></ul><ul><li>Sometimes spontaneously. </li></ul>LEPROSY REACTION
  51. 55. TYPES OF LEPRA REACTIONS <ul><li>Type I </li></ul><ul><li>Change in host CMI </li></ul><ul><li>Seen in borderlines </li></ul><ul><li>Skin and nerve lesions </li></ul><ul><li>Type II </li></ul><ul><li>Antigen antibody </li></ul><ul><li>Seen in LL & BL leprosy </li></ul><ul><li>Skin, nerve & systemic </li></ul><ul><li>involvement </li></ul>
  52. 56. Type I Lepra Reaction (Reversal Reaction) <ul><li>Seen in BT, BB & BL. </li></ul><ul><li>Sudden onset. </li></ul><ul><li>Eythematous & odematous changes in old lesions. </li></ul><ul><li>Appearing of new lesions. </li></ul><ul><li>Tenderness & swelling of peripheral nerves. </li></ul><ul><li>Treatment of type I Reaction: </li></ul><ul><li>Continue MDT. </li></ul><ul><li>NSAID. </li></ul><ul><li>Systemic corticosteroid. </li></ul>
  53. 57. Type II Lepra Reaction (ENL) <ul><li>Acute onset of constitutional symptoms. </li></ul><ul><li>Appearance of ENL-like skin lesions. </li></ul><ul><li>Visceral manifestations includes :- </li></ul><ul><li>Iridocyclitis, hepato-splenomegaly, epididmo-orchitis, nephritis, pleuritis, lymphadenitis & neuritis. </li></ul><ul><li>Treatment of type II Reaction: </li></ul><ul><li>Continue MDT. </li></ul><ul><li>NSAID </li></ul><ul><li>Thalidoamide ( clofazimine, corticosteroid ) </li></ul>
  54. 58. Erythema Nodosum Leprosum (ENL) <ul><li>Erythematous. </li></ul><ul><li>Tender . </li></ul><ul><li>Subcutaneous. </li></ul><ul><li>Resolve in 7 to 10 days. </li></ul><ul><li>Appear in crops. </li></ul><ul><li>Occur any where </li></ul><ul><li>Associated with fever & joint pains. </li></ul><ul><li>May be vesicular, pustular & may ulcerate </li></ul>
  55. 59. COMPLICATIONS OF PERIPHERAL NERVES
  56. 60. Peripheral nerves Sensory Motor Autonomic Hypoaestesia / anaestesia Muscle paralysis Lack of sweating & sebum Ulcers Ulnar nerve Claw hand Radial nerve Wrist drop Lt. popliteal Foot drop Post. tibial Claw toes Facial lagophthalmous Dry skin Cracked skin Ulcers
  57. 64. COMPLICATIONS OF EYE
  58. 65. Involvment of the ophthalmic division of the (5 th .) trigeminal nerve Corneal sensation imparment Patients ignore injuries keratitis, conjunctivitis and ulcers Involvment of zygomatic & temporal braches of the (7 th .) facial nerve. Lagophthalmos Unable to close the eye (unbliking stare)
  59. 68. Complications Of Bones <ul><li>Bone damage in Leprosy is confined to bones of hand , feet & skull. </li></ul>
  60. 70. In the skull two pathognomonic changes occurs 1- Atrophy of anterior nasal spine. Nasal collapse 2- Atrophy of maxillary alveolar process. Loss of upper central incisors These two skull changes known as “ facies leprosa ”
  61. 72. Thank you.

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