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MCQ and discussion
LEPROSY
- Dr. ANKUR KUMAR
AIIMS PATNA
1. Who discovered Mycobacterium leprae?
a. Robert Koch b. Hansen
c. Kitasato d. Louid Pasteur
Discovered by Gerhard Armauer Hansen in
1873.
2. What is the generation time of
Mycobacterium laprae
a. 20 minutes
b. 20 hours
c. 12-13 days
d. 20 weeks
3. A 40-year-old woman who has lived in southwest Louisiana all
her life presents to the emergency room. She has strange-
looking, raised areas on her face, arms, and legs. She also
complains that she is losing feeling in her fingers and toes. She
says that when she cuts or burns herself, she does not feel it
and that makes the injury even greater because she does not
know to pull away from the injuring source. A Gram stain of
scrapings from the raised areas on her skin shows thin bacterial
rods that do not take up the stain. However, an acid fast stain
of the same material shows numerous bacilli. What disease is
the woman most likely to have?
a. Borderline tuberculoid leprosy
b. Lepromatous leprosy
c. Scrofula
d. Tuberculoid leprosy
• Lady Windermere syndrome is caused by M. avium-
complex, usually in elderly female nonsmokers, resulting in
a very serious lung infection with this organism.
• Scrofula is a term usually reserved for tuberculosis of the
neck, but the disease is really a cervical lymphadenopathy
caused by Mycobacterium tuberculosis.
• The woman obviously has leprosy due to the presence of
acid-fast staining bacilli in the skin scrapings and the loss of
feeling in her fingers and toes. This is caused by the
bacterium infecting and destroying nervous tissue in these
areas. Leprosy is also known as Hansen disease, after the
discoverer of the causative organism of the disease,
Mycobacterium leprae.
• Tuberculoid leprosy (also called paucibacillary Hansen
disease) is the mild form of the disease with few organisms
observed in skin scrapings.
• Lepromatous leprosy is the fulminant form of the disease
with numerous bacilli seen in skin scrapings.
4. Single skin lesion is seen in which type
of Leprosy:
a. LL
b. TT
c. BL
d. BT
5. The most infectious type of leprosy
is:
a. Lepromatous leprosy
b. Tuberculoid leprosy
c. Borderline-tubercoloid leprosy
d. None of the above
6. Lepromatous leprosy is observed in
patients with:
a. Deficient cell mediated immunity
b. Adequate cell mediated immunity
c. Adequate humoral immunity
d. None of the above
7. Which type of hypersensitivity reaction
is involved in lepromin test?
a. Type I
b. Type II
c. Type III
d. Type IV
8. The following test is not used
for diagnosis of leprosy :
a. Lepromin test
b. Slit skin smear
c. Fine needle aspiration cytology
d. Skin biopsy
9. The characteristic finding in a case
of leprosy is:
a. Culture test is positive in 2-3 months in
LJ media
b. Long contact with tuberculoid leprosy
can transmit the disease
c. CMI is seen in Lepromatous leprosy
d. Macule lesion heals spontaneous
10. Exacerbation of lesions in patients of
borderline leprosy is seen in :
a. ENL (erythema nodosum leprosum)
b. Lepra reaction type 1
c. Jarisch-Herxheimer reaction
d. Both a & b.
11.The following drug is not used for the
treatment of type II lepra reaction :
a. Chloroquin
b. Thalidomide
c. Cyclosporine
d. Corticosteroids
12. Lepra cells found in lepromatous leprosy are
:
b. Neutophils
c. Lymphocytes
d. Macrophages
e. Plasma cells
13. Globi is :
a. Histocyte containing acid-fast bacillus
b. Lymphocyte containing acid-fast bacillus
c. Nutrophill containing acid-fast bacillus
d. Large lymphocyte containing acid-fast bacillus
ANSWERS
1. b
2. c
3. b
4. b
5. a
6. a
7. d
8. a
9. b
10. a
11. c
12. d
13. a
Key facts about LEPROSY -
 Leprosy is a chronic infectious
disease caused by an acid-fast,
rod-shaped bacillus,
Mycobacterium leprae.
 Not cultivable: M. leprae is not
cultivable either in artificial
culture media or in tissue
culture; (does not follow the
Koch's postulates).
 can be maintained in animal-
nine banded armadillo (Dasypus
noverncinctus) and foot pad of
mice (kept at a low temperature,
200C).
.
M. leprae
 Intracellular: Lepra bacilli are obligately intracellular and
strict aerobe.
 Less acid fast: Compared to tubercle bacilli, they are less
acid fast and can resist up to 5% sulfuric acid.
 Appearance: In smears made from skin lesions, they appear
in groups, called cigar-like bundles of bacilli(globi) present
inside lipid laden macrophages called virchow's lepra cells.
 multiplies very slowly
 incubation period – about 3 to 5 years.
 Lepromarous cases have longer incubation period than
tuberculoid cases.
not highly infectious.
transmitted via droplets, from the nose
and mouth, during close and frequent
contacts with untreated cases.
Untreated, leprosy can cause progressive
and permanent damage to the skin,
nerves, limbs and eyes.
Transmission
• not highly infectious
• The exact mechanism of transmission of
leprosy is not known
• transmitted via droplets, from the nose and
mouth, during close and frequent contacts
with untreated cases.
• occur at all ages (ranging from early infancy
to very old age).
Risk Factors -
• Close contact — Contacts of patients with leprosy have a higher risk
of developing leprosy than the general population
• People who live in the areas where leprosy is endemic
parts of India, China, Japan, Nepal, Egypt, and other areas
 especially those people in constant physical contact with
infected people.
• Immunity – immunocompromised individuals are more
susceptible to infection.
• Genetic influences - There is some evidence that genetic defects
in the immune system may cause certain people to be more likely
to become infected (region q25 on chromosome 6).
• Armadillo exposure — Leprosy is enzootic in the nine-banded
armadillo
Classification
• Two types of classification :
▫ Skin smear result classification. ( WHO )
▫ Clinical classification. (Ridley Jopling)
Classification -
▫ Skin smear result (WHO) classification :
1. Paucibacillary leprosy (PB) – few Bacilli;
• Two to five skin lesions with
• Negative skin smear results at all sites.
2. Multibacillary leprosy (MB);
• Any form of leprosy in which the patient shows positive
smears at any site
Classification -
Clinical (Ridley Jopling) classification :
1. Indeterminate leprosy (IL)
2. Tuberculoid leprosy (TT)
3. Lepromatous leprosy (LL)
4. Borderline leprosy (BL)
 Borderline tuberculoid leprosy (BT)
 Borderline borderline leprosy (BB)
 Borderline lepromatous leprosy (BL)
Difference b/n Tuberculoid leprosy & Lepromatous leprosy
Clinical features -
1. Skin lesions, usually anaesthetic
 Hypopigmented or erythematus patch / plaque .
2. Complete / partial loss of sensation.
 Painless wounds or burns on the hands or feet
 Paresthesias: tingling or numbness in the hands or feet
 Diminished sensation or loss of sensation within skin patch(es)
3. Thickening of peripheral nerves.
4. Lumps / swelling on the earlobes or face.
5. Tender, enlarged peripheral nerves.
Symptoms-
• Paucibacillary (PB) :
– Well defined skin lesions that are numb
• Multibacillary (MB) :
 Chronically stuffy nose and
 many skin lesions and
 nodules on both sides of the body
Sings -
• Large bumps on the skin that
 do not feel pain
 do not heal for weeks or months
• Muscle weakness
• Disappearance of eyebrows or eyelashes
Indeterminate leprosy :Hypopigmented patch
sensation normal, no palpable peripheral nerve and slit skin smear
negative
Tuberculoid Leprosy: Annular, erythematous, anasthetic patch with well
defined and raised borders and SSS Negative.
Tuberculoid leprosy: Two hypopigmented patches, hypoasthetic well
defined borders, palpable peripheral nerve and SSS negative.
Borderline lepromatous leprosy
(BL/MB)
Borderline lepromatous case showing borderline tuberculoid and
"punched- out" mid borderline lesions together with papular and
nodular lesions more typical of lepromatous disease.
A -Claw hand due to median
and ulnar nerve damage.
B- hands showing neurotrophic
atrophy.
Pathogenesis
• M. leprae is an obligate intracellular acid-fast bacillus with
unique ability to enter nerves
• The areas most commonly affected are- superficial
peripheral nerves , skin, mucous membranes of the upper
respiratory tract, eyes , and tests
• 95% of people who are exposed do not develop disease
• Tissue damage is depend upon -
 the degree to which cell-mediated immunity is expressed
 the extent of bacillary spread and multiplication
 immunologic complication and
 nerve damage
Diagnosis
• Diagnosis of leprosy- most commonly based
on the clinical sign and symptoms.
• In an endemic country or area, an individual
should be regarded as having leprosy if shows
one of the following cardinal signs :
 skin lesion consistent with leprosy and with
definite sensory loss, with or without
thickened nerves
 positive skin smears
Smear Microscopy
• Smear microscopy is done to demonstrate the
bacilli in the lesions.
• Specimen Collection-
Total 6 samples are collected;
4 from skin (forehead, cheek, chin and bunock)
1 from ear lobe and nasal mucosa by nasal
blow/scraping.
• With paucibacillary leprosy, no bacteria will be
detected.
Silt skin smear
• Silt skin smear prepared- from the skin and ear lobe
specimens.
• The edge of the lesion is the preferred site.
• Lesion is cleaned with spirit, then is pinched up light to
minimize bleeding.
• A 5 mm long incision is made with a scalpel, deep
enough to get into the infiltrated layers.
• After wiping off blood or lymph that may have exuded,
the scalpel blade is rotated transversely to scrape the
sides and base of the incision so as to obtain a tissue
pulp from below the epidermis- which is smeared
uniformly over an area of 8 mm diameter on a slide.
Silt skin smear
Nasal specimens
• Nasal blow: Early morning mucus material is
collected by blowing the nose on a clean
cellophane sheet
• Nasal scraping: By using a mucosal scraper to
scrape the nasal septum sufficiently so as to
remove a piece of mucous membrane ,
transferred onto a slide to make a uniform
smear.
• Biopsy from the thickened nerves and nodular
lesions may be necessary in some cases.
DIAGNOSIS OF LEPROSY
• Hypopigmented or reddish skin
lesion(s) with definite loss of sensation
• Damage to the peripheral nerves, as
demonstated by loss of sensation
• Weakness of the muscles of hands, feet
or face
• Positive skin smear
Treatment
• Common drugs
1. Dapson
2. Refampicine
3. Clofazimine
The combination of these three drugs
Is known as multi drug therapy (MDT)
• 6 month regimen for Paucibacillary (PB) Leprosy
 Dapson 100 mg (daily)
 Refampicin 600 mg (monthly)
• 12 month regimen for Multibacillary (MB) Leprosy
 Dapsone 100 mg (daily)
 Refampicin 600 mg (monthly)
 Clofazimine 300 mg (monthly) or
Clofazimine 50 mg (daily)
Complication -
• disfigurement
• hair loss (particularly on the eyebrows and eyelashes)
• muscle weakness
• permanent nerve damage in the arms and legs
• inability to use the hands and feet
• Nosebleeds
• iritis (inflammation of the iris of the eye), glaucoma
(an eye disease that causes damage to the optic
nerve), and blindness
• Infertility
• kidney failure
THANK
YOU

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Leprosy

  • 1. MCQ and discussion LEPROSY - Dr. ANKUR KUMAR AIIMS PATNA
  • 2. 1. Who discovered Mycobacterium leprae? a. Robert Koch b. Hansen c. Kitasato d. Louid Pasteur
  • 3. Discovered by Gerhard Armauer Hansen in 1873.
  • 4. 2. What is the generation time of Mycobacterium laprae a. 20 minutes b. 20 hours c. 12-13 days d. 20 weeks
  • 5. 3. A 40-year-old woman who has lived in southwest Louisiana all her life presents to the emergency room. She has strange- looking, raised areas on her face, arms, and legs. She also complains that she is losing feeling in her fingers and toes. She says that when she cuts or burns herself, she does not feel it and that makes the injury even greater because she does not know to pull away from the injuring source. A Gram stain of scrapings from the raised areas on her skin shows thin bacterial rods that do not take up the stain. However, an acid fast stain of the same material shows numerous bacilli. What disease is the woman most likely to have? a. Borderline tuberculoid leprosy b. Lepromatous leprosy c. Scrofula d. Tuberculoid leprosy
  • 6. • Lady Windermere syndrome is caused by M. avium- complex, usually in elderly female nonsmokers, resulting in a very serious lung infection with this organism. • Scrofula is a term usually reserved for tuberculosis of the neck, but the disease is really a cervical lymphadenopathy caused by Mycobacterium tuberculosis. • The woman obviously has leprosy due to the presence of acid-fast staining bacilli in the skin scrapings and the loss of feeling in her fingers and toes. This is caused by the bacterium infecting and destroying nervous tissue in these areas. Leprosy is also known as Hansen disease, after the discoverer of the causative organism of the disease, Mycobacterium leprae. • Tuberculoid leprosy (also called paucibacillary Hansen disease) is the mild form of the disease with few organisms observed in skin scrapings. • Lepromatous leprosy is the fulminant form of the disease with numerous bacilli seen in skin scrapings.
  • 7. 4. Single skin lesion is seen in which type of Leprosy: a. LL b. TT c. BL d. BT
  • 8. 5. The most infectious type of leprosy is: a. Lepromatous leprosy b. Tuberculoid leprosy c. Borderline-tubercoloid leprosy d. None of the above
  • 9. 6. Lepromatous leprosy is observed in patients with: a. Deficient cell mediated immunity b. Adequate cell mediated immunity c. Adequate humoral immunity d. None of the above
  • 10. 7. Which type of hypersensitivity reaction is involved in lepromin test? a. Type I b. Type II c. Type III d. Type IV
  • 11. 8. The following test is not used for diagnosis of leprosy : a. Lepromin test b. Slit skin smear c. Fine needle aspiration cytology d. Skin biopsy
  • 12. 9. The characteristic finding in a case of leprosy is: a. Culture test is positive in 2-3 months in LJ media b. Long contact with tuberculoid leprosy can transmit the disease c. CMI is seen in Lepromatous leprosy d. Macule lesion heals spontaneous
  • 13. 10. Exacerbation of lesions in patients of borderline leprosy is seen in : a. ENL (erythema nodosum leprosum) b. Lepra reaction type 1 c. Jarisch-Herxheimer reaction d. Both a & b.
  • 14. 11.The following drug is not used for the treatment of type II lepra reaction : a. Chloroquin b. Thalidomide c. Cyclosporine d. Corticosteroids
  • 15.
  • 16. 12. Lepra cells found in lepromatous leprosy are : b. Neutophils c. Lymphocytes d. Macrophages e. Plasma cells
  • 17. 13. Globi is : a. Histocyte containing acid-fast bacillus b. Lymphocyte containing acid-fast bacillus c. Nutrophill containing acid-fast bacillus d. Large lymphocyte containing acid-fast bacillus
  • 18. ANSWERS 1. b 2. c 3. b 4. b 5. a 6. a 7. d 8. a 9. b 10. a 11. c 12. d 13. a
  • 19. Key facts about LEPROSY -  Leprosy is a chronic infectious disease caused by an acid-fast, rod-shaped bacillus, Mycobacterium leprae.  Not cultivable: M. leprae is not cultivable either in artificial culture media or in tissue culture; (does not follow the Koch's postulates).  can be maintained in animal- nine banded armadillo (Dasypus noverncinctus) and foot pad of mice (kept at a low temperature, 200C). .
  • 20.
  • 21. M. leprae  Intracellular: Lepra bacilli are obligately intracellular and strict aerobe.  Less acid fast: Compared to tubercle bacilli, they are less acid fast and can resist up to 5% sulfuric acid.  Appearance: In smears made from skin lesions, they appear in groups, called cigar-like bundles of bacilli(globi) present inside lipid laden macrophages called virchow's lepra cells.  multiplies very slowly  incubation period – about 3 to 5 years.  Lepromarous cases have longer incubation period than tuberculoid cases.
  • 22. not highly infectious. transmitted via droplets, from the nose and mouth, during close and frequent contacts with untreated cases. Untreated, leprosy can cause progressive and permanent damage to the skin, nerves, limbs and eyes.
  • 23. Transmission • not highly infectious • The exact mechanism of transmission of leprosy is not known • transmitted via droplets, from the nose and mouth, during close and frequent contacts with untreated cases. • occur at all ages (ranging from early infancy to very old age).
  • 24. Risk Factors - • Close contact — Contacts of patients with leprosy have a higher risk of developing leprosy than the general population • People who live in the areas where leprosy is endemic parts of India, China, Japan, Nepal, Egypt, and other areas  especially those people in constant physical contact with infected people. • Immunity – immunocompromised individuals are more susceptible to infection. • Genetic influences - There is some evidence that genetic defects in the immune system may cause certain people to be more likely to become infected (region q25 on chromosome 6). • Armadillo exposure — Leprosy is enzootic in the nine-banded armadillo
  • 25. Classification • Two types of classification : ▫ Skin smear result classification. ( WHO ) ▫ Clinical classification. (Ridley Jopling)
  • 26. Classification - ▫ Skin smear result (WHO) classification : 1. Paucibacillary leprosy (PB) – few Bacilli; • Two to five skin lesions with • Negative skin smear results at all sites. 2. Multibacillary leprosy (MB); • Any form of leprosy in which the patient shows positive smears at any site
  • 27.
  • 28. Classification - Clinical (Ridley Jopling) classification : 1. Indeterminate leprosy (IL) 2. Tuberculoid leprosy (TT) 3. Lepromatous leprosy (LL) 4. Borderline leprosy (BL)  Borderline tuberculoid leprosy (BT)  Borderline borderline leprosy (BB)  Borderline lepromatous leprosy (BL)
  • 29.
  • 30. Difference b/n Tuberculoid leprosy & Lepromatous leprosy
  • 31.
  • 32. Clinical features - 1. Skin lesions, usually anaesthetic  Hypopigmented or erythematus patch / plaque . 2. Complete / partial loss of sensation.  Painless wounds or burns on the hands or feet  Paresthesias: tingling or numbness in the hands or feet  Diminished sensation or loss of sensation within skin patch(es) 3. Thickening of peripheral nerves. 4. Lumps / swelling on the earlobes or face. 5. Tender, enlarged peripheral nerves.
  • 33. Symptoms- • Paucibacillary (PB) : – Well defined skin lesions that are numb • Multibacillary (MB) :  Chronically stuffy nose and  many skin lesions and  nodules on both sides of the body
  • 34. Sings - • Large bumps on the skin that  do not feel pain  do not heal for weeks or months • Muscle weakness • Disappearance of eyebrows or eyelashes
  • 35.
  • 36. Indeterminate leprosy :Hypopigmented patch sensation normal, no palpable peripheral nerve and slit skin smear negative
  • 37. Tuberculoid Leprosy: Annular, erythematous, anasthetic patch with well defined and raised borders and SSS Negative.
  • 38. Tuberculoid leprosy: Two hypopigmented patches, hypoasthetic well defined borders, palpable peripheral nerve and SSS negative.
  • 39. Borderline lepromatous leprosy (BL/MB) Borderline lepromatous case showing borderline tuberculoid and "punched- out" mid borderline lesions together with papular and nodular lesions more typical of lepromatous disease.
  • 40. A -Claw hand due to median and ulnar nerve damage. B- hands showing neurotrophic atrophy.
  • 41. Pathogenesis • M. leprae is an obligate intracellular acid-fast bacillus with unique ability to enter nerves • The areas most commonly affected are- superficial peripheral nerves , skin, mucous membranes of the upper respiratory tract, eyes , and tests • 95% of people who are exposed do not develop disease • Tissue damage is depend upon -  the degree to which cell-mediated immunity is expressed  the extent of bacillary spread and multiplication  immunologic complication and  nerve damage
  • 42. Diagnosis • Diagnosis of leprosy- most commonly based on the clinical sign and symptoms. • In an endemic country or area, an individual should be regarded as having leprosy if shows one of the following cardinal signs :  skin lesion consistent with leprosy and with definite sensory loss, with or without thickened nerves  positive skin smears
  • 43. Smear Microscopy • Smear microscopy is done to demonstrate the bacilli in the lesions. • Specimen Collection- Total 6 samples are collected; 4 from skin (forehead, cheek, chin and bunock) 1 from ear lobe and nasal mucosa by nasal blow/scraping. • With paucibacillary leprosy, no bacteria will be detected.
  • 44. Silt skin smear • Silt skin smear prepared- from the skin and ear lobe specimens. • The edge of the lesion is the preferred site. • Lesion is cleaned with spirit, then is pinched up light to minimize bleeding. • A 5 mm long incision is made with a scalpel, deep enough to get into the infiltrated layers. • After wiping off blood or lymph that may have exuded, the scalpel blade is rotated transversely to scrape the sides and base of the incision so as to obtain a tissue pulp from below the epidermis- which is smeared uniformly over an area of 8 mm diameter on a slide.
  • 46. Nasal specimens • Nasal blow: Early morning mucus material is collected by blowing the nose on a clean cellophane sheet • Nasal scraping: By using a mucosal scraper to scrape the nasal septum sufficiently so as to remove a piece of mucous membrane , transferred onto a slide to make a uniform smear.
  • 47. • Biopsy from the thickened nerves and nodular lesions may be necessary in some cases.
  • 48. DIAGNOSIS OF LEPROSY • Hypopigmented or reddish skin lesion(s) with definite loss of sensation • Damage to the peripheral nerves, as demonstated by loss of sensation • Weakness of the muscles of hands, feet or face • Positive skin smear
  • 49. Treatment • Common drugs 1. Dapson 2. Refampicine 3. Clofazimine The combination of these three drugs Is known as multi drug therapy (MDT)
  • 50. • 6 month regimen for Paucibacillary (PB) Leprosy  Dapson 100 mg (daily)  Refampicin 600 mg (monthly)
  • 51. • 12 month regimen for Multibacillary (MB) Leprosy  Dapsone 100 mg (daily)  Refampicin 600 mg (monthly)  Clofazimine 300 mg (monthly) or Clofazimine 50 mg (daily)
  • 52. Complication - • disfigurement • hair loss (particularly on the eyebrows and eyelashes) • muscle weakness • permanent nerve damage in the arms and legs • inability to use the hands and feet • Nosebleeds • iritis (inflammation of the iris of the eye), glaucoma (an eye disease that causes damage to the optic nerve), and blindness • Infertility • kidney failure