Leprosy is a chronic infectious disease caused by Mycobacterium leprae bacteria. It primarily affects the skin and nerves. There are three main types - tuberculoid, lepromatous, and borderline. Symptoms include pale skin lesions and numbness or damage to nerves. Diagnosis involves clinical examination, slit skin smears, and biopsies. Treatment involves multidrug therapy over 6-12 months depending on type. Complications include reactions and disability from nerve damage. Prevention focuses on early detection and treatment to limit transmission and disability. Rehabilitation aims to reduce disability impacts and promote independence.

1. AN APPROACH TOWARDS A PATIENT OF
LEPROSY
Submitted
by
Dr.Faiqa Qadeer
1

2. 1) LEPROSY:
INTRODUCTION:
 Leprosy is also known as Hansen's disease, after the scientist who discovered M. leprae In 1873.
• Leprosy is an infectious disease that causes severe, disfiguring skin sores and nerve damage in the arms and
legs.
• Also known as Hansen’s disease
• Chronic infectious disease
• Characterized by lesions of the peripheral nerve, skin and mucous membrane of the URT(nasal mucosa)
• Develops slowly from 6 months up to 40 yrs.

3. Cause OF Leprosy
A slow-growing type of bacteria called Mycobacterium leprae.
Symptoms of Leprosy:
 primarily affects the skin and the nerves outside the brain and spinal cord.
 also affect the eyes and the thin tissue lining inside of the nose
The main symptom of leprosy :
 Disfiguring skin sores, lumps, or bumps that do not go away after several weeks. The skin
sores are pale-colored.
Nerve damage can lead to:
 Loss of feeling in the arms and legs and Muscle weakness.
MODE OF TRANSMISSION: (ACCORDING TO CDC)
 Although the mode of transmission of Hansen's disease remains uncertain, most investigators
think that M. leprae is usually spread from person to person in respiratory droplets.
Inhalation:

A large number of bacilli are discharged by infectious patient while talking, coughingand
sneezing. These bacilli enter healthy person through respiratory tract.

4. • INCUBATION PERIOD:
(3 - 5) years.
TYPES of Leprosy:
1) Tuberculoid:(paucibacillary leprosy)
 A mild, less severe form of leprosy.
 few patches of flat, pale-colored skin.
 The affected area of skin may feel numb because of nerve damage.
 Tuberculoid leprosy is less contagious than other forms.

5. 2) Lepromatous:
(multibacillary leprosy)
 A more severe form of the disease.
 widespread skin bumps and rashes.
 numbness, and muscle weakness.
 The nose, kidneys, and male reproductive organs may also be affected.
 It is more contagious than tuberculoid leprosy.
3) Borderline. This type of leprosy have symptoms of both the tuberculoid
and lepromatous forms

6. Signs and Symptoms
Early signs and symptoms of leprosy are very subtle
and occur slowly (usually over years).
First symptoms :
 Numbness and loss of temperature
sensation (cannot sense very hot or cold
temperatures)
As the disease progresses :
 The sensations of touch, then pain, and
eventually deep pressure are decreased or lost.
6

7. Clinical features:hypopegmented patch

8. Clinical features: ear nodules

9. Clinical features: nerve enlargement

10. Clinical features: neurological defecit

11. Long-term developing sequence of events
• Relatively painless ulcers, skin lesions of hypopigmented
macules (flat, pale areas of skin), and eye damage (dryness,
reduced blinking)
• Late stage: large ulcerations, loss of digits, and facial
disfigurement. (for example, hands, feet, face, and knees).
11

12. Classification & Clinical Presentation
TT BT BB BL LL
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1. RIDLEY AND JOPLING
CLASSIFICATION

13. Skin lesion with
sensory loss
Skin smears are
not available or
not dependable
Single skin
lesion
SLPB
Leprosy
2-5 skin lesions
PB Leprosy
> 5 Skin lesions
MB Leprosy
Skin smears are
available and
dependable
Smear negative
PB Leprosy
Smear positive
MB Leprosy
13
2. WHO
CLASSIFICATION

14. BT BB BL
Lesion no. Few (<5) Some Many
Lesion borders Well Less Roughly
Sensory impairment Marked Moderate Slight
Distribution of skin
lesions
Asymmetrical Asymmetrical Roughly symmetrical
Peripheral nerves Asymmetrical Asymmetrical Less Asymmetrical
Type of leprosy Multibacillary Multibacillary Multibacillary
Slit skin smear - /1+ 2+/ 3+ 4+
Note: Sometimes patients may have BT/BB or BB/BL or BL/LL 25

15. 26
Leonine
Face

16. Diagnosis of Leprosy
1. Clinical Examination.
2. Slit Skin Smear.
3. Skin Biopsy.

17. Clinical Examination
Cardinal skin signs of leprosy
1. Hypopigmented or erythematous patch / plaque
2. Complete / partial loss of sensation
3. Thickening of peripheral nerves

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2.Slit Skin Smear
• Simple and valuable test
• It is needed for diagnosis and to monitor the progress of the treatment

19. Slit Skin Smear (Reporting the smear)
Ridley’s logarithmic scale
(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).
30

20. TT BT BB BL LL
Skin Lesions
No. of Bacilli
Slit skin
test
Immunity
Clinical spectrum of leprosy
31

21. 21
LEPRA REACTION
• Sudden appearance of signs of inflammation in the skin lesions or nerves or eyes of a leprosy
person
• Redness, swelling and sometimes tenderness of the skin lesions.
• New skin lesions or symptoms suggestive of new nerve damage
• Muscle weakness in the hands or feet
• Crop of subcutaneous nodules

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TYPESOFREACTIONS
TYPE-I (REVERSAL) TYPE-II (ENL)
1. Delayed hypersensitivity 1. Antigen antibody reaction
2. Occurs in both MB and PB type of cases
(Borderline
group) i.e. unstable types like BT,BB,BL
2. Seen in MB cases (BL and LL types)
3. Skin lesions suddenly become reddish,
swollen, warm, painful and tender. New
lesions may appear.
3. Red, painful, tender subcutaneous nodules
(deep), appear in groups, recurrent and subside
within few days, better felt than seen
4. Nerves enlarged, tender and painful- neuritis 4. Nerves may be affected but not common
5. Other organs not affected 5. Other organs like eyes, kidneys and testis
may be involved
6. General symptoms- not common 6. Fever, joint pain, red eyes with watering

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• SIGNS OF REVERSAL REACTION
If any of the following sign is found, the reaction should be treated as severe:
• Loss of nerve function
• Pain or tenderness in one or more nerves
• Silent neuritis
• Marked swelling and redness in skin patches
• Skin lesion that remains ulcerated
• Marked oedema of the hands, feet or face

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• SIGNS OF ENL REACTION
If any of the following signs is found, the reaction should be treated as severe:
• Pain or tenderness in one or more nerves, with or without loss of nerve function
• Ulceration of ENL nodules
• Pain or redness of the eyes, with or without loss of visual acquity
• Painful swelling of testis or of the fingers
• Marked arthritis or lymphadenitis
• ENL reactions are complex medical problems requiring careful management

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TREATMENTOFREACTIONS
• Bed rest
• Rest to the affected nerves by analgesics and splinting
• Prednisolone- 1mg/kg/day, single morning dose after breakfast
- taper dose by 10 mg fortnightly till 20 mg/day
- thereafter taper by 5 mg/day
• Clofazimine - One capsule (100mg) TDS x 4 or more weeks
- One capsule (100mg) BD x next 4-12 weeks, followed by
- One capsule (100mg) OD x next 4-12 weeks or more
• Thalidomide – 200 mg BD or 100 mg QID

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TREATMENT GUIDELINES
MULTI BACILLARY PAUCI BACILLARY
ADULT CHILDREN ADULT CHILDREN
RIFAMCPICIN 600 mg once a
month
450 mg once a
month
600 mg once a
month
450 mg once a
month
CLOFAZIMINE 300 mg once a
month
50mg daily
150 mg once a
month
50 mg alternate
days
DAPSONE 100 mg daily 50 mg daily 100 mg daily 50 mg daily
TOTAL
DURATION
12 months 12 months 6 months 6 months
For children under 10 years of age:
Rifampicin: 10 mg/kg BW
Clofazimine: 1 mg/kg BW daily and 6 mg/kg BW monthly
Dapsone: 2 mg/kg BW daily

27. Treatment – before & after

28. RELAPSE
• Re-occurrence of the disease at any time after the completion of a full
course of treatment
• Generally rare
CRITERIA RELAPSE REACTION
Time since completion of
treatment
Usually more than 3 years Usually less than 3 years
Progression of signs
and symptoms
Slow Fast
Site of skin lesions In new places Over old patches
Pain, tenderness or swelling No Yes - skin and nerves
Damage Occurs slowly Sudden onset
General condition Not affected Fever, joints pain, red eyes
with watering

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ADVERSE REACTIONS TO MDT
Minor problems Drug Management
Red urine Rifampicin Reassurance
Brown discolouration of skin Clofazimine Counselling
Gastrointestinal problems All three Give drugs with food
Anaemia Dapsone Give iron and folic acid
More serious problems Drug Management
Itchy skin, rash, SJ syndrome Dapsone
Stop the drugs and consider
alternative regimen
Allergy, urticarial Dapsone or Rifampicin
Jaundice Rifampicin
Shock, purpura, renal failure Rifampicin

30. Vaccine for Leprosy
 Various countries around the world, namely India and Brazil, currently use the Bacillus
Calmette Guerin (BCG) vaccine for tuberculosis to double as a leprosy vaccine, as the
two diseases are caused by similar mycobacterial agents. However, the effectiveness of
this approach is widely disputable.
 The BCG vaccine is not used in the United States as a leprosy vaccine because of the
unproven effectiveness of the BCG vaccine as well as the low incidence of leprosy
patients in America.

31. 31
DISABILITY PREVENTION AND MEDICAL
REHABILITATION (DPMR) Aspects
Nomenclature:
• Anaesthesia
• Impairment
• Deformity
• Disability
• Handicap
• De-habilitation
• Destitution

32. 32
Important nerves involved in leprosy:
• Facial nerve
• Ulnar nerve
• Median nerve
• Radial nerve
• Lateral popliteal nerve
• Posterior tibial nerve

33. 33
ASSESSMENT AND GRADING OF DISABILITY
• Assessment of sensory function of nerve trunk
• Assessment of the motor function of nerve (VMT)
• Grading is done as follows:
 S (strong) = able to perform the movement against full resistance
 W (weak) = able to perform the movement but not against full resistance
 P (paralysed) = not able to perform the movement at all

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Grading of disability
Examination
of parts
WHO disability
grades
Sensory testing (ST) VMT
HANDS 0 Sensation present S
1 Sensation absent S
2 Sensation absent W or P
FEET 0 Sensation present S
1 Sensation absent S
2 Sensation absent W or P
EYES VISION LID GAP BLINKING
0 Normal No lid gap Present
2 Cannot count fingers
at 6 meters
Present/red eye
/corneal ulcer/opacity
Absent

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• Grade ‘0’ – No disability
• Grade ‘1’ – Anaesthesia over palms and soles
• Grade ‘2’ – Deformity or visible disability
• Limitations: does not measure the worsening or improvement by disability prevention and
medical rehabilitation
• EHF score - sum of all the individual disability grades for two eyes, two hands and two feet (0-12)

36. 36
STIGMA IN LEPROSY
• Social process, experienced or anticipated, characterised by exclusion, rejection, blame, or
devaluation that results from experience, perception, or reasonable anticipation of an adverse social
judgement about a person or group.
• TYPES:
• Felt stigma
• Enacted stigma
• Institutional stigma
• DETERMINANTS OF STIGMA:
• Lack of knowledge
• Attitude
• Fear
• Blame and shame

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REHABILITATION
• All measures aimed at reducing the impact of disability for an individual, enabling him or her to
achieve independence, social integration, a better quality of life and self actualization.
• COMMMUNITY BASED REHABILITATION (CBR):
A strategy within general community development for the rehabilitation, equalization of
opportunities and social inclusion of all people with disabilities.

38. • Leprosy on the decline in Pakistan WHO (December 16, 2013)
Leprosy Elimination:
 After controlling Leprosy in Pakistan in 1996, the programme has moved
on……..
The following services are included in the elimination programme:
 - Chemotherapy – all new patients on regular treatment.
 - Prevention and Treatment of Deformity.
 - Examination of Patient’s contact for early case detection and treatment.
 - Social and Economical Rehabilitation of patients and their families.
 - Health Education, Awareness and Community empowerment.

39. Thanks