management of nerve damage in leprosy

1. Management of Nerve Damage In Leprosy
Presenter : Dr Mamta

2. Introduction
• Chronic infectious disease that is caused by the intracellular
pathogen Mycobacterium leprae
• Most feared complication : Nerve damage

3. Nerve damage in leprosy
• ~10% of paucibacillary
• ~40% of multibacillary
• Subclinical neuritis – in all patients

4. • Records of 396 patients reviewed
• 36% (141/396) : either sensory or motor function impairment at
presentation
• Most common nerve affected : Posterior tibial nerve > Ulnar
• Sensory NFI > Motor NFI
Lepr Rev. 1994 Sep;65(3):20421.
Nerve damage in leprosy: an epidemiological and clinical
study of 396 patients in west Nepal
Van Brakel WH , Khawas IB.

5. • Patients with no nerve damage at presentation : 1621/ 3064
• Sensory and motor loss increased with age
• Higher among multibacillary patients
Int J Lepr Other Mycobact Dis. 1998 Dec;66(4):4516.
Incidence of nerve damage in leprosy patients
treated with MDT
Solomon S , Kurian N, Ramadas P, Rao PS.

6. Diagnosis

7. Clinical Evaluation
Nerve palpation
SUPRATROCHLEAR
SUPRAORBITAL
GREAT AURICULAR NERVE
INFRAORBITAL

8. Clinical Evaluation
ULNAR
RADIAL
RADIAL CUTANEOUS
COMMON PERONEAL
ANTERIOR TIBIAL
MEDIAN
SURAL
POSTERIOR TIBIAL

9. Clinical Evaluation
Look for :
1. Thickness
2. Consistency
3. Tenderness
4. Regularity

10. Grading of clinical findings :
Nerve Thickness Tenderness Neuritc pain
Grade Degree Description
0 None Nerve not thickened and feels normal
1 Mild Thickened compared to contralateral nerve
2 Moderate Thickening is rope like
3 Severe Nerve thickened and also nodular or
beaded
Indian Journal of Dermatology 2013; 58(1)

11. Grading of clinical findings :
Nerve Thickness Tenderness Neuritc pain
Grade Degree Description
0 None palpation not painful even when asked about it
1 Mild palpation painful only when asked about it
2 Moderate Indicates palpation is painful by wincing during
palpation or says so
3 Severe On palpation, tries to withdraw the limb or is
clearly distressed by any pressure on the nerve

12. Clinical Evaluation
Grading of clinical findings :
Nerve Thickness Tenderness Neuritc pain

13. • Inter-tester reliability study of the clinical assessment of skin
lesions and thickness of ulnar and popliteal nerves in
leprosy patients by different staff
• Reliability of clinical diagnostic skills based on both sensory
testing of skin lesions with the cotton wool method and
palpation of superficial peripheral nerves was unsatisfactory
Lepr Rev. 2006 Dec;77(4):371-6.
Inter-observer reliability in assessment of sensation of
skin lesion and enlargement of peripheral nerves in
leprosy patients.
Chen S, Wang Q, Chu T, Zheng M.

14. Clinical Evaluation
• Cotton
• Ball pen test
• Semmes Weinstein Filaments
• Pin prick test
• Folded paper
Sensory Testing : Touch and Pain

15. Semmes Weinstein Monofilaments
Colour Of Filament Force Clinical Correlation
Green 0.05 Normal
Blue 0.2 Diminished light touch
Purple 2 Diminished protective sensation
Red 4 Loss of protective sensation in hands
Orange 10 Loss of protective sensation in feet
Light Red 300 Deep pressure sensation

16. • Reliability of the SWM test was very good, closely followed by the
two point discrimination test
• Main source of variability between testers was testing skill and
experience
• Among the experienced physiotechnicians there was no
significant difference between intra and intertester reliability
• Reliability of pin prick test was poor than that of the SWM and two
point discrimination test

17. • Substantial levels of underdiagnosis of sensory loss
with ball point pen

18. Temperature Sensation
Thermal stimulator
Hot and Cold test tube
method

19. • Does not allow a quantification of the results, making it
difficult to be compared with subsequent tests
• Several factors interfere in its variability and repeatability
• It is recommended that such thermal tests be performed with
stimulators under strict temperature control

20. • Electrophysiology and Quantitative sensory testing detected far
more sensory and motor neuropathy than the standard tests
(Monofilament testing and Voluntary muscle testing)
• Sensory nerve conduction (particularly amplitude) and warm
perception testing proved by far the most sensitive in picking up sub-
clinical neuropathy
• Sensory Nerve Conduction was abnormal at least 12 weeks before
sensory impairment became clinically evident
Sensory and motor impairment detected by MFT and VMT are only
the tip of an ‘iceberg of neuropathy’ in leprosy

21. Voluntary Muscle Testing
Done using the modified Medical Research Council (MRC) scale
Grade 0 Complete paralysis
Grade 1 Perceptible contraction of muscles not resulting in joint
movements
Grade 2 Partial range of movement with no resistance
Grade 3 Full range of movement with no resistance
Grade 4 Full range of movement but with less than normal resistance
Grade 5 Full range of movement at the joint with normal resistance

22. Voluntary Muscle Testing
Done using the modified Medical Research Council (MRC) scale
Nerve Muscle tested
Ulnar Abductor digiti minimi
Median Abductor pollicis brevis
Common peroneal Tibialis anterior, peroneus longus and brevis
Posterior tibial Small intrinsic muscles of feet

23. Nerve palpation
• Sensitivity : 71% to 88% [ except median (43%) and sural (59%) nerves]
• Specificity : > 60% [low for ulnar (34%) and common peroneal (40%)
nerves]
Monofilament testing
• Sensitivity : 35-44%
• Specificity : >80%
Voluntary Muscle Testing
• Sensitivity : 4-5%
• Specificity : >90%
• Both MF testing and VMT assessment showed good specificity, but
moderate to low sensitivity
• NP was less specific but more sensitive than MF testing and VMT
assessment

24. Aim : Measurement of serum cytokines and antibodies to mycobacteria and
nerve components as potential markers for their possible association with
reactions and NFI
Results
• Phenolic glycolipid-1 IgM antibody levels were elevated in patients with
skin reactions and nerve function impairment
• Old sensory NFI is associated with significant elevation of PGL IgG, LAM
IgG and S100 antibody levels
• No correlation of ceramide or TNF-aipha levels with acute or chronic
nerve damage

25. Uitrasound : Normal Nerve

26. High Resolution Sonography for detection of nerve
damage in leprosy
Sonographic features of nerves in
leprosy
• Increase in cross sectional
area
• Fusiform enlargement
• Loss of fascicles
• Edema and increased
vascularity

27. Sonographic Classification of Nerves :
Group 1- Normal
Group II-Enlarged with
fascicular abnormalities
Group III- No fascicular
structure

28. Magnetic Resonance Imaging
• Diffusion Weighted MR Neurography
• Not widely used
Expensive
Inavailability

29. Imaging Biomarkers of Hansens Disease
• Thickening of nerve trunk
• Nerve edema
• Altered signal and fascicular structure
• Contrast enhancement
• Perineural fat stranding/fluid
• Denervation edema of skeletal muscles
• Intra/juxta neural abscesses

30. Magnetic Resonance Imaging

31. A
B
C
D
Axial MRI T1 (A) and T2 (B) images showing thickened common peroneal
nerve (arrow) with per neuritis appearing markedly hyperintense on T2
weighted images (B,C,D). The involved nerve (short arrow) is seen nicely
on T2 coronal (C) and sagittal (D) images

32. Nerve Conduction Study
Interpretation of electrophysiological
functions of a nerve is based on :
1. Velocity
2. Latency
3. Amplitude
Affected in demyelinating
disorders
Affected in axonal disorders

33. • Reduced nerve conduction velocities and changes in latencies and
amplitude
• Changes in sensory nerve conduction was more pronounced
• Sensory latencies and amplitude changes were more severe

34. 822 NCS
230 NCS before MDT 228 during MDT 364 after MDT
Normal study 30 (13.04%) 27 (11.84%) 35 (9.6%)
Severe
dysfunction
9 (3.6%) 2 (0.88%) 7 (1.8%)
Mononeuritis multiplex predominated in both sensory and motor NCS at all
periods

35. Principles of Management
1. Continue MDT
2. Anti-inflammatory therapy
3. Physical therapy and rest during active phase
4. Physiotherapy during recovery phase
5. Surgery when indicated

36. Anti-inflammatory Therapy
Non steroidal anti inflammatory drugs
Steroids
Clofazimine
Thalidomide
Azathioprine
Cyclosporin

37. Role of Steroids
• Anti –inflammatory
• Anti fibrotic
• Immunosuppressive

38. Steroid prophylaxis for prevention of nerve function impairment in
leprosy: randomised placebo controlled trial (TRIPOD 1)
• Prednisolone 20 mg/day for three months, with tapering dose in month 4, plus
multidrug treatment, compared with multidrug treatment alone
• Significant effect in the prevention of reaction and nerve function impairment at
four months, but this was not maintained at one year
The prognostic importance of detecting mild sensory impairment in
leprosy : A randomized controlled trial (TRIPOD 2)
• Prednisolone 40mg/day in tapering doses over 4 months, plus multidrug
treatment, compared with multidrug treatment alone
• No improvement in long term outcome in terms of recovery of touch sensibility
nor did it reduce the risk of leprosy reactions or nerve function impairment
beyond the initial 4-month treatment phase
• There is a strong tendency of mild sensory impairment to recover spontaneously

39. Treatment with corticosteroids of long-standing nerve function
impairment in leprosy: a randomized controlled trial (TRIPOD 3)
• Subjects were randomised to either prednisolone treatment
starting at 40 mg/day, tapered by 5 mg every 2 weeks, and
completed after 16 weeks, or placebo
• No demonstrable additional improvement in nerve function,
or in preventing further leprosy reaction events was seen in
the prednisolone group

40. Lepr rev. 2006 mar;77(1):25-33.
Multicentre, double blind, randomized trial of three steroid regimens in
the treatment of type-1 reactions in leprosy.
Rao PS, sugamaran DS, richard J, smith WC
• Objective: To compare three different steroid regimens in
treating type 1 reactions in leprosy in routine clinical practice
• 3 regimes : High dose long term, low dose long term and high dose
short term
• Result : 20-week regimens were significantly better than the 12-
week regimen
• High dose 20-week regimen was marginally and non-significantly
better than the low dose regimen

41. Weeks Dose of prednisolone
1-2 40mg
3-4 30mg
5-6 20mg
7-8 15mg
9-10 10mg
11-12 5mg
WHO regimen

42. Weeks Dose
1-2 40mg
3-4 30mg
5-6 20mg
7-8 15mg
9-10 10mg
11-12 5mg
ILEP REGIMEN
Weeks Dose
1-4 40mg
5-8 30mg
9-12 20mg
13-16 15mg
17-20 10mg
21-24 5mg
PB leprosy MB leprosy

43. Weeks Dose of
prednisolone
1-2 40mg
3-4 30mg
5-8 20mg
9-12 15mg
13-16 10mg
17-20 5mg
NLEP regimen

44. Week Dose Week PB Dose Week MB Dose Week Dose
1-2 40mg 1-2 40mg 1-4 40mg 1-2 40mg
3-4 30mg 3-4 30mg 5-8 30mg 3-4 30mg
5-6 20mg 5-6 20mg 9-12 20mg 5-8 20mg
7-8 15mg 7-8 15mg 13-16 15mg 9-12 15mg
9-10 10mg 9-10 10mg 17-20 10mg 13-16 10mg
11-12 5mg 11-12 5mg 21-24 5mg 17-20 5mg
WHO ILEP NLEP

45. Week Dose Week PB Dose Week MB Dose Week Dose
1-2 40mg 1-2 40mg 1-4 40mg 1-2 40mg
3-4 30mg 3-4 30mg 5-8 30mg 3-4 30mg
5-6 20mg 5-6 20mg 9-12 20mg 5-8 20mg
7-8 15mg 7-8 15mg 13-16 15mg 9-12 15mg
9-10 10mg 9-10 10mg 17-20 10mg 13-16 10mg
11-12 5mg 11-12 5mg 21-24 5mg 17-20 5mg
WHO ILEP NLEP

46. Week Dose Week PB Dose Week MB Dose Week Dose
1-2 40mg 1-2 40mg 1-4 40mg 1-2 40mg
3-4 30mg 3-4 30mg 5-8 30mg 3-4 30mg
5-6 20mg 5-6 20mg 9-12 20mg 5-8 20mg
7-8 15mg 7-8 15mg 13-16 15mg 9-12 15mg
9-10 10mg 9-10 10mg 17-20 10mg 13-16 10mg
11-12 5mg 11-12 5mg 21-24 5mg 17-20 5mg
WHO ILEP NLEP

47. Anti-inflammatory Therapy
Non steroidal
anti
inflammatory
drugs
Steroids
Clofazimine
Thalidomide
Azathioprine
Cyclosporin
Mechanism Dose Adverse Effects
G
C
Inhibition of mitochondrial respiratory chain, & thus
aerobic respiration in M.leprae
↑free radical production

48. Anti-inflammatory Therapy
Non steroidal anti
inflammatory
drugs
Steroids
Clofazimine
Thalidomide
Azathioprine
Cyclosporin
Mechanism Dose Adverse Effects
Mechanism in neuropathy : Anti-inflammatory action
Immunosuppressive effects:
• Alters functions of phagocytes (monocytes,
neutrophils)
• Increases size & number of lysosomes
better destroy organisms
• Inhibits mobility
• Inhibits lymphocyte transformation
• Inhibits Th1 subtype of T-helper cells

49. Anti-inflammatory Therapy
Non steroidal anti
inflammatory
drugs
Steroids
Clofazimine
Thalidomide
Azathioprine
Cyclosporin
Mechanism Dose Adverse Effects
300mg/day X
12 Weeks
200mg/day X
12 Weeks
100mg/day X
12-24 Weeks
Duration of Rx should not exceed 1 year

50. Anti-inflammatory Therapy
Non steroidal anti
inflammatory
drugs
Steroids
Clofazimine
Thalidomide
Azathioprine
Cyclosporin
Mechanism Dose Adverse Effects
• Orange brown discoloration of skin
• Anticholinergic action
• Transient rash
• Photo-toxicity (rare)
• Serious effects/ Dose related effects- enteropathy

51. Combination of clofazimine and corticosteroids is in every instance
the ideal regime for controlling neuritic complications and a striking
reversal of these manifestations can be expected
Conclusion

52. Anti-inflammatory Therapy
Non steroidal anti
inflammatory
drugs
Steroids
Clofazimine
Thalidomide
Azathioprine
Cyclosporin
Mechanism Dose Adverse Effects
• Reduces chemotactic factors
• Inhibits IgM synthesis
• Significant reduction in CD4 T Lymphocytes
• Reduces plasma soluble IL-2 receptor
• Decrease IL -12 Production
• Significant reduction in TNF-α ,IFN-γ production

53. Anti-inflammatory Therapy
Non steroidal anti
inflammatory
drugs
Steroids
Clofazimine
Thalidomide
Azathioprine
Cyclosporin
Mechanism Dose Adverse Effects
400 mg per day
Reduce to 300 mg per day within a
week
Reduce by 100 mg every month
Stabilise on the lowest dose -
continue for 2-3 months

54. Anti-inflammatory Therapy
Non steroidal anti
inflammatory
drugs
Steroids
Clofazimine
Thalidomide
Azathioprine
Cyclosporin
Mechanism Dose Adverse Effects
• Teratogenicity
• Peripheral neuropathy
• Venous thromboembolism
• Sedation
• Hypothyroidism
• Hypoglycemia
• Constipation
• Pedal edema

55. • 40 patients
• 2 Arms : AP (12 weeks azathioprine at 3 mg/kg/d plus 8 week
reducing course prednisolone starting at 40 mg/d) or P (12week
reducing course prednisolone starting at 40 mg/d)
• No difference in clinical outcome in the AP and P groups
Transactions of the Royal Society of Tropical Medicine and Hygiene Volume 98, Issue 10, October 2004, Pages 602–609

56. • Open prospective trial including 9 nepali and 33 ethipion patients
• Treated with ciclosporin ( 5-7.5mg/day) for 12 weeks and followed up for
24 weeks
• Nepalis : 75-100% improved in all acute clinical parameters
67-100% patients maintained improvement, except for those
with acute sensory nerve impairment among whom 67%
relapsed after stopping treatment
• Ethiopians : skin lesions improved in all and 50-60% had peripheral nerve
function improvement
Trans R Soc Trop Med Hyg. 2007 Oct;101(10):100412

57. Nerve pain and skin lesions showed significant improvement

58. Monthly perineural injection of 4 mg/ml dexamethasone phosphate for
6 consecutive months
Marked improvement in the motor distal latency (DL) and motor
conduction velocity (MCV) of the right median nerve

59. • Double blind, randomized, control clinical trial
• 1 ml PRP vs platelet poor plasma (PPP) as control
• Evaluation : Two point discrimination test (TPDT) and visual
analog scale (VAS)
• Perineural injection of PRP was shown to be significantly
more effective than PPP (P <0.05)

60. Role of Biologics ???

61. • 52 year female
• Case of borderline lepromatous leprosy with recurrent episodes of
erythematous tender nodules and thickened tender nerves
• Unresponsive to standard therapy (prednisolone, thalidomide,
clofazimine, pentoxifylline)
• 3 doses of infliximab 5mg/kg (0,2 and 6 weeks)
• Not developed any new episode post infliximab

62. • 2 patients in the United States who received infliximab for
arthritis and subsequently developed borderline lepromatous
• Recovery was accompanied by the development of type 1
reactions in both patients

63. • Collection of reports done through web search
• 7 cases of development of leprosy with biologics
• 2 cases of ENL treated successfully with infliximab

64. Surgical Intervention
• No improvement or deterioration while on steroid
• Corticosteroid are either contraindicated or not tolerated
due to adverse effect
• Nerve abscess
• Intractable pain despite vigorous immunosuppressive
therapy
• Sudden paralysis
Indications

65. Surgical options :
1. Neurolysis
2. Nerve abscess drainage
3. Nerve transposition

66. • Early resolution of pain was seen after surgery
• Muscle strength increased in half of the patients
• Significant decrease of prednisone doses after surgery

67. Surgical decompression of nerve
trunks
• Indication:
• Failure of medical and auxillary treatment
• Procedure:
• Release external compressing factor
• Divide epineurium
• Relieve the fascicles from being stangulated by the
sclerosed epineurium

68. Nerve abscesses
• Cold abscess: surgical intervention- draining the abscess,
mopping, necrotic content , removing adherent slough,
excising the abscess
• Hot abscess: surgery rare.

69. Reconstructive surgeries
• Aims to restore function and form as far as possible and to
prevent further disability.
• Will not restore sensory loss
• Pre and post-operative physiotherapy is essential.
• Order of priority : eyes> feet>hands

70. Prevention
• Early diagnosis and regular treatment
• Prevention of leprosy reactions

71. 98% of patients developing type 1 reaction and neuritis were seropositive
for IgM anti-PGL-1 Abs
Strong link between facial patches and cutaneous T1R and enlarged ulnar
nerves and neural T1R
Antiphenolic glycolipid seropositivity, a positive bacterial index, and
disease in more than two body areas were identified as risk factors for
both skin and neural T1R

72. Aim : To determine whether addition of low dose steroid for the initial 8
months of multi drug therapy can prevent further deterioration of nerve
function in multibacillary leprosy patients
Result : The proportion of patients showing deterioration of nerve function
was significantly higher in MDT group, while proportion of patients showing
improvement was more in group receiving steroids with MDT
Role of prophylactic steroids ???
• TRIPOD 1 trial investigated the role of low dose steroids in prevention of
type 1 reaction in MB patients
• Incidence of type 1 reactions was lower in the group receiving steroids
during the treatment period but no long term benefit was found

73. • 1st Group : MB-MDT + High dose clofazimine
• 2nd Group : MB-MDT
• Followed up for 2 years
The difference in incidence rates of neuritis between the two groups was
significant (p < 0.01), suggesting that clofazimine may have a useful
prophylactic role against neuritis/Type I reaction and nerve damage

74. Special situations
HIV
Pregnancy

75. Summary
• Prevention is better than cure
• Thorough clinical evaluation is must
• Time to look into newer diagnostic modalities
• Steroids – cornerstone of therapy
• Consider surgical options whenever necessary

76. Thank You