Current scenario of Leprosy in Nepal and identification and laboratory diagnosis of causative agent

1. Educational Excursion
The Leprosy Mission
Nepal
Prepared By:-
Sandeep Paudel

2. Contents
• Objective of Excursion
• Introduction
• History and background of leprosy
• History of TLM-N
• Leprosy in Nepal
• Classification of Leprosy
• Cardinal Signs
• Lab Diagnosis
• Treatment

3. Objective of Excursion
• To find out current scenario of Leprosy in
Nepal and identification and laboratory
diagnosis of causative agent

4. Introduction
• Leprosy is a chronic infectious disease caused by
an acid-fast, rod-shaped bacillus, Mycobacterium
leprae.
• M. leprae multiplies very slowly and the
incubation period of the disease is about five
years.
• Symptoms can take as long as 20 years to appear.
• Leprosy is not highly infectious.
• Leprosy is transmitted via droplets, from the nose
and mouth, during close and frequent contacts
with untreated cases.

5. Cont…
• Untreated, leprosy can cause progressive and
permanent damage to the skin, nerves, limbs
and eyes.
• The disease mainly affects the skin, the
peripheral nerves, mucosa of the upper
respiratory tract and also the eyes.
• Leprosy is curable and treatment provided in
the early stages averts disability.

6. History and background of leprosy
• Leprosy was recognized in the ancient civilizations of China,
Egypt and India.
• The earliest documented account of leprosy is around 1550
B.C on Egyptian papyrus.
• Throughout history, the badly affected have often been
hated by their communities and families (stigmatization).
• Although leprosy was treated differently in the past, the
first advance in treatment occurred in the 1940s with
development of the drug Dapsone, which arrested the
disease.
• But duration of the treatment was many years, even a
lifetime, making it difficult for patients to follow.

7. History of TLM-N
• The Leprosy Mission began work in Nepal in 1957, opening
Anandaban Hospital on a quiet hill side near Lele in Lalitpur
District, some 18km south from the centre of Kathmandu.
• At that time leprosy was a very visible health problem in
Nepal, the only recognised treatment being limited in its
effect.
• The developing work included out-patient as well as in-
patient services.
• Over the years major developments have included the
addition of a Training Centre, the development of
Mycobacterial Research Laboratory and the start of
Community-Based Rehabilitation programmes.

8. Leprosy in Nepal
• The number of people being diagnosed with leprosy in Nepal is
greatly reduced from earlier years, nevertheless, it continues to be
a health issues, in particular in the Terai area neighbouring India.
• In 2015 the Government Leprosy Control Division has reported the
number of new case diagnoses in the last year as 3253.
• The General Health Services run by the Government now extend
throughout Nepal and are primarily responsible for diagnosis and
treatment with the standard multiple drug therapy.
• Leprosy is most common in the poorest sectors of local
communities. As in many countries, persistent traditional attitudes
towards leprosy in Nepal mean that people developing the initials
signs of leprosy fear the consequences, personal and social as well
as physical.
• Caste and gender-based prejudices further exacerbate the
situation.

9. Cont….
• Delay in diagnosis and treatment, for any reason, places the
person affected at risk of developing irreversible nerve
impairments affecting sensation and movement.
• TLM Nepal is involved in training Government General
Health Service Medical Officers and other staff in the
diagnosis and treatment of leprosy and also provides
technical support.
• Through Anandaban Hospital it provides specialist services
in reconstructive surgery and treatment for people
experiencing complications due to leprosy.
• These are accessed locally and by referral from
Government centres across Nepal.

10. Classification of Leprosy
• Two types of classifications:
• Skin smear result classification
• Clinical classification

11. SKIN SMEAR RESULTS 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

12. CLINICAL 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)

13. CARDINAL SIGNS
• Numbness : hands & feet
• Painful and/or tender nerves
• Burning sensation in the
skin
• Painless swelling or lumps
in the face and earlobes
• Loss of eyebrows and or
eyelashes.

14. (a) Nodules on the face
(b) skin patch on the face
(c) an enlarged nerve in
the neck

15. DIAGNOSIS
• Diagnosis of leprosy is most commonly based
on the clinical signs and symptoms. These are
easy to observe by any health worker after a
short period of training.
• Only in rare instances there is a need to use
laboratory and other investigations to confirm
a diagnosis of leprosy.

16. LAB DIAGNOSIS
1. Specimens
2. Acid fast staining
3. Skin and nerve biopsy
4. Animal inoculation
5. Lepromin test

17. 1. SPECIMENS
Nasal mucosa, skin lesions, ear
lobules.
 Skin and nerve biopsy.

18. Edges of the lesion.
Slit and scrape
method:
• Pinch the site tight
• Incise
• Scrape & collect
material
• Smear on a slide
SKIN:

19. SKIN BIOPSY:
Active edges of the patches
NERVE BIOPSY :
From thickened nerves

20. 2. ACID FAST STAINING
 Ziehl-Neelson method
 Decolourising agent = 5% sulphuric acid
 Lepra cells confirm the diagnosis
of lepromatous
leprosy.

22. i. Bacteriological index (B.I)
:
Number of total bacilli in a tissue.
B.I is calculated by totalling the
grades and divided by no. of smears.
Minimum of 4 skin lesions,a nasal
swab & both the ear lobes are to be
examined.

26.  Percentage of uniformly stained
bacilli out of the total number of bacilli
counted.
For assessing the progress of
patients on chemotherapy.
ii. MORPHOLOGICAL
INDEX(M.I) :

27. • For histological
confirmation of
tuberculoid bacilli ( as
they cannot be
demonstrated in direct
smear)
• Skin biopsy is also useful
in diagnosis and accurate
classification of leprosy
lesion.
3. SKIN AND NERVE BIOPSY

28. Obligate intracellular parasite.
 Lacks many necessary genes for
independent survival.
WHY CAN’T WE CULTIVATE
Mycobacterium leprae
IN AN ARTIFICIAL CULTURE
MEDIUM???

29. 4. ANIMAL INOCULATION
 Nine banded armadillo
 Injection of ground tissue from
lepromatous nodules or nasal
scrapings from leprosy patient
into the foot pad of mice.
 Typical granuloma at the site of
inoculation within 6 months.

30. 5. LEPROMIN TEST
• Delayed type of hypersensitive reaction.
• First described by Mitsuda in 1919.
• Lepromins used as antigens may be of
human origin (lepromin H) or armadillo
derived (lepromin A).

31. Procedure :
 Carried out by the intradermal
injection of 0.1 ml of lepromin.

32. 1)Early reaction of
Fernandez
2)Late reaction of
Mitsuda
Biphasic response:

33. Early reaction
of Fernandez
Erythema &
induration
Develops in 24-48 hrs &
usually remains for 3-5 days
Late reaction
of Mitsuda
Appears 1-2 weeks after
the injection, reaching a
peak in 4 weeks.
Appears in the form of nodule
that may ulcerate. Takes few
weeks to heal.

34. USES OF LEPROMIN TEST:
a) Classification of leprosy:
- Positive in tuberculoid leprosy
- Negative in lepromatous leprosy
b) Assessment of prognosis:
- Positive lepromin test indicates a good
prognosis.
- Negative lepromin test indicates a bad
prognosis.

35. c) Assessment of resistance:
- To assess the resistance of an individual to
leprosy.
- Resistance is indicated by positive
lepromin test.

37. TREATMENT
• Multidrug therapy (MDT) treatment has been made
available by WHO free of charge to all patients
worldwide since 1995, and provides a simple yet highly
effective cure for all types of leprosy.
• The drugs used in WHO-MDT are a combination of:
• Multi Bacillary (MB) leprosy :-Rifampicin + Clofazimine
+ Dapsone
• Paucibacillary (PB) leprosy :- Rifampicin + Dapsone
• Among these Rifampicin is the most important anti
leprosy drug and therefore is included in the treatment
of both types of leprosy.
• 1 dose of Rifampicin can kills 99.97% bacteria