Leprosy Module 1

Module 1:

LEPROSY: The Disease

Module 1:

LEPROSY: The Disease

WHAT IS LEPROSY?

Leprosy is a chronic infectious disease caused by Mycobacterium leprae,

WHAT IS LEPROSY?

Leprosy is a chronic infectious disease caused by Mycobacterium leprae,

an acid-fast, rod-shaped bacillus that mainly affects the skin, peripheral nerves, mucosa of the upper respiratory tract and eyes.

an acid-fast, rod-shaped bacillus that mainly affects the skin, peripheral nerves, mucosa of the upper respiratory tract and eyes.

It has a very long incubation period or latency which ranges from 3 to 15 years.

It has a very long incubation period or latency which ranges from 3 to 15 years.

• Leprosy is an infectious disease directly transmitted from man to man.

• Leprosy is an infectious disease directly transmitted from man to man.

• It is acquired through prolonged exposure.

• It is acquired through prolonged exposure.

• Only a small proportion of the population is affected (5-10%).

• Only a small proportion of the population is affected (5-10%).

• It is transmitted from one untreated person to another via the respiratory tract.

• It is transmitted from one untreated person to another via the respiratory tract.

DIAGNOSIS OF LEPROSY:

Diagnosis of leprosy is mainly based on clinical signs and symptoms.

DIAGNOSIS OF LEPROSY:

Diagnosis of leprosy is mainly based on clinical signs and symptoms.

Only in rare instances is there a need to use laboratory and other investigations to confirm a diagnosis of leprosy.

Only in rare instances is there a need to use laboratory and other investigations to confirm a diagnosis of leprosy.

An individual should be regarded as having leprosy if he exhibits the following cardinal signs:

An individual should be regarded as having leprosy if he exhibits the following cardinal signs:

Hypo-pigmented or reddish skin lesion(s) with definite sensory loss;

Hypo-pigmented or reddish skin lesion(s) with definite sensory loss;

Peripheral nerve damage, as demonstrated by loss of sensation and muscle weakness in the hands, feet and/ or face;

Peripheral nerve damage, as demonstrated by loss of sensation and muscle weakness in the hands, feet and/ or face;

Positive skin smear.Positive skin smear.

Other signs of leprosy are: Other signs of leprosy are:

Skin lesion(s) with a decrease or loss of sweating and/or hair growth;





Constant redness in the eyes from irritation and dryness;







Loss of eyebrows and eyelashes (madarosis);









Nasal congestion / obstruction and frequent nosebleed;

Nasal congestion / obstruction and frequent nosebleed;


Collapse of nose bridge;Collapse of nose bridge;



Enlargement of the breast in males (gynecomastia);






Mobile or stiff clawing of fingers and toes;








Chronic ulcers, usually in the sole of the foot, palm of the hands and fingers.

Chronic ulcers, usually in the sole of the foot, palm of the hands and fingers.

Diagnosis of leprosy is mainly based on

clinical signs and symptoms.

Diagnosis of leprosy is mainly based on

clinical signs and symptoms. i

The development of complications can be effectively prevented through early detection, correct diagnosis and effective treatment.

The development of complications can be effectively prevented through early detection, correct diagnosis and effective treatment.

i

PATIENT’S HISTORY:

The leprosy case history should have the following information:

PATIENT’S HISTORY:

The leprosy case history should have the following information:

1. The nature of the first lesion or symptom and its progress.

1. The nature of the first lesion or symptom and its progress.

This is because the skin lesion usually develops slowly over several months and is not troublesome.

This is because the skin lesion usually develops slowly over several months and is not troublesome.

• When did the patient first notice the lesion?

• When did the patient first notice the lesion?

Ask:Ask:

?• What was its appearance?• How did it feel? Was it painful?

Itchy?

• What was its appearance?• How did it feel? Was it painful?

Itchy?

PATIENT’S HISTORY:PATIENT’S HISTORY:

2. Past Treatment.2. Past Treatment.

• What did the patient do when he first noticed the lesion?

• What did the patient do when he first noticed the lesion?

Ask:Ask: ?• Did he apply any drug(s)?• What was the effect of this/these

drug(s)?

• Did he apply any drug(s)?• What was the effect of this/these

drug(s)?


3. Other Illnesses.3. Other Illnesses.

Pay attention to contra-indications to MDT drugs; or any other illness requiring special attention and/or referral.

Pay attention to contra-indications to MDT drugs; or any other illness requiring special attention and/or referral.

• Does the patient have a history of liver disease?

• Does the patient have a history of liver disease?

Ask:Ask: ?• Allergy to drugs?• If yes, what drugs?• Allergy to drugs?• If yes, what drugs?


4. Contact with Persons With Leprosy (PWLs)

4. Contact with Persons With Leprosy (PWLs)

This information will help determine the patient’s susceptibility to the disease.

This information will help determine the patient’s susceptibility to the disease.

• Does/did anyone in the family have leprosy?

• Does/did anyone in the family have leprosy?

Ask:Ask: ?• Does he have a friend or

acquaintance who has/had leprosy?

• Does he have a friend or acquaintance who has/had leprosy?

TESTING THE FEELING IN THE SKIN PATCHES

HOW TO TEST FOR SENSATION OF SKIN LESION?

• Patient be positioned comfortably depending on the spot where you want to examine.

• Show the object to be used for testing.• Initially test the normal skin & subsequently on the

suspected patch. Do it several times with the patient eyes open until he understands what you are trying to do.

• Repeat the test with patient blindfolded to find out if the lesions are insensitive.

• A “YES” response must be elicited during the testing procedure to confirm if patient feels the stimulus.

REFERRAL

1. CONFIRMATION OF DIAGNOSIS OF SUSPECTED LEPROSY CASE

2. RELAPSE

3. SEVERE REACTIONS AND OTHER COMPLICATIONS OF LEPROSY

4. SUSPECTED HYPERSENSITIVITY TO ANY OF THE MDT DRUGS

CLASSIFICATION:CLASSIFICATION:

Leprosy can be classified on the basis of clinical manifestations and skin smear results.

Leprosy can be classified on the basis of clinical manifestations and skin smear results.

The Ridley-Jopling classification has seven (7) types of leprosy:

The Ridley-Jopling classification has seven (7) types of leprosy:

CLASSIFICATION: (Ridley-Jopling)CLASSIFICATION: (Ridley-Jopling)

1. Indeterminate (I).1. Indeterminate (I).

Solitary, ill-defined, faintly hypopigmented macule, with partial loss of sensation.


1. Indeterminate (I)1. Indeterminate (I)

Solitary, ill-defined hypopigmented macule on left cheek; only partially anesthetic.


Solitary, ill-defined, faintly hypopigmented macule on the dorsum of the wrist; minimal surface changes; partially insensitive.



Single, slightly hypochromic macule with ill-define borders on the dorsum of the lower right forearm; minimal surface changes; partially anesthetic.



2. Tuberculoid (TT)2. Tuberculoid (TT)

Small, solitary marginally hypopigmented oval lesion, with papulated well-defined margins with flat, slightly atrophic central area insensitive to pain.


Faintly hypochromic, rounded macule with discontinuously papulate borders, fairly defined, anesthetic, above smallpox vaccination scar on the left arm.



Solitary, well-defined early tuberculoid lesion with slightly papulate borders; completely anesthetic.



Sharp-edged, hypopigmented, ringworm-like lesion with finely papulate borders; anesthetic.



Superficial, circinate lesion with pinkish, elevated, finely granular margins; center is insensitive to touch and pain.



Well-defined, hypopigmented lesion with dry surface and moderately raised granular margins; completely anesthetic.



3. Borderline Tuberculoid (BT)


Rounded lesion with wide, slightly brownish and scaly elevated margins fairly well-defined, center flat, with noticeable hair loss; at posterior aspect of the leg; anesthetic.


One of several sharp-edged, erythematous patches on the patient, with fairly thick granular margins and small satellite lesions; anesthetic.




Well-defined, dry and rough surfaced plaque on cheek, insensitive to touch and pain; note papulo-nodular lesions near eye and upper lip




Distinct, erythemato- hypochromic patch with a dry surface and raised, well defined margins showing satellite lesions; anesthetic.




Large patch with wide, raised erythematous well-defined margins sloping toward center of lesion; central portion is anesthetic.




Multiple, sharply- demarcated, scaly reddish-brown plaques; these subsiding lesions are only partially anesthetic.




Large, thickly infiltrated, sharp-edged plaque with slightly scaling surface; anesthetic.




Extensive, subsiding lesions showing large, clear center areas surrounded by well-defined, slightly raised, inner and outer margins; centers are anesthetic.




4. Borderline (BB)4. Borderline (BB)

Fairly extensive succulent plaque with sharply demarcated clear central area; peripheral edges sloping into surrounding normal skin; central uninvolved area anesthetic.


Several “punched-out” lesions very characteristic of borderline leprosy; central areas are anesthetic.



Irregular, erythematous, infiltrated bands around a large, anesthetic central “immune” area; inner margins of lesion tend to be better defined than the outer margins.



Classical “punched-out” lesions of borderline leprosy; central “immune” areas are anesthetic.



5. Borderline Lepromatous (BL)


Numerous and widespread borderline-type plaques, annular lesions, papules and macules; center of large lesions show some loss of sensation.


Thick, erythematous plaques on face and ears. Lesions are not sharply defined and show no sensory impairment.






Bilaterally distributed, irregularly shaped, erythematous, infiltrated patches; these are not anesthetic.




Fairly uniform symmetrically distributed, infiltrated, maculo-papular lesions, none of which show sensory impairment.


6. Sub-polar Lepromatous (LLs)


Symmetrically distributed infiltration with prominent macular lesions. Note borderline-type, punched-out patches on the wrist.




Symmetrical infiltration and erythematous macules, with an unusual borderline-type plaque on the left buttock.




Extensive, symmetrically distributed infiltration with almost coalescent macules and plaques. These lesions are not anesthetic. Note small rounded borderline-type plaque on the left lumbar area.


7. Polar Lepromatous (LLp)


Early lepromatous leprosy with recognizable diffuse infiltration all over face and ears.


Fairly advanced lepromatous leprosy, with symmetrically distributed diffuse infiltration, nodules on face and ears, and madarosis.




Advanced lepromatous leprosy, with marked diffuce infiltration, madarosis and loss of eyelashes.




Advanced lepromatous leprosy with diffuse infiltration coupled with nodules over eyebrows, cheeks, ala nasae and chin, as well as earlobes.




Advanced lepromatous leprosy with diffuse infiltration and nodular lesions.



The World Health Organization (WHO) classifies leprosy into only three (3) types:

The World Health Organization (WHO) classifies leprosy into only three (3) types:

• Single Lesion Paucibacillary (SLPB)• Paucibacillary (PB)• Multibacillary (MB)

• Single Lesion Paucibacillary (SLPB)• Paucibacillary (PB)• Multibacillary (MB)


Characteristic SLPB PB MB

Lesions:• Surface Normal, dry

or scalyNormal, dry or scaly, absence of hair growth

Smooth & shiny, some lesions may be dry



Lesions:• Type Macule Infiltrated

patchesMacules, plaques, papules & infiltration



Lesions:• Number One (1) Two (2) to

five (5)More than five (>5)



Lesions:• Border ill-defined to

well-definedWell-defined, clear-cut margins

Vague, sloping outwards, merges imperceptibly with surrounding skin



Lesions:• Sensitivity Impaired

Cutaneous nerves involved

Impaired or absent

Cutaneous nerves involved

Normal or slightly diminished

Main peripheral nerve trunks involved



Nerve Involvement:

None Zero (0) to one (1)

More than one (1)



Slit Skin Smear:

Negative Negative Positive

Any patient showing a positive skin smear, irrespective of the clinical classification, should be treated with the Multibacillary (MB) regimen.

Any patient showing a positive skin smear, irrespective of the clinical classification, should be treated with the Multibacillary (MB) regimen.

i

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Leprosy Module 1

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