Leprosy

Dr Meenakshi Khapre
AIIMS DRRISHIKESH
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 Learning Objectives
At the end of the lecture the student must be able to:

• Describe the epidemiological determinants of leprosy

• Describe the Clinical Features & classification of leprosy

• Discuss the Prevention and Treatment strategies and the NLEP

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• As men and armies roamed the globe in search
of conquest, M.Leprae traveled with them

• Kustha roga & attributed to punishment or curse

from God

• Also called Hansen’s disease

• A communicable disease

• Leading cause of permanent disability

• Mainly affect the skin , peripheral nerves, eyes,
mucosa of the upper respiratory tract
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 Characteristics features
• Hypo pigmented patches

• Partial or total loss of cutaneous sensation in

affected areas

• Presence of thickened nerves

• Presence of acid fast bacilli in skin or nasal

smears

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 Why Leprosy important ?
• Affects Nerve and produce disability/disfigurement
• Much Stigma associate with leprosy
• Effective treatment(MDT) available
• Early diagnosis & Treatment Prevent disability
• “Care after Cure” very crucial
• Diagnosis doesn’t require any sophisticate
investigation
• No effective vaccine available
• Patient doesn't play sick role
• Treatment available free of cost
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 LEPROSY GLOBAL SCENARIO
Year 1981 1985 1995 2005 2014 2015

Registered
Cases 120,00,000 52,00,000 12,98,480 2,86 ,063 2,15,656 2,13,899
(lakhs)

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Top 13 High leprosy Burden Countries
Rank Country No. New Leprosy Case 2014-15
1 India 125 785(58.8%)
2 Brazil 31 064(14.5)
3 Indonesia 17 025(7.9%)
4 Ethiopia 3 758
5 Bangladesh 3 622
6 Congo 3 272
7 Nepal 3046
8 Nigeria 2 983
9 Myanmar 2 877
10 Sri Lanka 2 157
11 Tanzania 1 947
12 Philippines 1 655
13 Madagascar 1 617
Total (13 countries) (%) 200 808 (94%)
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Gross Total ( all countries) 213 899
Year 1981 1985 1995 2005 2013 2014 2016
Registere
39,53,700 32,00,000 8,07,257 1,48, 910
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10
d Cases
 Determinants of Leprosy

Host

Agent Environment

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 Causative Organism/ Agent

 Mycobacterium Leprae

 Acid or Alcohol Fast Organism

 Slow growing – 12-14 days to divide

 Non Cultivable – Production of

vaccine difficult

 Life span :
About 6 months,
Longer in case of Persisters
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 Causative Organism/ Agent

 Source: Human being.

 Reservoir: None

 Transmission: Air-Borne / Droplets

 Portal of Entry: Respiratory route

 Portal of Exit: Respiratory tract / nose

 Long Incubation Period: 5 – 7 years

 Attack rates: 4.4% -12% in household contacts of LL

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 Host Factors.
 95% population naturally immune to
leprosy in India

 Age : 10 -20 years (Any Age)

 Gender : Male > Female

 BCG Vaccination Status

 Occurrence of leprosy by clusters

Family clusters influencing factors are
Sharing of same environment
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 Environmental Factors

 Socio-Economic Factor:

Overcrowding,
Lack of hygiene,
Lack of ventilation

 Migration: Affecting
elimination

 Fear of Stigma &

discrimination

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• High infectivity, low pathogenicity
• Airborne: droplet infection, skin to skin contact
• Attack rates: 4.4% -12% in household contacts of LL
• Host Factors: Age, sex, migration, immunity, genetic
factors- HLA-DR2 and HLA-DR3 (BL), HLA-DQ1 (LL)
• Susceptibility children especially 12 years old and below
• Environmental Factors
• Social Pathology: stigma, psychosocial factors.
• IP: 3-5 yrs in LL, shorter in TL.

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 Classification
Indian Classification
• Intermediate type
• Tuberculoid type
• Borderline type
• Lepromatous type
• Pure neuritic type
Madrid Classification
• Intermediate type
• Tuberculoid type
• Borderline type
• Lepromatous type

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• Ridley-Jopling Classification: based on clinical
manifestation
– Tuberculoid (TT)
– Borderline Tuberculoid (BT)
– Midborderline (BB)
– Borderline Lepromatous (BL)
– Lepromatous (LL)

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 WHO Classification:
based on number of lesions and presence of
bacilli on a skin smear
• Paucibacillary: 5 or few lesions with absence of
organisms on smear
– Usually includes tuberculoid and borderline
tuberculoid forms

• Multi-bacillary: Marked by 6 or more lesion with

possible visualization of bacilli on smear
– Includes the Lepromatous, borderline lepromatous
and midborderline forms
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Tuberculoid/Paucibacillary
• Occurs in individuals who have a vigorous cellular
immune response to the organism
• Host cell mediated immune responses are intact
• Disease usually involves the skin and peripheral
nerve
• Skin often has one or a few well-demarcated,
hypopigmented, or erythematous, hypoesthetic or
anesthetic lesions, often with raised, active
spreading edges and central clearing
• Characterized by the presence of non-necrotizing
granulomas in the dermis and peripheral nerves
with AFB absent or few in number.

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• Nerve involvement is usually asymmetric
• Low numbers of bacteria in skin lesions
(<5 skin lesions, with absence of
organisms on smear)
• Lepromin test is positive and there is a
predominance of helper CD4+ over CD8+ T
lymphocytes at sites of infection.

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Signs of Tuberculoid Leprosy
– Skin Lesions
• Sharply demarcated, hypopigmented
macules
– Enlarged peripheral nerves
– Neuropathy
• Ulnar nerve
• Superficial Radial Cutaneous
• Median nerve
• Common Peroneal nerve
• Greater Auricular

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– Hypoesthesia
• Temperature is the first sensation
that is lost. Patients cannot sense
extremes of hot or cold.
• The next sensation lost is light
touch, then pain, and finally deep
pressure.
• These losses are especially
apparent in the hands and feet;
therefore, the chief complaint may
be a burn or ulcer in an anesthetic
extremity.

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 Lepromatous/Multibacillary

• Cell-mediated immunity is diminished

• Disease usually has extensive skin
involvement
• Skin lesions : infiltrated nodules and plagues
and occur in cooler regions of body, with
sparing of axilla, groin and scalp
• Nerve involvement- usually symmetric
• High numbers of bacteria in skin lesions (>6
skin lesions)
• Results of skin tests with antigen from killed
organisms (lepromin) is nonreactive
• Predominance of suppressor CD8+ over CD4+
T lymphocytes.

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 Physical Findings in Lepromatous Disease
• Skin lesions
– Poorly defined borders
– Raised, indurated lesions
– Affects Face, Ears, Wrists, Elbows,
Buttocks and Knees
• Hoarseness
• Loss of eyebrows (madarosis)
• Nasal collapse
• Lagophthalmos (inability to close the
eye), a late finding in LL, results from
involvement of the zygomatic and
temporal branches of the facial nerve
(cranial nerve [CN] VII).
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• Involvement of the ophthalmic branch of the
trigeminal nerve (CN V2) can result in
reduced corneal reflex, leaving dry eyes and
reduced blinking.
• Keratitis, Glaucoma, Iridocyclitis,
• Leonine facies – skin of the face becomes
thickened and corrugated

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 Boderline (Dimorphous)
• Single or multiple well-
defined skin lesions similar
to tuberculoid lesions but
with a raised center and
delayed development of
dysesthesia

• Often subdivided into

borderline lepromatous and
borderline tuberculoid

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 Indeterminate Leprosy
• Early form of leprosy that may
develop into any other form

• Typified by hypopigmented
macule with indistinct edges
and no associated dysesthesia

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 Early sign and symptoms
• Change in the color of the skin
• Loss of sensation on the skin lesion
• Decrease/loss of sweating and hair growth
over the lesion
• Muscle weakness
• Pain and redness of the eyes
• Nasal obstruction or bleeding
• Ulcers that do not heal

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 Late sign and symptoms

• Madarosis
• Lagophthalmos
• Clawing of fingers and toe
• Sinking of nosebridges
• Gynecomastia
• Chronic ulcers

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• Diagnosis is currently base on clinical signs and
symptoms especially in the history of contact
with person with leprosy
• Slit Skin Smear, Biopsy
• Bacterial Index: 7 sites, PBL <2, MBL >2
• Morphological Index
• Foot pad culture,
• Histamine test: Used to diagnose postganglionic nerve injury.
– Histamine diphosphate is dropped on normal skin and affected skin, and a
pinprick is made through each site. The site forms a wheal on normal skin
but none where nerve damage is present.
• Immunological tests
• Tests for CMI, and humoral immunity
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 Ridley’s Logarithmic Scale for BI
• 6+ Many clumps of bacilli (> 1000) in each
field (on an average)
• 5+ 100–1000 bacilli in each field (on an
average)
• 4+ 10–100 bacilli in each field (on an average)
• 3+ 1–10 bacilli in each field (on an average)
• 2+ 1–10 bacilli in 10 fields
• 1+ 1–10 bacilli in 100 fields
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 Treatment
Daily, Self- Monthly Months of
Type of Leprosy
Administered Supervised Treatment

Paucibacillary Dapsone 100 mg Rifampicin 600 mg 6 months

Dapsone 100 mg Rifampicin 600 mg

Multibacillary 12 months
Clofazimine 50 mg Clofazimine 300 mg

Dapsone 2 mg/kg Rifampicin 10 mg/kg

Pediatric Same as in adults
Clofazimine
Clofazimine 6 mg/kg
1mg/kg

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 Complications of Medical Therapy
Type 1 reaction
– Reversal reaction, or lepra type 1 reaction:
– A delayed-type hypersensitivity reaction that arises when a
borderline case shifts toward borderline lepromatous with
treatment.
– Reflect the development of an appropriate immune response
and the local generation of tumor necrosis factor-alpha and
interferon-gamma.
– The reaction is characterized by edema and erythema of
existing skin lesions, the formation of new skin lesions, neuritis,
and additional sensory and motor loss.
Treatment includes NSAIDs and high-dose steroids.
• Prednisone is given at a dose of 40-60 mg/day with a decreasing taper
of 5 mg every 2-4 weeks.
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Type 2 reaction
– Erythema nodosum leprosum (ENL), lepra type 2
reaction:
– A complication of the lepromatous form of the
disease.
– Characterized by the development of inflamed
subcutaneous nodules accompanied by fever,
lymphadenopathy, and arthralgias.
– Treatment- prednisolone, clofazimine, or thalidomide
– Mild ENL reactions are treated with aspirin 600-1200
mg/day in 4-6 doses per day

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– Severe ENL reactions are treated with
prednisone 60-80 mg/day with a slow taper,
reducing by 5-10 mg every 2-4 weeks,
depending on response and severity, to
prevent residual deformity and nerve
damage.

– Alternatively, thalidomide 100 mg PO 4 times

per day (if available and if no
contraindications) can be used in cases that
involve large subcutaneous plaques, arthritis,
and temperature of more than 38.8°C.

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• Lucio phenomenon:

– A severe complication of multibacillary

leprosy that is marked by blue hemorrhagic
plaques and necrotic ulcerations.
– The bacilli may extend to the endothelial
cells along with the appearance of necrotic
epidermis and vasculitis with thrombus
formation and endothelial proliferation.

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 Leprosy Control
• Medical Measures
– Estimation of problem
– Early case detection (case finding methods-contact,
group & mass survey)
– MDT
– Surveillance
– Immunoprophylaxis, Chemoprophylaxis
– Deformities
– Rehabilitation
– Health education
• Social Support, Programme mgt. and evaluation
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 Prevention & Control of Leprosy

Non Cultivable

No Vaccine available

No Primary Prevention

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Pathways of Disease Transmission
HOST Exposure PATHOGEN

D V E
i e n
r c v
Incubation e t i
Period c o r
t r

PATHOGEN
Infection

Disease

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Death Recovery
 Repellents
Points for 7 Bednets
control Exposure

measures V
D E
i e n
Vaccination r c v
1 6
e t i
c o r
t r

Infection 4
Isolation
treatment
Prophylaxis 2

5
Disease
Treatment 3
Death Recovery
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Disability
 NLEP
• NLCP-1955, NLEP-1983
• SAPEL, LEC
• LEM
• Rehabilitation
• Tenth five year plan goals for leprosy
elimination- to bring PR of leprosy to less than
1 case per 10,000 population

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 Challenges till remains
1. there are pockets of high endemicity in the
country where there is ongoing transmission.
2. many hidden cases in the community as
revealed by the sample survey conducted by
Indian Council for Medical Research (ICMR).
3. new case detection rate has remained almost
the same since 2005,
4. disability rates in new cases has been rising
due to a delay in diagnosis
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 Three pronged Strategies
1. leprosy case detection campaign (LCDC)” in highly
endemic districts;
2. focused leprosy awareness campaign using ASHA
and multipurpose health workers in “Hot Spots,”
where new cases with Grade 2 Disability (G2D) are
detected;
3. area-specific plans for case detection in hard to
reach areas.
The SPARSH Leprosy Awareness Campaign (SLAC) was
launched on 30th January 2017 and is a program
intended to promote awareness and address the issues
of stigma and discrimination .
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• Chemoprophylaxis :
• Vaccine : Mycobacterium Indicus Prani (MiP)
vaccine in a project mode in India from the
year 2016
• Nikusth, a web-based reporting system for
leprosy

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NLEP Logo

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