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Comparing the Clinical and

Histological Diagnosis of Leprosy

and Leprosy Reactions in the
INFIR Cohort of Indian Patients
with Multibacillary Leprosy

SubtDiana N. J. Lockwood1 *, Peter

Nicholls2 , W. Cairns S. Smith3 , Loretta
Das4 , Pramila Barkataki4 , Wim van Brakel5
, Sujai Suneetha6¤itle

Presented by:
Consultant :

• Leprosy is a disease that affects skin and peripheral nerves because of Mycobacterium

• Diagnosing leprosy and the immunological reactions that complicate this disease is not
always straightforward.

• They can be diagnosed clinically by examination or by microscopic examination of the skin


• The clinical manifestations of leprosy are determined by the immune response of the
patient to Mycobacterium leprae.

Tuberculoid (TT)
Paucibacillary leprosy (PB)
and are treated with six
five skin lesions and/or months of PB multi-drug
Borderline one nerve involved
Tuberculoid (BT) therapy (MDT)

Borderline Borderline (BB)

multi-bacillary (MB) leprosy

Borderline Lepromatous (BL) and receive 12 months of
five skin lesions and/or MB MDT.
more than one nerve
Lepromatous (LL) involved Allow to compare the
clinical and histological
Pure Neural (PN) and Indeterminate (I) classifications
Aim of study:
to study correlations between clinical and
histological diagnosis of reactions.

1. The clinical and histological leprosy diagnoses in cohort

2. The clinical and histological diagnoses of T1R
3. The clinical and histological diagnoses of ENL

DESIGN: cohort study of 303 newly registered MB patient

The subject from The Leprosy Mission (TLM) hospitals in Naini

LOCATION and Faizabad.The histopathological analysis was done at the
LEPRA Society Blue Peter Research Centre in Hyderabad,
Andhra Pradesh

newly registered MB patients requiring a

full course of MDT
• Classification process

Ridley diagnosis Reviewed Final
Jopling (slit skin together diagnosis

• Clinical case definitions of reactions

 Type 1 or Reversal Reaction (T1R)
a patient had erythema and oedema of skin lesions. A patient could have a skin reaction only,
or a nerve reaction only, or a skin and nerve reaction.
 Erythema Nodosum Leprosum. (ENL)
a patient had crops of tender subcutaneous skin lesions. There may have been accompanying
neuritis, iritis, arthritis, orchitis, dactylitis, lymphadenopathy, oedema and fever.
• Database : Microsoft Access database
• Skin Biopsies

Stained with
Haematoxylin & Eosin
(H&E) to study
Section in sagittal
Fixed in 10% buffered
plane at 5µm thickness
on a Leica microtome
Fite Faraco stain to
Elliptical incision from identify acid fast bacilli
active skin lesion (AFB)
Transported to the Blue
Frozen in liquid Peter Research Center
Nitrogen for processing and
• Diagnosis of Leprosy
Cellular Infiltrate / granuloma


Nerve inflammation


Bacterial index of granuloma

Ridley Jopling classification

Classification Pathohistology
Lepromatous leprosy (LL): macrophage and foam cell collections present with numerous
bacilli interspersed with sparse number of lymphocytes.

Borderline lepromatous (BL) leprosy macrophage granulomas, numerous lymphocytes and

moderate numbers of bacilli
Borderline tuberculoid (BT) leprosy lympho-epithelioid granuloma presents with occasional
Langhans giant cells.
Tuberculoid leprosy (TT): immature epithelioid cells are present together with Langhans
giant cells and numerous lymphocytes.
Indeterminate leprosy some nerve inflammation is seen with rare AFB and an
absence of clear epithelioid or macrophage granulomas.
Non-specific inflammation inflammation was present without the specific features for
leprosy, notably neural inflammation and AFB
Type 1 Reaction (T1R): at least two of the following features were present:
granulomas with extra and intracellular oedema, dilated
vascular channels, separation of dermal collagen, evidence of
an intense delayed-type hypersensitivity response with acute
damage to dermal nerves and granuloma.
ENL reaction polymorphonuclear neutrophilic infiltrate on the background of
a macrophage granuloma accompanied by oedema and often
with evidence of vasculitis and/or panniculitis was seen.

• Validation of Histological Diagnosis

• 66 slides was sent to a second pathologist who used the same scoring system for diagnosis of
leprosy and reactions.

• Only agreed on one ENL diagnosis.

• Patients at risk of developing T1R and ENL

• The NSL group was excluded from both groups

• Ethical considerations

• the Indian Council of Medical Research and the Research Ethics Committee of the Central JALMA
Institute for Leprosy in Agra gave ethical approval.
Diagnosis of Leprosy

4 biopsies too small 299 biopsies were

303 Recruited or too superficial with adequate for
inadequate dermis examination