LEPROSY ( MORBUS HANSEN )

Dr AMBAR RIALITA SpKK

DEFINITION :

Chronic infection disease Mainly affects the skin, peripheral nerves, mucosa upper respiratory tract, reticulo endothelial system, eye, bone , testis, except central nervous system.

AETIOLOGY :

Mycobacterium leprae

Curved rod shaped Acid Fast Bacilli Gram positive 1 8 long, 0,2 0,5 Intracellular Prefer a growth temperature of less than 37 C Can not be cultured

EPIDEMIOLOGY :
Africa / Central Asia ---- World All ages ranging : early infancy to very old age 15 25 years old >> Both sex : Males : Females = 2 : 1 Very long period : 3 5 years 1990 : 7 / 10,000 ----- 2000 : 1 / 10,000

TRANSMISSION :
Contact person - Respiratory tract - Skin - Immunity - Virulence - Physical - Environment : - Biological - Social

The Microbiology of Leprosy :

M. leprae can not be cultured

Bacteriological examination : 1. Diagnosis 2. To get a cross spectrum 3. Evaluations 4. Prognosis

Material :
Skin lession Ear lobe Nasal secretions / Nose blows

DIAGNOSIS of LEPROSY :
If shown one or more of the following cardinal signs : 1. Hipopigmented or reddish skin lession with definite loss of sensation 2. Involvement of the peripheral nerves, as demonstrated by definite enlargement / thickening peripheral nerves with loss of sensation 3. Skin smear positive for Acid Fast Bacilli Not Yet ----- Observation for 3 6 months

Measurement of the Bacterial Index :

1. Diagnosis 2. To get a cross the spectrum 3. Therapy evaluation

Scoring the B I :
Average Number of Acid Fast Bacilli 1000 / field 100 1000 / field 10 100 / field 1 10 / field 1 10 / 10 fields 1 10 / 100 fields 0 / 100 fields Bacterial Index (BI) 6+ 5+ 4+ 3+ 2+ 1+ 0

Morphological Index :
The proportion or percentage of regularly stained bacteria of the total scored Ridley ( 1971 ) : - Regularly stained bacteria = Solidly bacteria - Irregularly stained bacteria = Fragmented + Granular bacteria

M I will be a guide in determining :

1. Response to treatment 2. Drug resistance 3. Determining the infectiousness of a patient
Treatment --- M I quickly B I slowly

If M I and then : possibility

Irregularly Malabsorbtion Drug resistance

THE AIM OF CLASSIFICATION OF LEPROSY :

1. 2. 3. 4.

Infectious / Non infectious Possible infectious Possible Disability Duration of treatment

CLASSIFICATION
SPECTRUM
Ridley & Jopling TT BT BB BL LL

MADRID Indeter- Tuber- Border- Lepromatous minate culoid line WHO ( 1988 ) Paucy Bacillar Leprosy Multi Bacillar Leprosy

CLINICAL LEPROSY
Indeterminate Infectious (-) Children TT Infectious (-) 23 lesion BT Infectious (-) Satelit lesion Macules : hipopigmented / reddish BB Infectious BL Infectious LL Infectious

Punch Out Dimorphous features and tend symmetry Symetrical Symetripapul, cal papul, nodules nodules

HipopigMacules mented / hipopigpink : Face, mented back, buttock

CLINICAL LEPROSY
Indeterminate Loss of sensation (-) TT (+) BT (+) BB (+) BL LL Sensory Stocking loss, and gloves decreases anesthesia sweating and hair growth Nerve damaged (-) (+) 3 - 4 Nerve damaged (-) (+) 5 - 6

Nerve (+) swollen (-) Lepromin (-) Acid Fast Bacilli (-) (+) 4 (-)

(+)

(+)

(+) 3 (+) / (-)

(+) 1 -2 (+) 3

TREATMENT of LEPROSY :
Multi Drug Therapy : - Prevention & treatment of resistance - As short a period of time for treatment - To interrupt the transmission of the infection

W H O ( 1997 ) :
Paucibacillary Single Lesion Leprosy (one lesion) Paucibacillary Leprosy (2-5 skin lesion) Multibacillary Leprosy (More than 5 skin lesion)

I. P B SINGLE LESION
CHILD ADULT

Rifampicin 300 mg
Ofloxacin 200 mg Minocycline 50 mg

Rifampicin 600 mg
Ofloxacin 400 mg Minocycline 100 mg

Dosage : Single Dose R O M

II. P B 2 5 SKIN LESION

CHILD Monthly Treatment : Day 1 : Rifampicin 450 mg Dapsone 50 mg ADULT Monthly Treatment : Day 1 : Rifampicin 600 mg Dapsone 100 mg

Daily : Daily : Day 2 28 Day 2 28 Dapsone 50 mg/daily Dapsone 100 mg/daily Duration of treatment : 6 - 9 Months

III. M B :
CHILD
Monthly treatment Day 1 : Rifampicin 450 mg Clofazimine 150 mg Dapsone 50 mg
Daily 2 28 : Clofazimine 50 mg / daily Dapsone 50 mg / daily

ADULT
Monthly treatment Day 1 : Rifampicin 600 mg Clofazimine 300 mg Dapsone 100 mg
Daily 2 28 : Clofazimine 50 mg / daily Dapsone 100 mg / daily

Duration of treatment : 12 18 months

LEPROSY REACTIONS :
Type 1 reaction Type 2 reaction : Reversal reaction : Erythema Nodosum Leprosum ( E N L reactions )

Manifestation of :
1. Reversal reaction
Mild Skin Nerve
- Lesion become reddish & swollen - Enlarge, painfull (-) - Nerve damage (-) - < 6 weeks

Severe
- Same & rarely new skin lesion - Fever, malaise - Enlarge, painfull (+) - Nerve damage, loss sensation - > 6 weeks - Same - Ulceration - Swollen on hand & foot - Nerve enlarge -- > 6 weeks

Skin & - Lesion become reddish Nerve - Painful on peripheral

nerves - < 6 weeks

2. E N L reaction
MILD SEVERE

Skin

Skin nodules : - Tender reddish - Ulceration

Enlarge Painful (-) Nerve damage (-) Not involvement Swollen, Painful (-)

Skin nodules >> - Painful - Ulceration - Fever & malaise

Enlarge Painful & swollen Nerve damage Painful Visual impairment Painful, Enlarge - Same - Very painful - Fever

Nerve

Eye Testis

Skin, nerve, Same eye, testis

TREATMENT of REACTION :
Prednisone : 30 80 mg / daily and then tappering off Continued M D T without interruption MILD REACTION : - Immobilization - Rest SEVERE REACTION : Reffered to the nearest hospital

MH tipe BB

MH tipe BL

MH tipe BT

MH indeterminate

MH tipe TT

MH tipe LL

MH tipe LL

Eritema Nodusum Leprosum(ENL)

Lepromatous leprosy. Note the diffuse infiltration of the face with leonine facies and madarosis.

Sequele of leprosy. The patient has madurosis, a saddle nose and blindness in the left eye. Courtesy of Evangeline Handog, M.D.