Leprosy o Also known as Hansens Disease o a chronic infectious disease caused by Mycobacterium leprae (An acid-fast, rodshaped bacillus

that mainly affects the skin, peripheral nerves, mucosa of the upper respiratory tract and eyes. ) o Early symptoms begin in cooler areas of the body and include loss of sensation. o transmitted from one untreated person to another via the respiratory tract (nasal secretions or droplets) o The route of transmission has not been definitively established, although human-to-human aerosol spread of nasal secretions is thought to be the most likely mode of transmission in most cases. Leprosy is not spread by touch, since the mycobacteria are incapable of crossing intact skin. Living near people with leprosy is associated with increased transmission. Among household contacts, the relative risk for leprosy is increased 8- to 10-fold in multibacillary and 2- to 4-fold in paucibacillary forms. An individual should be regarded as having leprosy if he exhibits the following cardinal signs: o Hypo-pigmented or reddish skin lesion(s) with definite sensory loss o Peripheral nerve damage, as demonstrated by loss of sensation and muscle weakness in the hands, feet and/ or face o Positive skin smear Pathophysiology

The areas most commonly affected by leprosy are the superficial peripheral nerves, skin, mucous membranes of the upper respiratory tract, anterior chamber of the eyes, and testes. These areas tend to be cooler parts of the body. Tissue damage is caused by the degree to which cell-mediated immunity is expressed, the extent of bacillary spread and multiplication, the appearance of tissue-damaging immunologic complications (ie, lepra reactions), and the development of nerve damage and its sequelae. M leprae is an obligate intracellular acid-fast bacillus with a unique ability to enter nerves.

Symptoms
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Painless skin patch accompanied by loss of sensation but not itchiness (Loss of sensation is a feature of tuberculoid leprosy, unlike lepromatous leprosy, in which sensation is preserved.) LEPROSY Page 1

Sunshine Adeline Mackie

Loss of sensation or paresthesias where the affected peripheral nerves are distributed o Wasting and muscle weakness o Foot drop or clawed hands (may result from neuritic pain and rapid peripheral nerve damageCharacteristic clawed hand deformity caused by ulnar involvement in leprosy. o Ulcerations on hands or feet (ulcer at the metatarsal head )Chronic nonhealing ulcer at the metatarsal head resulting from loss of sensation in the feet o Lagophthalmos, iridocyclitis, corneal ulceration, and/or secondary cataract due to nerve damage and direct bacillary skin or eye invasion Symptoms in reactions o Type 1 (reversal) - Sudden onset of skin redness and new lesions o Type 2 (erythema nodosum leprosum - Many skin nodules, fever, redness of eyes, muscle pain, and joint pain Patient with erythema nodosum leprosum type 2 reaction several weeks after initiation of drug therapy.
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The first physical signs of leprosy are usually cutaneous. The subtype of leprosy often determines the degree of skin involvement.

Physical examination should include the following: o Evaluation of skin lesions o Careful sensory and motor examination o Palpation of peripheral nerves for pain or enlargement, with particular attention paid to the following locations: Elbows - Ulnar nerve Wrist - Superficial radial cutaneous and median nerves Popliteal fossa - Common peroneal nerve Neck - Great auricular nerve Physical findings in specific leprosy subtypes include the following: o Tuberculoid leprosy The initial lesion is often a sharply demarcated hypopigmented macule that is ovoid, circular, or serpiginous. The lesions may be somewhat elevated with a dry scaly center and erythematous borders. Common lesion sites include the buttocks, face, and extensor surfaces of limbs. The perineum, scalp, and axilla are not normally involved because of the temperature differential in these zones, as predilection is toward cooler zones. LEPROSY Page 2

Sunshine Adeline Mackie

As the disease progresses, lesions tend to destroy the normal skin organs such as sweat glands and hair follicles. Superficial nerves that lead from the lesions tend to enlarge and are sometimes palpable. The patient may experience severe neuropathic pain. Nerve involvement can also lead to trauma and muscle atrophy. Lepromatous leprosy This form is characterized by extensive bilaterally symmetric cutaneous involvement, which can include macules, nodules, plaques, or papules. Multiple flat hypopigmented lesions on shoulder and neck, suggestive of multibacillary leprosy. Note ulceration of hypothenar area of hand, indicative of ulnar neuropathy. Unlike lesions in tuberculoid leprosy, those in lepromatous leprosy have poorly defined borders and raised and indurated centers. As in all forms of leprosy, lepromatous lesions are worst on cooler parts of the body. Common areas of involvement include the face, ears, wrists, elbows, buttocks, and knees. Hoarseness, loss of eyebrows and eyelashes, and nasal collapse secondary to septa perforation may occur in advanced cases of disease. Involvement of the eye may include keratitis, glaucoma, or iridocyclitis. Man with advanced deformities caused by unmanaged leprosy. Keratitis, loss of eyebrow, thickened skin, and typical hand impairments. The leonine facies associated with leprosy develop as the disease progresses, and the facial skin becomes thickened and corrugated. Axillary and inguinal adenopathy may develop, in addition to scarring of the testes and subsequent gynecomastia and sterility. Nerve involvement in lepromatous leprosy is not as severe as in tuberculoid leprosy, since nerves, although visibly thickened and highly infected, still function reasonably well in early stages of the disease. Borderline tuberculoid leprosy: The lesions are few or moderate and asymmetric with almost complete anesthesia. Peripheral nerves are often involved and thickened asymmetrically, and cutaneous nerves are sometimes enlarged.

Midborderline leprosy: The number of skin lesions is moderate, and they are asymmetrical and somewhat anesthetic. Peripheral nerves may be somewhat symmetrically enlarged, but cutaneous nerves are not. LEPROSY Page 3

Sunshine Adeline Mackie

Borderline lepromatous leprosy: Moderate to numerous slightly asymmetrical skin lesions appear with minor or no anesthesia. Peripheral nerves are often enlarged symmetrically, but cutaneous nerves are not. Indeterminate leprosy: Skin lesions are typically either hypopigmented or hyperpigmented macules or plaques. Patients may note that these lesions are anesthetic or paresthetic.

Diagnosis 1. majority of cases of leprosy are diagnosed by clinical findings, especially since most current cases are diagnosed in areas that have limited or no laboratory equipment available. -Hypopigmented patches of skin or reddish skin patches with loss of sensation, thickened peripheral nerves, or both clinical findings together often comprise the clinical diagnosis. 2. Skin smears or biopsy material that show acid-fast bacilli with the ZiehlNeelsen stain or the Fite stain (biopsy) can diagnose multibacillary leprosy, or if bacteria are absent, diagnose paucibacillary leprosy 3. Other tests can be done, but most of these are done by specialized labs and may help a clinician to place the patient in the more detailed Ridley-Jopling classification and are not routinely done (lepromin test, phenolic glycolipid-1 test, PCR, lymphocyte migration inhibition test or LMIT). Other tests such as CBC test, liver function tests, creatinine test, or a nerve biopsy may be done to help determine if other organ systems have been affected. Management 1. Multi-Drug Therapy (MDT) accepted standard treatment for leprosy. It is a combination of two (2) or more anti-leprosy drugs:
Dapsone Rifampicin Clofazimine Ofloxacin Minocycline

a 24-month treatment for multibacillary (MB or lepromatous) cases using rifampicin, clofazimine, and dapsone. a six-month treatment for paucibacillary (PB or tuberculoid) cases, using rifampicin and dapsone Sunshine Adeline Mackie LEPROSY Page 4