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Leprosy

Leprosy. Dr. Syed Waleem Pasha. Introduction. Chronic granulomatous disease Skin and nerves Mycobacterium leprae Disease depends on degree of cell mediated immunity expressed by the individual towards M. leprae Nerve damage – considerable morbidity Stigmatised - leper. Organism.

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Leprosy

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  1. Leprosy Dr. SyedWaleem Pasha

  2. Introduction • Chronic granulomatous disease • Skin and nerves • Mycobacterium leprae • Disease depends on degree of cell mediated immunity expressed by the individual towards M. leprae • Nerve damage – considerable morbidity • Stigmatised - leper

  3. Organism • Mycobacterium leprae (M. leprae) • Cannot be grown in vitro • Doubling time is 12 days • Withstand drying for upto 5 months • Differs from M. tuberculosis by only 29 functional genes

  4. Epidemiology • 4 million people – disabled by leprosy • 750000 new cases annually • Most cases – children • 70% cases in India • Male>female • HIV is not a risk factor for leprosy • Transmission • Untreated lepromatous pt discharge bacilli from nose • Infection acquired through nose (airborne) • Hematogenous spread to skin and nerves

  5. Pathogenesis • Incubation period • Tuberculoid cases: 2-5 years • Lepromatous cases: 5-10 years • Predilection to Schwann cells and skin macrophages • Three aspects of pathogenesis • Immune responses • Nerve damage • Immune mediated reaction • Ridley – Jopling spectrum of responses

  6. Pathogenesis • Tuberculoid Pts • Th1 -type response • IL 2 and IFN g • Positive lepromin test • Clears bacteria • Local tissue destruction • Granuloma formation • Lepromatous Pts • T cell and macrophage anergy • Th2 –type response • Poor reponse • Negative lepromin test

  7. Clinical features • Skin lesion • Effects of peripheral nerve damage • Lepra reaction

  8. Clinical features • Skin • Macules or papules • Anesthesia + loss of sweating • Lepromatous • Papules / nodules • Numerous • Diffuse infilteration of skin • Tuberculoid • Few • Hypopigmentedmacules

  9. Clinical features • Peripheral neuropathy • Sites of predilection • Upper limbs: Ulnar, Median, Radial, Radial cutaneous • Lower limbs: Common peroneal, Posterior tibial, Sural • Head and Neck: Facial, Greater auricular • Characteristic signs • Regional sensory loss • Dysfunction of muscles • Thickened

  10. Clinical features • Secondary complications due to nerve damage • Eye involvement: • Corneal ulceration due to trauma • Damage to facial and trigeminal nerve

  11. Differences between tuberculoid and lepromatous leprosy

  12. Lepra reactions

  13. Pure neural leprosy • Only in India • No skin lesions • Asymmetrical involvement of peripheral nerves

  14. Investigations • Diagnosis is clinical • Slit skin smears/ skin biopsy • Acid fast bacilli • Histology on biopsy • Bacterial index

  15. Differential Diagnosis • Skin • Pityriasisversicolor • Vitiligo • Post inflammatory depigmentation • Psoriasis • Vitiligo • Nerves • Thickeneing • Charcot-Marie-Tooth disease • Amyloidosis • Polyneuropathy • HIV, alcohol, diabetes, vaculitis, heavy metal poisoning

  16. Treatment - principles • Stop the infection by chemotherapy • Treat reactions • Educate the Pt about leprosy • Prevent disability • Social and psychological support

  17. Chemotherapy • Multi drug combinations • Paucibacillary • 2-5 skin lesions • Tuberculoid (TT) • Slit skin smear negative BT • Multibacillary • >5 skin lesions • Skin smear positive BT • All BB, BL and LL

  18. First line drugs: • Rifampicin • Dapsone • Clofazimine • Second line drugs: • Pefloxacin, ofloxacin • Minocycline • Clarithromycin

  19. WHO recommended MDT

  20. Treatment of lepra reactions • Type 1 • steroids • Type 2 • High doses steroids • Thalidomide • Chloroquine

  21. Thank u

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