Leprosy type 1 (reversal) reactions and their management

The type of leprosy that affects an individual depends on the immune response mounted against the organism. This leads to a spectrum of disease which may be complicated by immunological phenomena called reactions. Antimicrobial chemotherapy is effective in treating the Mycobacterium leprae infection but up to 30% of individuals with borderline disease experience Type 1 reactions (T1Rs). T1Rs are immunologically mediated episodes, localised in skin and nerves, which are a major cause of nerve function impairment. Nerve function impairment may result in disability and deformity. We review the frequency and features of Type 1 reactions. The data from the limited number of randomised controlled trials of treatment are discussed. These four randomised controlled trials were all conducted in south Asia. The accepted treatment of T1Rs is with oral corticosteroids but there is no consensus about the dose or duration of treatment due to the lack of data. One randomised controlled trial showed that patients treated with a 5 month course of prednisolone (total dose 2.31 g) were less likely to need additional prednisolone than those treated with a 3 month course of prednisolone (total dose 2.94 g). This study did not use nerve function as an outcome measure. The improvement in nerve function impairment with steroid treatment is highly variable, with 33-73% of nerves recovering fully. Optimal steroid regimes and alternative treatments need to be identified if the disability associated with leprosy is to be minimised. Search strategy Papers for this review were identified by repeated searches of the Cochrane Clinical Trials Register, PubMed and LILACS with various combinations of the following search terms 'leprosy', 'lepra', 'reaction', 'steroids', 'corticosteroids', 'reversal', 'Type 1', 'Hansen*'. Searches were complete to the end of November 2008.

Detection and classification of leprosy: future needs and strategies

This paper focuses on the obstacles and dilemmas in detection and classification of leprosy cases and suggested strategies for the same. This review attempts to raise some cardinal issues within leprosy diagnosis and the need for capacity building at clinical and field level in light of research conducted. It also recommends strategies to overcome these obstacles.

Methods for the Classification of Leprosy for Treatment Purposes

The World Health Organization advocates 2 leprosy treatment regimens on the basis of disease classification (as multibacillary or paucibacillary) by skin lesion count. This method, which, in the Philippines, results in a high prevalence (78%) of patients with multibacillary leprosy, was directly compared with classification using standard histopathological and microbiological criteria in 264 currently untreated patients with leprosy. Of those whose leprosy was classified as paucibacillary, 38%-51% of patients had multibacillary leprosy according to classic criteria and were thus at risk of undertreatment according to World Health Organization recommendations.

Observations on reactions of leprosy in the field

In order to assess the incidence of reaction in leprosy, it would be necessary to examine the data from a field control unit. In this study, it was found, at a fully monitored control unit, that Type I reaction occurred in 3.9% of borderline cases and Type II in 23.7% of LL and BL cases. Even so, the load of reaction is not high since reaction of Type I and Type II together are seen only in 3.7% of all types of cases. A majority of them are of mild or moderate degree and could be treated as out-patients. Of the borderline cases, the BB type showed maximum rate of reaction. The BL type can present with both Type I and Type II reactions with a total incidence of 12.8%. While the BT type constituted 74% of total cases, reaction of Type I occurred in 3.1% of cases. Reaction also occurred in 0.8% of RFT cases.

Fine needle aspiration cytology in reactional and non-reactional leprosy

BACKGROUND

Histopathological evaluation of skin lesions is not feasible in many leprosy endemic areas. Fine needle aspiration cytology (FNAC) is a simpler tool compared to histopathology for the evaluation of the cytomorphology of skin lesions.

AIMS

To study the cytomorphology of leprosy lesions in fine needle aspirates and correlate it with the histopathology.

METHODS

Seventy leprosy patients diagnosed and classified according to Ridley Jopling scale were included. Fine needle aspirates were taken from the lesion followed by a skin biopsy from the same site for histopathological examination after H/E staining.

RESULTS

Borderline leprosy patients with Type I reaction showed significantly large numbers of giant cells, collagen and elastin in their smears as compared to those without reaction. The smears were more heavily cellular with fragmented collagen and elastin along with significant increase in neutrophils in patients with Type II reaction while foamy macrophages with fatty background were common in non-reactional lepromatous leprosy patients. A complete correlation between histopathological and cytomorphological findings was observed in 77.3% of cases.

CONCLUSION

FNAC may be used as an alternative tool to assess leprosy lesions in areas where histopathological services are not readily available.

Evaluation of leprosy patients with 1 to 5 skin lesions with relevance to their grouping into paucibacillary or multibacillary disease

BACKGROUND

Patients with 1 to 5 skin lesions are arbitrarily categorized as belonging to the paucibacillary (PB) group for treatment purposes. With the decreasing prevalence of leprosy in India and modifications in leprosy program, the relevance of this grouping needs further study.

AIMS

To study a group of leprosy patients with 1 to 5 skin lesions and compare the clinical parameters with histopathological findings and bacteriological status of the skin and nerve to evaluate the relevance of this grouping.

METHODS

Seventy seven patients of leprosy with 1 to 5 skin lesions were included in the study. The number of skin lesions was recorded. Slit skin smears (SSS) and skin biopsies were taken in all patients and nerve biopsy was performed in 19 of them. The biopsies were evaluated for the type of pathology and AFB status.

RESULTS

In these 77 patients (single skin lesions, 42; two lesions, 18; three lesions, 10; four lesions, 5; and five lesions, 2 patients) the clinical classification was indeterminate leprosy (IL) in 4, tuberculoid leprosy (TT) in 4 patients and borderline tuberculoid leprosy (BT) in 69 patients. Skin smears were positive only in 1 patient. The histological diagnoses in the skin were IL in 13, TT in 3, BT in 48 and borderline lepromatous (BL) in 4 patients. Acid-fast bacilli (AFB) were found in 14 out of 77 skin biopsies. Of the 19 nerve biopsies, 17 showed histological features of BT leprosy; of these, 12 demonstrated AFB on Fite staining. The bacillary index of granuloma (BIG) ranged from 1+ to 2+. The clinico-histopathogical correlation was 63% in the BT group, with 4 patients of this group showing features of BL on histopathology. When the presence of AFB was assessed, the percentage of positivity was 1.3% in SSS, 18% in skin biopsies and 63% in nerve biopsies.

CONCLUSION

Our results point to the non-homogeneous nature of this group of leprosy patients with 1 to 5 skin lesions, with varied bacteriological and histopathological features. The significance of MB type findings on histopathology in patients grouped as PB leprosy should be resolved so that these patients may be given the drug therapy and the duration of therapy they warrant.

Use of protein microarrays to define the humoral immune response in leprosy patients and identification of disease-state-specific antigenic profiles

Although the global prevalence of leprosy has decreased over the last few decades due to an effective multidrug regimen, large numbers of new cases are still being reported, raising questions as to the ability to identify patients likely to spread disease and the effects of chemotherapy on the overall incidence of leprosy. This can partially be attributed to the lack of diagnostic markers for different clinical states of the disease and the consequent implementation of differential, optimal drug therapeutic strategies. Accordingly, comparative bioinformatics and Mycobacterium leprae protein microarrays were applied to investigate whether leprosy patients with different clinical forms of the disease can be categorized based on differential humoral immune response patterns. Evaluation of sera from 20 clinically diagnosed leprosy patients using native protein and recombinant protein microarrays revealed unique disease-specific, humoral reactivity patterns. Statistical analysis of the serological patterns yielded distinct groups that correlated with phenolic glycolipid I reactivity and clinical diagnosis, thus demonstrating that leprosy patients, including those diagnosed with the paucibacillary, tuberculoid form of disease, can be classified based on humoral reactivity to a subset of M. leprae protein antigens produced in recombinant form.

Leprosy situation in Brazil

We present the situation of leprosy in Brazil, reporting about epidemiology, clinical criteria for classification, multidrugtherapy and special situations, as co-infection. This material was presented in the 79th Annual Meeting of Japanese Hansen's Disease Association in May 2006, during a discussion about the Japanese Guidelines for leprosy treatment.

[Guideline for the treatment of Hansen's disease in Japan (Second edition)]

ad hoc committee of Japanese Leprosy Association recommends revised standard treatment protocol of leprosy in Japan, which is a modification of World Health Organization's multidrug therapy (WHO/MDT, 1997). For paucibacillary (PB) leprosy, 6 months treatment by rifampicin and dapsone (MDT/PB) is enough. However, for high bacterial load multibacillary (MB) leprosy, 12 months treatment seems insufficient. Thus, (A) For MB with bacterial index (BI) > or = 3 before treatment, 2 years treatment by rifampicin, dapsone and clofazimine (MDT/MB) is necessary. When BI become negative and active lesion is lost within 2 years, no maintenance therapy is necessary. When BI is still positive, one year of MDT/MB is added (3 years in total), followed by maintenance therapy by dapsone and clofazimine until BI negativity and loss of active lesions. (B) For MB with BI < 3 or fresh MB (less than 6 months after the onset of the disease) with BI > or = 3, 1 year treatment by MDT/MB is necessary. When BI become negative and active lesion is lost within one year, no maintenance therapy is necessary. When BI is still positive or active lesion is remaining, additional therapy with MDT/MB for one more year is recommended. This is a simplification of first version in 2000. Brief summary of diagnosis, purpose of therapy, character of drugs, and prevention of deformity is also described.

Comparative profile of new leprosy cases coming to a referral institute in pre- and post-integration periods

This article presents findings from a retrospective analysis of 3031 new leprosy cases attending the Out-patient Department of the Regional Leprosy Training and Research Institute, Raipur, Chhattisgarh, during the period January 2000-December 2005. The analysis was carried out in order to compare the profiles of new leprosy cases between pre- and post-integration periods. The cut-off date, in order to distinguish between the two groups, was determined as 31st December 2002. A comparison was made between the two groups on identified host- and disease-related variables and its significance was tested using suitable statistical tests. The results showed that there was more than 50% increase in the number of new leprosy cases coming to the OPD of the RLTRI during the post-integration period. The mean age at registration showed an increase of 0.9 years, while the proportion of child and female cases showed a decrease of 7.7% and 4.3% respectively during the same period. Significant decline was also recorded in the proportion of grade II deformity cases (11.8%) and cases with type I lepra reaction (11.4%) during the post-integration period. The study emphasizes the need for developing an effective referral mechanism and proper screening of cases at the PHC level for better utilization of referral institutions in a need-based manner.

Self-care programme to prevent leprosy-related problems in a leprosy colony in Champa, Chattisgarh

A self-care programme aimed at preventing leprosy-related physical disabilities in a leprosy colony in Champa, Chattisgarh, India, is described. Once the initial resistance was overcome through persistent and caring attitudes, the residents accepted the challenges for self-care. The outcome at the end of one year showed significant decline (41%) in ulcer rates, significant use of MCR footwear (43%), and significant proportion (over 90%) of patients and their families practising and helping in self-care activities.

[Recent condition of new leprosy patients in Japan]

Most of 148 newly registered leprosy patients in the past 10 years from 1995 to 2004 in Japan had received some examinations, such as histopathology test (85%), skin smear test (84%), estimation of PGL-I antibody titer (55%) or detection M. leprae with PCR method (41%). 17% of newly patients should receive wrong therapy, if they had not had aforesaid clinical examinations in addition to count skin lesions. Improvement of technical level at skin smear test should be required for accurate treatment program in Japan. In Japanese patients, the number has been decreasing year by year; epidemiological condition was different between in Okinawa prefecture and in others, about ratio of sex, kind of type and age group.

Cyclooxygenase 2 expression in vessels and nerves in reversal reaction leprosy

Tissue expression of cyclooxygenase (COX)2, an inducible enzyme synthesizing eicosanoids in inflammation, was studied in reversal reaction (RR) leprosy in comparison with nonreactionary leprosy. COX2 was consistently expressed in cells of the mononuclear-macrophage lineage across the leprosy spectrum. Only in RR, the following two additional sites showed COX2 expression in the dermis and subcutis: 1) microvessels and 2) nerve bundles and isolated nerve fibers. The same sites also express vascular endothelial growth factor (VEGF). This is in keeping with experimental models relating VEGF to COX2 expression, with VEGF enhancing prostaglandin production through COX2 stimulation and prostaglandin synthase expression. We postulate that selective COX2 inhibitors, which are currently used in several inflammatory conditions, could be considered for RR treatment to reduce acute symptoms caused by tissue edema and possibly prevent long-term nerve damage, the main complication of RR.

[Conjugal leprosy]

OBJECTIVES

Determining the occurrence of leprosy amongst couples and establishing the type of leprosy in index and secondary cases.

METHODS

The characteristics of leprosy were studied between 1980 and 2000 in Atlántico Department located on the Colombian Caribbean Coast. Clinical histories of patients registered in the Leprosy Control Programme were reviewed. Clinical exams were performed and personal interviews carried out with couples suffering from leprosy.

RESULTS

Twenty-six married couples were found to be suffering from leprosy, representing 5.4% of leprosy cases detected during the study period. They were aged from 20 to 89. 65.4% of the index cases were men and 22 (84.6%) were multibacillary, lepromatous cases; two had indeterminate leprosy and two were suffering from tuberculoid leprosy. Sixty-one percent of the secondary cases were paucibacillary patients, 42% of them being tuberculoid. No paucibacillary cases were associated with multibacillary leprosy in the couples. Only two couples had consanguinity. None of the couples had had leprosy at the time of being married. The time between leprosy being detected in index cases and the disease being detected in secondary patients varied from 5 to 40 years. Disabilities were more common in the feet and to a higher degree in lepromatous index cases who had had the disease for a longer time than the secondary cases because these were more frequently paucibacillary patients who had a disease having shorter evolution.

CONCLUSIONS

In spite of ongoing, prolonged contact, conjugal leprosy is not frequent and requires several years to develop in the second person. Lepromatous leprosy in index cases was more frequently associated with leprosy in the couple. When the primary case was paucibacillary, no multibacillary leprosy occurred in the secondary case.

MDT-MB therapy in paucibacillary leprosy: a clinicopathological assessment

BACKGROUND

The World Health Organization recommends treatment regimens for paucibacillary (PB) and multibacillary (MB) leprosy, which differ in their duration and components. Hence accurate classification of the disease is required. To overcome difficulties in classification Uniform Multi Drug Therapy (U-MDT) has been recommended.

AIM

To evaluate the benefit of adding clofazimine to paucibacillary regimens in leprosy patients by measuring clinical and histological resolution.

METHODS

Forty-four paucibacillary patients were included in the study. Twenty-two patients were given MDT-PB regimen and the remaining MDT-MB regimen for six months . Skin biopsies were done before the commencement and at the end of treatment. Clinical and histological resolutions were measured according to the standard criteria a laid down. The results were analyzed using Fishers' test and Crammers' V test.

RESULTS

Clinical improvement was observed in 90.9% in the MB group as compared to 27.3% in the PB group. Regression in the nerve swelling was observed in 70% in the MB group and in 37.5% in the PB group while histological resolution was observed in 72.8% and 54.5% respectively.

CONCLUSIONS

Addition of clofazimine helps to resolve leprosy lesions both clinically and histologically, thus justifying the concept of Uniform MDT regimen for all patients.

Is increasing MB ratio a positive indicator of declining leprosy?

In recent years, an increasing MB ratio-trend has been seen in most state reported leprosy data in India and elsewhere. The programme of leprosy all over the world has been integrated with general health system (GHS). This has given rise to gross under reporting of leprosy cases and increasing MB ratio. This paper examines this critical issue and attempt to find out the causes of this trend. The findings suggest clearly that increasing MB ratio is the result of early cases of leprosy being missed out. This can be to the extent of 73% when MB ratio is reached to 47.5%.

Physical Distance, Genetic Relationship, Age, and Leprosy Classification Are Independent Risk Factors for Leprosy in Contacts of Patients with Leprosy

BACKGROUND

Close contacts of patients with leprosy have a higher risk of developing leprosy. Several risk factors have been identified, including genetic relationship and physical distance. Their independent contributions to the risk of developing leprosy, however, have never been sufficiently quantified.

METHODS

Logistic-regression analysis was performed on intake data from a prospective cohort study of 1037 patients newly diagnosed as having leprosy and their 21,870 contacts.

RESULTS

Higher age showed an increased risk, with a bimodal distribution. Contacts of patients with paucibacillary (PB) leprosy with 2-5 lesions (PB2-5) and those with multibacillary (MB) leprosy had a higher risk than did contacts of patients with single-lesion PB leprosy. The core household group had a higher risk than other contacts living under the same roof and next-door neighbors, who again had a higher risk than neighbors of neighbors. A close genetic relationship indicated an increased risk when blood-related children, parents, and siblings were pooled together.

CONCLUSIONS

Age of the contact, the disease classification of the index patient, and physical and genetic distance were independently associated with the risk of a contact acquiring leprosy. Contact surveys in leprosy should be not only focused on household contacts but also extended to neighbors and consanguineous relatives, especially when the patient has PB2-5 or MB leprosy.

Comparison of two systems of classification of leprosy based on number of skin lesions and number of body areas involved--a clinicopathological concordance study

BACKGROUND AND AIMS

WHO guidelines classify leprosy patients for therapeutic purposes into paucibacillary (PB) and multibacillary (MB) leprosy based on the number of skin lesions. An alternative system of classification has been in practice in Nepal from 1985 onwards, based on the number of body areas involved in patients of leprosy. We attempted a clinicopathological approach for comparison of these two systems of classification in leprosy patients for their ability to demarcate patients into groups of PB and MB leprosy.

MATERIALS AND METHODS

The study included 108 leprosy patients (80 males and 28 females). Complete clinical examination and body charting was carried out in each patient noting the count of skin lesions and the number of body areas involved. Slit skin smears and skin biopsies were taken from an active skin lesion in all patients.

RESULTS

On analysis, it was observed that there was good clinicopathological correlation between patients with 5 or < 5 skin lesions and 2 or < 2 body areas involved. (Clinical 95% and histological 96%) A similar correlation was also observed in the other group of patients with > 5 skin lesions and > 2 body areas involved, (Clinical 94% and histological 96%). There were almost identical numbers of patients represented in these two groups of classification.

CONCLUSIONS

Our findings suggest that patients with involvement of 2 or less body areas can be classified as PB leprosy and those with more than 2 body areas involved can be classified as MB leprosy for the purposes of therapy. The study of areas of involvement in leprosy patients not only provides additional patient information but also adds another parameter as a basis for the study of leprosy patients.

Leprosy in the Department of Dermatology, Chang Gung Memorial Hospital at Kaohsiung from 1988 to 2004: a clinical and histopathologic study of 13 cases

BACKGROUND

Leprosy has long been in Taiwan, but it has never been eradicated. Incidental cases are easily overlooked nowadays because most younger dermatologists are unfamiliar with this disease.

METHODS

We review and analyze 13 cases diagnosed as leprosy at the Department of Dermatology, Chang Gung Memorial Hospital at Kaohsiung from 1988 to 2004, all of which were histopathologically proven.

RESULTS

The ages of the 13 recruited patients ranged from 31 to 73 (mean, 58.6) years, without a gender preference (male: female, 7:6). Two male patients were under 40 years old; one was a foreign worker from Thailand and the other was a local person in Penghu working as the chief officer on a fishing boat. The most-common clinical subtype was lepromatous leprosy (5/13), followed by borderline lepromatous leprosy, borderline tuberculoid leprosy, and tuberculoid leprosy (each 2/13), and then borderline leprosy and indeterminate leprosy (each 1/13). The initial clinical impression before the histopathological diagnosis included granuloma annulare, generalized eczema, lymphoma, syphilis, papular urticaria, cutaneous tuberculous infection, Sweet's syndrome, erythema annulare centrifugum, and hematoma. Most of these patients only received irregular treatment after the diagnosis was made and were soon lost to follow-up.

CONCLUSIONS

With increasing numbers of foreign workers and immigrants living in Taiwan in recent years, leprosy seems to have become a challenging diagnosis for younger dermatologists. Dermatologists should keep this ancient disease in mind and not overlook it. Because of the necessity of prolonged medication, complete treatment and long-term follow-up of leprosy cases will remain a major problem in public health.

Clinico-pathological study of 12 cases of patients with leprosy admitted to Sina Hospital, Hamadan, Iran, from 1991 to 2000

BACKGROUND

Leprosy is considered a chronic disabling condition. Many clinical and immunological aspects of the disease remain ill defined.

AIM

The study of clinico-pathological and laboratory findings of patients with leprosy admitted to Sina Hospital, Hamadan, Iran, from 1991 to 2000.

METHODS AND PATIENTS

This is a descriptive retrospective cross-sectional study. The statistical community comprised all patients diagnosed leprosy. This diagnosis was clinical and confirmed through pathology (skin-biopsy) and laboratory (peripheral smear) measures.

RESULTS

In this study, the disease was more common in males than females with a mean age of 48.5 +/- 16.2 years. Most of the patients were more than 40 years old. Among 12 patients in this study, six cases were urban and six cases were rural. Six cases were living in Hamadan province and two cases migrated to Hamadan province (one of them from Afghanistan and the other from Kurdestan). Clinical diagnosis was confirmed by pathology in 11 cases, but in one case the clinical diagnosis did not match the pathology. In four cases the clinical diagnosis did not match the peripheral smear. Eight cases were admitted just once. Four cases had a history of recurrence and readmission (two patients had one time recurrence and the other two patients had two recurrences). There was no difference in the clinical findings between first presentation and recurrence. From the point of complication and disability, extremity disability was more common than eye disability. Increased severity of complications was found in patients with a delayed diagnosis and incomplete treatment.

CONCLUSION

This study showed that a rapid and correct diagnosis and complete treatment was necessary for prevention of complication and disability in patients with leprosy. Also the accuracy of pathology (skin biopsy) in the diagnosis exceeded the peripheral smear. Skin biopsy is recommended to confirm the diagnosis in all cases of leprosy. In the absence of pathology, patients must be considered as multibacillary patients and treated as such.