Antibodies to sulfatide in leprosy and leprosy reactions

Antibodies to sulfatide have been reported in various demyelinating peripheral polyneuropathies. We have investigated the diagnostic value of these antibodies in leprosy. Anti-sulfatide IgM in leprosy patients was not significantly elevated. High anti-sulfatide IgG titers were observed in individuals from endemic areas, irrespective of their leprosy status, while western European controls were negative. No significant correlation was found between IgM or IgG antibody titers and leprosy classification, although multibacillary patients had higher anti-sulfatide IgM titers than paucibacillary patients. In addition, 23 patients developing leprosy reactions were followed longitudinally. Antibody titers in these patients fluctuated slightly during the follow-up period. There was no association with the occurrence of leprosy reactions or treatment. Thus, IgG titers against sulfatides are high in both leprosy patients and healthy controls in endemic areas, whereas such antibodies are not found in western European controls, suggesting that these antibodies are induced by environmental factors, such as microorganisms.

Significance of histopathological classification in leprosy

A retrospective blind study was carried out on 2640 patients of leprosy to correlate the histopathological and clinical classification of leprosy using the criteria laid down by Ridley and Jopling. There was complete agreement between histopathological and clinical classification in 81.8% of the cases, with one step deviation in 5.1% of the cases. Histopathological diagnosis of indeterminate leprosy in high percentage (15.9%) as against 3.3% of indeterminate leprosy clinically in our series was an interesting feature. Type-wise correlation between histopathological with clinical classification was very high, it being the highest in LL (98%) followed by TT (97%), BT, BB and BL (95%, 89% and 87% respectively).

[Leprosy epidemiology in a cohort of household contacts in Rio de Janeiro (1987-1991)]

This study aimed to identify factors influencing the development of leprosy (Hansen's disease) in household contacts. A dynamic cohort was analyzed from 1987 to 1991 at the Hansen's Disease Department of the Oswaldo Cruz Foundation in Rio de Janeiro. The incidence rate was 0.01694 person-years of follow-up. Nevertheless, for subjects at the end of the first year of follow-up the incidence rate was 0.06385 (end of second year, 0.03299; end of third year, 0.02370; end of fourth year, 0.018622; and end of observation period, 0.01694). A stepwise multivariate logistic regression model was proposed to study the risk of developing leprosy, including co-prevalent cases, totaling 758 contacts. In the final model, the risk was associated with a negative Mitsuda skin test (OR = 3.093; CI 95% = 1.735-5.514), prior BCG vaccination (OR = 0.3802; CI 95% = 0.2151-0.66719), and multibacillary primary clinical form (OR = 2.547; CI 95% = 1.249-5.192). The results showed that both multibacillary leprosy and specific immune status are significant indicators for developing the disease in a cohort of household contacts.

Nerve function impairment in leprosy: design, methodology, and intake status of a prospective cohort study of 2664 new leprosy cases in Bangladesh (The Bangladesh Acute Nerve Damage Study)

The Bangladesh Acute Nerve Damage Study (BANDS) is a prospective cohort study designed to investigate epidemiological, diagnostic, therapeutic and operational aspects of acute nerve function impairment in leprosy. The study is based at a single centre in Bangladesh, in an area with a high prevalence of leprosy. The centre, Danish Bangladesh Leprosy Mission, has a well-established vertical leprosy control programme. In this paper, the study design and methodology are described, together with definitions of nerve function impairment (NFI) used in this and subsequent papers. The study recruited 2664 new leprosy cases in a 12-month period. The male:female ratio is 1.25:1, and 17.61% of the cohort are under 15 years of age. In all, 83.33% of the cohort are paucibacillary (PB), and 16.67% multibacillary (MB). However, the MB rate amongst males is 19.72%, and amongst females is 12.85%, despite an equal period of delay to diagnosis. 55% of patients presented for treatment within 12 months of developing symptoms 6.12% of the total number of cases were smear positive, and 36.71% of the MB cases were smear positive. 9.61% of the total number of cases were graded as having World Health Organisation (WHO) disability grade 1, and 5.97% had grade 2. Amongst MB cases, 27.48% had WHO grade 1 disability present, and 18.24% had grade 2 present, compared with 6.04% and 3.51%, respectively, amongst PB cases. A total of 11.90% of the cohort had sensory NFI of any kind, and 7.39% had motor NFI. Ninety patients presented with NFI needing treatment (3.38%), and of these, 61 (67.78%) had silent NFI. MB patients had a prevalence of reaction/NFI needing treatment nearly 7 times higher than PB cases (15.32% amongst MB; 2.30% amongst PB), and males nearly double that of females (5.67% amongst males, 2.96% amongst females). The most commonly affected nerve by function impairment was the posterior tibial (sensory) with 6.46% of nerves affected (9.38% of patients), followed by the ulnar nerve with 3.23% of nerves impaired (5.56% of patients). Future research and publications, building on this foundation, will focus on the following areas: the incidence of NFI and reactive events, the risk factors for developing NFI, and the response to treatment of patients developing acute NFI.

Lymphoproliferative responses of leprosy patients and healthy controls to nitrocellulose-bound M. leprae antigens

The lymphoproliferative responses of 51 leprosy patients and 11 healthy contacts were analyzed using the nitrocellulose-bound specific antigen fractions from the cell-free extract of Mycobacterium leprae. The main proliferation-inducing fraction for peripheral blood mononuclear cells of the healthy contacts was found to be the Fraction II, bearing antigens in the range of 66-45 kDa. However, this fraction failed to induce lymphoproliferation in the leprosy patients, unlike healthy contacts (p < 0.032). The number of responders as well as the strength of the responses to 66-45 kDa proteins were found to be low in the leprosy patients compared to the healthy contacts. Further, preliminary analysis with the subfractions of Fraction II produced a similar pattern, suggesting that the immune response to the antigens in the range of 66-45 kDa M. leprae proteins remains suppressed in subjects with clinical signs and symptoms of the disease.

Palmoplantar lesions in leprosy

Palms and soles are considered immune to leprosy. A study was carried out to assess the frequency of lesions over palms and soles and to correlate their occurrence with various parameters. Two hundred eighty leprosy patients were screened for lesions over palms and soles. Palmo-plantar lesions were observed in 10% of the patients screened. Slit-skin smears and biopsies were done from routine sites and palmo-plantar lesions. Histopathology and slit-skin smear confirmed the presence of disease. Eight were in type I reaction, and 50% of patients with type I reaction screened showed lesions over palms and/or soles. The reason for this is not known; probably inapparent lesions become apparent during reactions. Lesions of various morphology were observed. Silky hand was observed in one case.

Leprosy

Leprosy is an ancient disease which is still poorly understood and often feared by the general public and even by some healthcare professionals. Fortunately, improvements in the management of leprosy over the past three decades have diminished the stigma and greatly altered the outlook for patients. Public understanding of the disease has benefited from WHO's goal of eliminating leprosy as a public health problem by the year 2000. Unfortunately that goal has also led many to believe that leprosy has been or will soon be eradicated. This will not happen in the near future because, despite a fall in registered cases, the incidence of the disease has changed very little, and eradication of a bacterial infectious disease such as this is unlikely with chemotherapy alone. Nevertheless, as a result of the WHO's efforts, patients nearly everywhere should have access to care, and the incidence may begin to diminish if adequate control efforts are maintained beyond the year 2000. Given the mobility of patients today a physician anywhere may occasionally see a case or be asked about the disease so a basic understanding of leprosy and its management should prove useful.

LDH isozymes with anomalous bands in semen of leprosy patients

Activity of LDH isozymes was evaluated electrophoretically on 7% acrylamide gel in semen of 37 leprosy patients (15 with borderline, 12 with borderline tuberculoid and ten with lepromatous leprosy) and ten fertile men of 30-45 years of age. Significantly lower activities were recorded of LDH1 in all categories of leprosy patients. Similarly, lowering of LDH2 activity was noticed in borderline and lepromatous cases only, lowering of LDH4 activity in lepromatous cases only and LDH5 activity was lowered in borderline leprosy patients. Lowest activity of LDH3 and absence of LDHx were found in lepromatous leprosy. However, in borderline tuberculoid patients, LDH3 and LDHx were significantly higher. This exceptional increase in activity was found to be due to presence of additional (anomalous) isozymes bands of LDH3, LDHx and LDH4 in 25% of borderline tuberculoid patients. Additional bands of LDH3 have also been located in 40% of the borderline leprosy patients.

Use of a whole blood assay to monitor the immune response to mycobacterial antigens in leprosy patients: a predictor for type 1 reaction onset?

Longitudinal studies are more appropriate than cross-sectional studies for investigating changes in the immune response to Mycobacterium leprae during leprosy, such as occur in type 1 (reversal) reactions. A test for predicting the onset of reactions in leprosy would greatly reduce disability associated with leprosy. Whole blood assays are appropriate for longitudinal studies of the in vitro T-cell response, as they are robust and reproducible, and require only a small volume of blood. Whole blood assays were used to assess the natural variation in the 'normal' T-cell response to mycobacterial antigens in healthy UK donors, and healthy Nepali donors, tested over 6 months. This was compared with variation in T-cell responses measured over 6 months in 22 leprosy patients in Nepal, including eight who developed type 1 reactions during this time. The in vitro T-cell response to M. leprae sonicate, M. tuberculosis PPD, the mitogen PHA, and (in the UK study) recombinant mycobacterial antigens (70 kD and 30/31 kD proteins) was measured by lymphoproliferation and interferon-gamma (IFN gamma) responses, and variation in responses over time in each subject calculated as a coefficient of variation (CV). The baseline high, low or non-responder status of the healthy UK donors remained stable. The magnitude of IFN gamma responses varied by mean CV ranging from 26% (to PPD) to 63% (to Mtb 70 kD); proliferation responses showed less variation, ranging from mean CV of 18% (to PHA) to 47% (to Mtb 70 kD). Response variation was independent of lymphocyte number in culture. Similar variation in lymphoproliferation responses to MLS, PPD and PHA was observed in the group of healthy Nepali subjects, and in Nepali leprosy patients who did not experience reactions during the study. Of the eight leprosy patients who developed type 1 reactions, four (two BT, one BB, one BL) showed significantly increased proliferation to MLS at the time of reaction (74-300% above baseline); four (one BB, two BL, one LL) remained low or non-responders to MLS throughout. An alternative marker of immune response--anti-phenolic glycolipid-1 (PGL-1) antibody titre--was not predictive of reaction onset in these patients. This study demonstrated that whole blood assays provide reproducible in vitro measurements that can be used to monitor changes in T-cell responses to M. leprae antigens; their practical use as a diagnostic marker of type 1 reaction onset is discussed.

Conjunctival biopsy in patients with leprosy

The authors examined the eyes of 120 leprosy patients comprising of 30 cases each of tuberculoid, indeterminate, borderline and lepromatous leprosy. The investigation included biopsy of the bulbar conjunctiva on the upper temporal quadrant of the right eye. The study patients included both who were untreated, those that were being treated and those who were in observation after the end of treatment. The aim of the study was to identify the presence of M. leprae in the conjunctiva. Four such cases were found: one borderline patient with no treatment and three lepromatous patients who were being treated with MDT.

Articular inflammatory manifestations in patients with different forms of leprosy

OBJECTIVE

To study the articular inflammatory manifestations of leprosy.

METHODS

Sixty patients with leprosy from a public clinic in São Paulo, Brazil, participated in a study regarding their articular manifestations. The diagnosis and classification of leprosy were established by the clinical picture, skin smears, skin biopsy, and delayed hypersensitivity test to Mycobacterium leprae antigens (Mitsuda test). According to the Madrid and Ridley-Jopling classifications, 46 patients had lepromatous leprosy, 7 had borderline leprosy, 4 had tuberculoid leprosy, and 3 had indeterminate leprosy. History, general and articular examinations, and roentgenograms were employed and complemented in several cases by scintigraphic examinations with technetium methylene diphosphonate and computed tomographic studies.

RESULTS

Three patients were excluded from study due to an association with a rheumatic disease. Among the 57 remaining patients, 44 had peripheral arthritis characterized by involvement of small joints (23/44), large joints (4/44), or both (17/44). The mean duration of arthritis was 11 years (range 1 mo to 51 yrs). Arthritis was detected in all subtypes of patients with leprosy. Supplementary radiological evaluation established the extent of inflammation and diagnosis of sacroiliitis. The diagnosis of sacroiliitis, based on the presence of sclerosis, erosions, and narrowing of the cartilage space in the sacroiliac joints, was established in 35 of 55 radiographs. Sacroiliitis varied from grade I to III, according to the Bennet and Wood classification, and was bilateral in most cases (30/35). There was no significant correlation between low back pain and the finding of sacroiliitis.

CONCLUSION

Articular inflammatory manifestations may exist in patients with different forms of leprosy, and can follow a chronic course. In addition, sacroiliitis is a common, previously unrecognized manifestation in patients with leprosy.

Leprosy type 1 reaction as the first manifestation of borderline lepromatous leprosy in a young native German

While leprosy is usually a chronic disease, leprosy reactions may lead to acute problems. These reactions most often occur after initiation of therapy, but can also develop before treatment. Leprosy rarely presents with a reaction. We describe a German patient who presented in this unusual way in order to demonstrate the various tools used to confirm the diagnosis. A young German woman suddenly developed progressive functional loss of the left hand and within a few weeks an increasing number of erythematous macules and nodules appeared. Histological examination of a skin biopsy revealed tuberculoid granulomas, some located around small nerves; acid-fast bacilli were detected microscopically and DNA from Mycobacterium leprae was identified by polymerase chain reaction in the biopsy and a nasal swab; serological tests were positive. The disease was classified as borderline lepromatous leprosy. The acute neuritis followed by skin lesions represented a leprosy type 1 reaction in which the immune system reacts to bacilli previously unrecognized in nerve tissue, both in nerve and skin.

Progress of impairment scores following commencement of chemotherapy in multibacillary leprosy patients

STUDY AIM

To investigate the progress of impairment over time in multibacillary (MB) leprosy patients.

STUDY DESIGN

Retrospective cohort study.

STUDY POPULATION

One-thousand-eighty-two MB patients newly registered in nine field clinics in the Western Region of Nepal between 1980 and 1993.

METHODS

Data on impairment at diagnosis and at yearly intervals afterward were collected from patient records of MB patients already released from multidrug therapy (MDT). The World Health Organization (WHO) 1988 "disability" grading scale (0-2, for both eyes, hands and feet--six sites) was used as a measure of impairment. For the analysis we summed the WHO grading for the six sites into an eyes-hands-feet (EHF) sum score (minimum 0, maximum 12). The EHF score at 2 years of follow up was used to compute the main outcome measures: impairment at 2 years, yes or no, and deterioration of impairment compared with diagnosis. The combined effect of age, sex, classification and impairment status at diagnosis on the outcome was examined with logistic regression.

RESULTS

At diagnosis, 55.8% of the patients had some impairment. This proportion decreased over 2 years to 43.9%. Among patients without initial impairment, 31/310 (10%) developed impairment during the study period. This was 81/396 (20.5%) among patients with impairment at diagnosis. The adjusted odds ratio (OR) for developing impairment was 1.87 [95% confidence interval (CI) 1.06-3.32] for patients with initial sensory impairment (WHO grade 1). and 1.98 (95% CI 1.15-3.4) for those with initial visible deformity (WHO grade 2). Among patients with impairment at diagnosis, 195/396 (49.2%) had improved after 2 years.

CONCLUSIONS

The proportion of patients with impairment after 2 years of antileprosy treatment was 12% less than at diagnosis. Among patients without initial impairment, 10% had developed some impairment after 2 years. The risk of developing impairment was almost double for those with sensory impairment or visible deformity at diagnosis. For purposes of monitoring, evaluation and planning, both the proportion of patients with sensory impairment (WHO grade 1) and the proportion with visible deformity (WHO grade 2) should be reported at diagnosis and at release from treatment.