Diabetic status of patients with leprosy in Kuwait

Shared challenges to the control of complex intracellular neglected pathogens

The complex intracellular pathogens Mycobacterium tuberculosis, Mycobacterium leprae, Leishmania spp., and Burkholderia pseudomallei, which cause tuberculosis, leprosy, leishmaniasis, and melioidosis respectively, represent major health threats with a significant global burden concentrated in low- and middle-income countries. While these diseases vary in their aetiology, pathology and epidemiology, they share key similarities in the biological and sociodemographic factors influencing their incidence and impact worldwide. In particular, their occurrence in resource-limited settings has important implications for research and development, disease prevalence and associated risk factors, as well as access to diagnostics and therapeutics. In accordance with the vision of the VALIDATE (VAccine deveLopment for complex Intracellular neglecteD pAThogeEns) Network, we consider shared challenges to the effective prevention, diagnosis and treatment of these diseases as shaped by both biological and social factors, illustrating the importance of taking an interdisciplinary approach. We further highlight how a cross-pathogen perspective may provide valuable insights for understanding and addressing challenges to the control of all four pathogens.

Lepra Reactions: Mimickers and Mirror to Unmask Complex Cases of Leprosy

Leprosy is a silent disease with protean manifestations, especially during lepra reactions (LRs). Cases with atypical leprosy or LR simulate a number of conditions misdiagnosed frequently. Here, three classical cases of leprosy are reported for their complex presentation. Leprosy was hidden in Case 1 due to co-existing diabetes. COVID vaccination induced LR unmasked all leprosy lesions, which were extensive, large, bizarre and spreading to various immune zones. Case 2 presented with high-grade fever, tachycardia, generalized erythema and body aches. A detailed workup unveiled his leprosy with a rare presentation of Type 1 lepra reaction (T1LR) with erythroderma and severe systemic symptoms. Case 3 mimicked sarcoidosis and lupus erythematosus (LE) on routine workup. She had facial lesions in the malar area, photosensitivity, joint pains, raised angiotensin-converting enzyme (ACE) levels and positive anti-nuclear antibodies. Peri-appendageal granulomas on histopathology and therapeutic response to multidrug therapy helped in the early diagnosis of leprosy.

The efficacy of a whole foods, plant-based dietary lifestyle intervention for the treatment of peripheral neuropathic pain in leprosy: a randomized control trial protocol

Introduction

Despite effective treatment of leprosy via WHO-approved multi-drug therapy (MDT), patients still suffer from debilitating neuropathic sequelae, including peripheral neuropathic pain (PNP), and continue to develop intercurrent etiologies (such as diabetes), and progressive existing neuropathy over time. Strategies seeking to improve physiological and metabolic wellness, including those that reduce systemic inflammation and enhance immune responsiveness to neurotoxic factors may influence underlying neuropathic etiologies. A whole food plant-based diet (WFPBD) has been shown to be effective in the management of neuropathic pain due to diabetes, limiting severity and relevant symptomology. Diabetes remains a significant sequela of leprosy, as up to 50% of patients in reaction requiring corticosteroids, may develop a biochemical diabetes. As nutritional interventions may modulate both leprosy and diabetes, a specific exploration of these relationships remains relevant.

Objectives

(1) To demonstrate the effect of a WFPBD lifestyle intervention, on neuropathic pain variables in leprosy; and (2) To contextualize the significance of diet in the treatment of chronic sequelae in leprosy by evaluating tolerability and side effect profile.

Methods

A prospective, randomized, controlled, single-blind, multicentre interventional trial is described. Weekly one-hour dietary counseling sessions promoting a WFPBD emphasizing vegetables, fruits, whole-grains, nuts, and legumes, omitting animal products, and limiting fat intake over a six-month duration will be implemented. Participants will be 70 age and sex-matched individuals experiencing active or treated "cured" leprosy and PNP, randomized to either intervention or control groups. Primary outcome measures include efficacy via visual analog scale, subjective questionnaire and objective quantitative sensory testing, as well as safety, tolerability, and harms of a WFPBD on PNP in leprosy. This study will be initiated after Research Ethics Board (REB) approval at all participating sites, and in advance of study initiation, the trial will be registered at ClinicalTrials.gov.

Expected impact

It is hypothesized that WFPBDs will mitigate progression and severity of PNP and potentially reduce the adverse events related to standard corticosteroid treatment of leprosy reactions, thereby reducing disease severity. By examining the effects of WFPBDs on PNP in leprosy, we hope to illuminate data that will lead to the enhanced therapeutic management of this neglected tropical disease.

The impact of single-cell genomics on the field of mycobacterial infection

Genome sequencing projects of humans and other organisms reinforced that the complexity of biological systems is largely attributed to the tight regulation of gene expression at the epigenome and RNA levels. As a consequence, plenty of technological developments arose to increase the sequencing resolution to the cell dimension creating the single-cell genomics research field. Single-cell RNA sequencing (scRNA-seq) is leading the advances in this topic and comprises a vast array of different methodologies. scRNA-seq and its variants are more and more used in life science and biomedical research since they provide unbiased transcriptomic sequencing of large populations of individual cells. These methods go beyond the previous “bulk” methodologies and sculpt the biological understanding of cellular heterogeneity and dynamic transcriptomic states of cellular populations in immunology, oncology, and developmental biology fields. Despite the large burden caused by mycobacterial infections, advances in this field obtained via single-cell genomics had been comparatively modest. Nonetheless, seminal research publications using single-cell transcriptomics to study host cells infected by mycobacteria have become recently available. Here, we review these works summarizing the most impactful findings and emphasizing the different and recent single-cell methodologies used, potential issues, and problems. In addition, we aim at providing insights into current research gaps and potential future developments related to the use of single-cell genomics to study mycobacterial infection.

A review of nutrition in neuropathic pain of leprosy

Leprosy is a neglected tropical disease (NTD) that continues to burden low- and middle-income countries (LMICs), despite being eliminated as a public health concern by the World Health Organization (WHO) in 2000. The causative agents, Mycobacterium leprae and Mycobacterium lepromatosis, affect nearly 200,000 individuals globally each year, with over 19,000 new cases detected in the Americas in 2020 alone. Canada has experienced an increasing incidence of leprosy, due to rising levels of travel and migration from endemic areas, reaching over 37,000 individuals with leprosy by the end of 2020. Patients experience a spectrum of signs and symptoms including hypopigmented cutaneous macules alongside peripheral neuropathy including peripheral neuropathic pain (PNP) and disabling sensory neuropathies. Despite the development of effective and curative therapeutics via multidrug therapy (MDT), many barriers to treatment adherence and effective immunological control of the pathogen challenge the care of patients with leprosy. Socioeconomic barriers, such as disability-related social stigma and often undiagnosed nutritional deficiencies, have resulted in heightened disease severity. PNP therapeutics are associated with significant side effects and remain ineffective as the majority of individuals will not experience a greater than 30% reduction of symptoms. Nutrient supplementation is known to be instrumental in reducing host oxidative stress, strengthening the immune system and mitigating comorbidities. Likewise, dietary lifestyle interventions known to be physiologically beneficial have recently emerged as powerful tools conferring neuroprotective effects, potentially mitigating PNP severity. However, a significant knowledge gap concerning the effect of adequate nutrition on host immunological control of leprosy and PNP severity exists. Further evaluation of this relationship will provide key insight into the pathogenesis of leprosy, strengthening the current body of literature.

Causes of Death among Persons Affected by Leprosy in Korea, 2010-2013

In addition to the complications of leprosy, people affected by leprosy (PALs) can suffer from chronic diseases. We evaluated the recent pattern of deaths among Korean PALs and compared it with that in the general population. We analyzed the death certificate data of 1,359 PALs from 2010 through 2013. The all-cause and cause-specific standardized mortality ratio (SMR) and standardized mortality with 95% CI were calculated. Malignancy had the highest standardized mortality, with 130.9 deaths per 100,000 persons, followed by cardiovascular diseases (CVDs; 85.5 deaths) and respiratory diseases (38.2 deaths). Of malignancies, liver cancer caused the greatest number of cancer deaths (40.0 deaths). The all-cause mortality of PALs was significantly lower than that in the general population, corresponding to an SMR of 0.84 (95% CI 0.79-0.88). Deaths from malignancy and CVDs were significantly lower, corresponding to SMRs (95% CIs) of 0.88 (0.79-0.98) and 0.75 (0.67-0.84), respectively. The death rates for lung and stomach cancers were lower, whereas mortality due to liver cancer was higher, with an SMR of 1.79 (95% CI 1.43-2.22). Except for liver cancer and infection, the causes of mortality of PALs tend to be lower than that in the general population. The most common underlying cause of death in PALs was stroke, followed by ischemic heart disease, liver cancer, and pneumonia.

Risk factor for <em>Mycobacterium leprae</em> detection in household contacts with leprosy patients: a study in Papua, East Indonesia

BACKGROUND In the era of leprosy eradication, Jayapura is still one of the biggest leprosy pockets in Papua, Indonesia. The trend for leprosy case detection rate has remained relatively stable over recent years. This study was aimed to detect Mycobacterium leprae in household contacts and to evaluate the associated factors with the detection. METHODS This cross-sectional study recruited household contacts of leprosy patients who were diagnosed consecutively from March to August 2015 in Hamadi Point of Care, Jayapura. The leprosy patients were diagnosed using polymerase chain reaction (PCR). For each leprosy patient, up to four household contacts that had no symptom were included. Every household contact received screening through DNA detection of M. leprae extracted from nasal swab specimens and examined using PCR. Factors for bacteria detection included intensity, time duration and number of contacts living together in the same house, and random blood glucose levels were evaluated. Bivariate analysis was used to associate them with M. leprae detection in household contacts. RESULTS From 107 household contacts of 35 patients who had leprosy, M. leprae was detected in 19.6%. Household contacts with leprosy patients for >1 year was a risk factor for detection (OR = 12.45; 95% CI = 1.595–97.20; p = 0.002). Blood glucose (p = 0.444), ethnic (p = 0.456), sleeping proximity to leprosy case (p = 0.468) and relatives (p = 0.518) give no effect to M. leprae detection in household contacts. CONCLUSIONS Among the various risk factors studied, duration of living together with the patient significantly increased the risk of M. leprae transmission.

The double burden of diabetes and global infection in low and middle-income countries

Four out of five people in the world with diabetes now live in low- and middle-income countries (LMIC), and the incidence of diabetes is accelerating in poorer communities. Diabetes increases susceptibility to infection and worsens outcomes for some of the world’s major infectious diseases such as tuberculosis, melioidosis and dengue, but the relationship between diabetes and many neglected tropical diseases is yet to be accurately characterised. There is some evidence that chronic viral infections such as hepatitis B and HIV may predispose to the development of type 2 diabetes by chronic inflammatory and immunometabolic mechanisms. Helminth infections such as schistosomiasis may be protective against the development of diabetes, and this finding opens up new territory for discovery of novel therapeutics for the prevention and treatment of diabetes. A greater understanding of the impact of diabetes on risks and outcomes for infections causing significant diseases in LMIC is essential in order to develop vaccines and therapies for the growing number of people with diabetes at risk of infection, and to prioritise research agendas, public health interventions and policy. This review seeks to give an overview of the current international diabetes burden, the evidence for interactions between diabetes and infection, immune mechanisms for the interaction, and potential interventions to tackle the dual burden of diabetes and infection.

The global diabetes epidemic: what does it mean for infectious diseases in tropical countries?

Tropical countries are experiencing a substantial rise in type 2 diabetes, which is often undiagnosed or poorly controlled. Since diabetes is a risk factor for many infectious diseases, this increase probably adds to the large infectious disease burden in tropical countries. We reviewed the literature to investigate the interface between diabetes and infections in tropical countries, including the WHO-defined neglected tropical diseases. Although solid data are sparse, patients with diabetes living in tropical countries most likely face increased risks of common and health-care-associated infections, as well as infected foot ulcers, which often lead to amputation. There is strong evidence that diabetes increases the severity of some endemic infections such as tuberculosis, melioidosis, and dengue virus infection. Some HIV and antiparasitic drugs might induce diabetes, whereas helminth infections appear to afford some protection against future diabetes. But there are no or very scarce data for most tropical infections and for possible biological mechanisms underlying associations with diabetes. The rise in diabetes and other non-communicable diseases puts a heavy toll on health systems in tropical countries. On the other hand, complications common to both diabetes and some tropical infections might provide an opportunity for shared services-for example, for eye health (trachoma and onchocerciasis), ulcer care (leprosy), or renal support (schistosomiasis). More research about the interaction of diabetes and infections in tropical countries is needed, and the infectious disease burden in these countries is another reason to step up global efforts to improve prevention and care for diabetes.

Sanitation for all: the global opportunity to increase transgenerational health gains and better understand the link between NCDs and NTDs, a scoping review

The global sanitation divide is narrowing. However, in many countries in Asia and Africa, the gap between rural and urban sanitation coverage is rather widening. Moreover, there is an increase in the burden of non-communicable diseases (NCDs), notwithstanding to the already high burden of neglected tropical diseases (NTDs). A scientific query is building on how the global 'sanitation for all' goal will address the dual burden of NTDs and NCDs, and help further understand the link between the two. This paper aims to discuss the link between i) sanitation and NTDs, and ii) sanitation and NCDs through a scoping review of the literature.

The clinical & neurophysiological study of leprosy

OBJECTIVES

The aim of this study was to evaluate neurological and neurophysiological features of leprosy.

METHODS

Seventy seven hospitalized leprosy patients (52 male, 25 female) were examined neurological and neurophysiologically between 2010 and 2012. Standard procedures were performed for evaluating sensory and motor conduction studies to all patients. Motor studies were carried out on median, ulnar, tibial and common peroneal nerves. Sensory studies were carried out on median, ulnar and sural nerves. Sympathetic skin response (SSR) recordings on both hands and feet, and the heart rate (R-R) interval variation (RRIV) recordings on precordial region were done in order to evaluate the autonomic dysfunction.

RESULTS

The mean age was 59.11±14.95 years ranging between 17 and 80 years. The mean duration of disease was 35.58±18.30 years. Clinically, the patients had severe deformity and disability. In neurophysiological examinations, sensory, motor conduction studies of the lower extremities were found to be more severely affected than upper, and sensory impairment predominated over motor. Abnormal SSRs were recorded in 63 (81.8%) cases of leprosy. Abnormal RRIVs were recorded in 41 (53.2%) cases and abnormal RRIVs with hyperventilation were recorded in 55 (71.4%) cases of leprosy. Significant differences were found between SSR and sensory conduction parameters of median, ulnar nerves as well as motor conduction parameters of median, ulnar and peroneal nerves (p<0.05).

CONCLUSION

Peripheral nervous system dysfunction is accompanied by autonomic nervous system dysfunction in leprosy patients. Sympathetic involvement may predominate over parasympathetic involvement.