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HANSENS DISEASE LEPROSY chronic granulomatous disease skin, peripheral nerves,upper respiratory tract eyes First discovered in 1873

in 1873 by Norweigan physician, Gerhard, Henrik, Armauer Hansen Swan cell of peripheral and cutaneous nerves Prevalence in endemic areas reduce but continuous to be the same Philippines is the largest contributor of new leprosy cases in 2005 MB cases account for 94.3%

To prematurely consign leprosy to history books guarantees unnecessary future morbidity-K. J. Thompson YEAR 2002 2003 2004 2005 2006 2007 RANK 2 4 2 2 5 2 NUMBERS 1752 971 1067 1224 990 1224

DEFINITION OF A CASE LEPROSY A person having one or more of the following features, and who has still to complete a full course of treatment THE THREE CARDINAL SIGNS OF LEPROSY Hypopigmented or reddish skin lesions with definite loss of sensation Involvement of peripheral nerves( thickening, loss of sensation Skin smear positive for acid fast bacilli

Retrieve defaulters with signs of active disease Relapse patient who previously completed a full course treatment Does not include - Cured persons with late reactions - Or residual disabilities

CLINICAL SPECTRUM TT (cell mediated immunity) BT BB BL LL( antibody response) WHO MULTI-DRUG THERAPY PAUCIBACILLARY (I or TT OR BT) Rifampicin 600 mg monthly Dapsone 100 mg daily 6-9 month treatment MULTIBACILLARY Rifampicin 600 mg monthly Dapsone 100 mg daily Clofazimine 300 mg monthly +50 mg daily 1 year treatment

ROM REGIMEN Single Lesion Paucibacillary (SLPB) Rifampicin 600mg Ofloxacin 400 mg Minocyclin 100 mg Single dose

Nerve Function Assessment Monofilament (sensory )testing/ ballpen testing, nylon monofilament testing Voluntary muscle testing

Nerve examination sites Sensory Zygomatic Marginal mandibular Cervical Facial Trigeminal Median Ulnar

Sensory testing Cornea (Surface of the eye) Blinking < 5 blinks per minute= loss of sensation of cornea Self-care (sun glasses) Stopped blinking within 6 months--steroids Voluntary Muscle testing Test motor function by resistance Strong (normal) weak, paralyzed Strengthening exercise for loss of function Loss of function within 6 months must be treated with steroids MOTOR NERVE TESTED KEY MOVEMENT Facial Tight eye closure Ulnar Little finger out Median Thumps up Radial wrist up Common Peroneal Foot up

VOLUNTARY MUSCLE GRADING SCALE Muscle grade SWP scale MRC scale STRONG 5 4 3 WEAK 2 Range of motion Resistance Intervention

Complete Complete Complete Reduced Muscle Flicker none

Full Reduced None None None None

Normal Muscle, no intervention needed Monitor patient for possible NFI If < 12 mos,: prednisolone treatment and rest/ splinting If > 12 mos, do passive ROM exercises to prevent joint stiffness

1 PARALYZED 0

WHO GRADING OF DISABILITIES HANDS AND FEET Grade 0 Grade 1 Grade 3

No anesthesia No visible deformity/damage Anesthesia No visible deformity/damage Anesthesia Visible Deformity/ damage

TREATMENT OF LEPROSY IN SPECIAL SITUATIONS: Patient cannot take rifampicin Length of treatment 6 months Drug Clofazimine Ofloxacin Minocyclin Clofazimine + either Ofloxacin or minocycline Dose 50 mg daily 400 mg daily 100 mg daily 50 mg daily 400 mg daily 100 mg daily

followed by additional 18 mos

Patient cannot take clofazimine: 24 month regimen MDT Rifampicin 600 mg once a month Ofloxacin 100 mg once a month Dapsone 100 mg daily

Patient cannot take dapsone: Rifampicin 600 mg once a month with supervision Clomazipine 300 mg once a month under supervision and 50 mg daily without supervision Pregnancy and lactation Continue MDT Do not start MDT during first trimester of pregnancy Single dose treatment for single lesion PB leprosy deffered until delivery Reactions in leprosy Rapid shift from pole to the other produces an inflammatory reaction May occur in any type but more commonly in multi-bacillary type Response to dead bacteria May develop after treatment is completed 30% of leprosy cases will have reactions

REVERSAL REACTION TYPE I TYPE/CLASSIFICATION PB AND MB ETIOLOGY -change in delayed hypersensitivity to M. Leprae -associated increase in specific CMI in those patient sundergoing a shift in communication whether slight or marked MANIFESTATIONS -lesions gradually become swollen and erythematous -last weeks or months -fever rare

ERYTHEMA NODOSUM (TYPE II) MB only -immune complex disease

-crops of painful papules developing in a few hours and lasting for a few days - successive crops occur over months/ years, fever pain present -neuritis, iritis, orchitis, LAD, arthritis, proteinuria, ulcerations

COMPLICATION

-skin ulceration, laceration, paralysis, anesthesia

Major cause of nerve damage in leprosy ENL (TYPE II REACTION) Erythema nodosum leprosum with the appearance of multiple papulomodules in a patient with lepromatous leprosy.

TYPE 1 REACTION increased edema

presence of satellite lesions nerve tenderness

TREATMENT OF LEPRAE REACTIONS TYPE I: Prednisone (20-60 mg per day) TYPE II: Thalidomide (100- 200 mg per day)

If prednisone is contraindicated or insufficient to control recurrence, may give Clofazimine 300 mg/ day during the first month 200 mg/ day during the second month 100 mg/ day during the third month

NERVE FUNCTION IMPAIRMENT Nerve damage (anesthesia, pain, muscle weakness, dryness of the skin)---misuse of limb--- Ulceration, infection, deformity--STIGMA SEQUELAE OF LEPROSY Madarosis- loss of eye brow Lagopthalmos Gynecomastia Papal hand sign, contracture of 4th and 5th fingers, ulnar nerve movement hand flexion contraction of all fingers Orchitis leading to sterility Shortening of digits Foot drop Neuropathic ulcers of plantar surface (sensory neuropathy)

SUMMARY Leprosy is curable with MDT if taken regularly and continuously Leprosy becomes non- infectious after taking MDT MDT packs are available in government rural health units, free of charge During the course of treatment leprosy may occur Impairments of eyes, hands and feet are preventable

MIMICKERS OF LEPROSY Is it really leprosy? Hyposthethic skin lesions Chronic dermatitis (thickened skin) Enlarged peripheral Nerve Poor examination technique Nonspecific enlargement ex. Manual workers, athletes

Pityriasis versicolor-lepromatous leprosy Pityriasis alba-indeterminate leprosy Tuberculoid leprosy- post inflammatory hypopigmentation Tinea corporis Leukemia cutis=ENL Borderline tuberculoid= Psoriasis Histoid leprosy= Neurofibromatosis Lupus Vulgaris= borderline leprosy

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