Pennsylvania State University

Leprosy
Mycobacterium leprae & Mycobacterium lepromatosis

Jane Chung
Microbiology 201 Honors
Dr. Porter
November 29, 2016

Chung
2
Introduction:
In numerous accounts in the bible, leprosy is mentioned. It has said that lepers, people
with leprosy, were told to leave the community because of their disease. Many people feared this
disease that was commonly associated with uncleanliness and sin. Famously, many people know
the story of how Jesus performed a miracle and healed a leper. Nowadays, we only hear of this
ancient disease in church, but it is not an immediate concern anymore in industrialized societies.
However, it might be careless for people to forget about the bacteria that causes leprosy
simply because it no longer seems relevant to the human population. This is because leprosy
causing bacteria, Mycobacterium leprae and Mycobacterium lepromatosis has been found in
industrialized societies. This time, these bacteria have been using squirrels as hosts when most
scientists thought Mycobacterium leprae and Mycobacterium lepromatosis strictly infected
humans, with the exception of armadillos in the Americas. Additionally, there has been an
increasingly amount of cases of Mycobacterium lepromatosis in S. vulgaris red squirrels, an
endangered species (Avanzi et al., 2016). Therefore, M. leprae and M. lepromatosis needs to be
further monitored to see its potential implications to humans and the environment.
This research paper will outline a good portion of the research and information about M.
leprae and M. lepromatosis, showing what researchers already know and what researchers need
to continue researching on. Specifically, this research paper will go through characteristics of M.
leprae, pathology of M. leprae, the symptoms, diagnosis, and treatment of leprosy, M.
lepromatosis, and epidemiology of leprosy.
Characteristics of M. leprae
M. leprae is a rod-shaped (bacillus) animal pathogen that is sized and shaped similarly to
Mycobacterium tuberculosis, about 3-10 microns long. It usually bundles together in palisades

Chung
3
and form clumps or globi in lepra cells. Though it is primarily rod shaped, it can also be seen in
spherical forms (WHO). Mycobacterium leprae belongs to the genus Mycobacterium, which is
characterized by the mycolic acid layer on their cell walls. This mycolic acid layer gives the cell
wall a waxy surface and is hard to penetrate (Porter). Therefore, M. leprae must be stained
through acid-fast stain, and has a long doubling time. This long doubling time, which will be
discussed in detail in the next section, is because many nutrients cannot be transported through
the pores of its mycolic acid layer (Cole et al., 2001).
Cole et al. (2001) was able to sequence the whole genome of M. leprae and found that it
lost many of its genes through evolution. M. leprae consists of one circular chromosome of
3,268,203 bps. 50% of its genes are pseudogenes and are non-functional. It is estimated that it
lost more than 2,000 genes. About 27% of these pseudogenes are still expressed in M.
tuberculosis, indicating that M. leprae lost these genes due to reductive evolution (Cole et al.,
2001).
Moreover, there is still difficulty in determining some characteristics and mechanisms
related to M. leprae because it cannot be grown in vitro. Instead, researchers have to collect
limited information by growing M. leprae in vivo with genetically engineered rats and armadillos
(Telis, 2013). Hopefully, researchers will develop better techniques to research M. leprae and its
mechanisms.
Pathology:
Mycobacterium leprae is believed to enter the human body through the respiratory
system (Chapter 5: Pathogenesis). It also may be possible that Mycobacteirum leprae can enter
through the skin, but that has not been confirmed. Also, the presence of M. leprae in nasal
secretions of lepromatous patients shows that M. leprae can be transmitted through nasal

Chung
4
mucous. There could be up to 10 million living M. leprae per day in a nasal secretion (Bhat &
Prakash, 2012). Researchers have also found M. leprae in the superficial keratin layer of
lepromatous patients, suggesting that the organism could exit along with the sebaceous
secretions (Scollard). These modes of transmission are still up to debate, though transmission
through nasal mucous is widely accepted.
Once inside the nose, it can bind the fibronectin protein present in the nasal mucous.
Then, the fibronectin protein can help M. leprae adhere to the nasal epithelial cell by using the
fibronectin receptors on the nasal epithelial cell (Byrd et al., 2003). After binding to nasal
epithelial cells, M. leprae usually travels to neural tissue, but it can also be found in
macrophages, muscle cells, and endothelial cells in blood vessels. M. leprae specifically enters
the Schwann cells of the neural tissue. But because it prefers cooler temperatures, it enters the
Scwann cells in the cutaneous nerves and peripheral nerves in the face and the limbs (Chapter 5:
Pathogenesis). This is done by using its ligand, PGL-1 glycolipid to attach to laminin-2 and its
receptors called a-dystroglycan. Laminin-2 is a protein constitutent of the extracellular basal
lamina and a-dystroglycan is a part of the dystroglycan complex in the plasma membrane of
Schwann cells. M. leprae specifically colonizes non-myelinating Schwann cells, but it can also
cause damage to myelinating Schwann cells through attachment, and then inducing
demyelination on its peripheral nerves, which leads to Schwann cell dedifferentiation. This
dedifferentiation makes non-myelinating Schwann cells similar to myelinating Schwann cells,
enabling M. leprae to invade with ease. It induces demyelination by its PGL-1 interfering with
the DRP2-dystroglycan complex that is needed for myelination (Brophy, 2002). Specifically,
bacterial ligation with the neuregulin receptor ErbB2 and thus its activation, decreases the
signaling of Erk1/2. This downregulation of Erk1/2 leads to demyelination, which leads to

Chung
5
degeneration of its associated axons (Tapinos et al., 2006). Note that this degeneration lead to the
neuropathic symptoms in the human body.
Inside the cells, the bacilli start to grow and multiply. It takes about 12-14 days to divide
from one to two, indicating how slow its growth can be. After sufficient growth in one cell, it
will burst out and infect many other surrounding cells, encouraging growth (Chapter 5:
Pathogenesis). The incubation period of M. leprae is still uncertain, though there have been
cases as early as a few weeks to 30 years. The average incubation period is about three to ten
years (Bhat & Prakash, 2012).
Soon after, the bodys immune system will react to the infected cells and utilize its
macrophages. However, it depends on the strength of ones immune system that determines the
symptoms and types of leprosy because of its effectiveness in eradicating the bacteria. Because
of strong cell mediated immunity, most people are immune to developing leprosy. A strong cell
mediated immunity response can result in no symptoms at all, eventual healing of the skin
lesions, or Pauci-bacillary leprosy (Chapter 5: Pathogenesis). This is also known as
Tuberculoid and Borderline Tuberculoid leprosy, and these types of leprosy are more mild and
less contagious than Multi-bacillary leprosy (Bhat & Prakash, 2012). In the body of a strong cell
mediated immunity, granuloma formation occurs in the cutaneous nerves due to the
macrophages. Eventually, the cutaneous nerve swells and dies because despite the invasion of
only a few fascicles, M. leprae produces an inflammation response in the epineurium. There, the
inflamed epineurium compresses and destroys the unmyelinated sensory and autonomic fibers
first and then the myelinated motor fibers. The strong cell mediated response usually contains the
damage to only the Schwann cell nerve, though M. leprae can also migrate to the skin anytime
and create skin lesions. However, sometimes Pauci-bacillary leprosy may turn into Multi-

Chung
6
bacillary leprosy if left untreated. Multi-bacillary leprosy occurs in weak cell mediated immunity
(Chapter 5: Pathogenesis). Multi-bacillary is also known as Midborderline, Borderline
lepromatous and Lepromatous leprosy, with Lepromatous leprosy being the most severe form
(Bhat & Prakash, 2012). M. leprae remains unnoticed in the body, multiples and destroys the
nerve. Once it bursts out of the infected cells, it can be engulfed by macrophages. This gives it
the ability to not only multiply in the macrophages, but also to travel to different areas of the
body to infect (Chapter 5: Pathogenesis). There, it spreads to other parts of the body like the
skin, the liver and some other organs (Scollard). If left untreated, M. leprae can further damage
the body and lead to disability.
Symptoms of Leprosy
As mentioned previously, infection of M. leprae mainly affects the skin and the
peripheral nerves. In skin lesions, it is usually hypo-pigmented and variable in size and number.
Also, the type of skin lesions that form is variable, from macule (flat) to papules or nodules
(raised). The texture of the skin lesions can either be dull and dry, or shiny and soft. On the
surface, little hair growth is seen in addition to a loss of sweating. These areas have either a
reduced sensation or a loss of sensation to heat, touch and pain (numbness) (Chapter 5:
Pathogenesis). This loss of sensation can lead to further injuries in those areas of the body
because the injuries can remain unnoticed. Figure 2 illustrates the differences between the types
of leprosy based on skin lesions. For the peripheral nerves, infection may lead to enlarged
nerves, muscle weakness or paralysis. Damage in the peripheral nerves of the eyes lead to eye
complications including blindness (Hansens Disease). The infection can also affect mucous
membranes of the upper respiratory tract. These membranes may swell, thicken and ulcerate

Chung
7
(Chapter 5: Pathogenesis). Therefore, this may result in nosebleeds and a stuffy nose
(Hansens Disease).
Diagnosis of Leprosy
Because M. leprae cannot be cultured, it cannot be identified using basic laboratory tests.
Instead, doctors can perform a variety of tests like PCR, immunological tests, slit-skin smear
tests, or biopsies as a means to diagnose leprosy. However, none of these tests can be used alone
to confirm leprosy due to its disadvantages. For example, PCR, which can identify the DNA of
M. leprae, can easily test false positive due to contamination. Immunological tests like the
lepromin test only tests positive for certain types of leprosy like Tuberculoid leprosy. The slitskin smear test smears dermal fluid from both ear lobes, both knees, both elbows, and other areas
with skin lesions onto slides. These smears are air-dried, heat-fixed and Fite stained. (Fite stain
enhances the acid-fast characteristic of M. leprae as its acid-fast is weak.) Then, the samples are
examined under the microscope for the number of acid-fast microorganisms per oil-immersion
field. Then, it is scored with the Bacteriological Index as seen in Figure 3. For skin lesions
biopsies, acid-fast microorganisms are also analyzed after being Fite stained. Unfortunately,
biopsies and slit-skin smear tests may not always result in acid-fast microorganisms even though
someone is infected with M. leprae. In these situations, doctors must rely on observations of
perineural and/or granuloma inflammation in addition to several symptoms, dermatological
findings, or a history of possible exposure (Scollard). This can usually be diagnosed as Paucibacillary leprosy.
Treatment of Leprosy
To treat leprosy, a multidrug therapy regime is used in order to lower the possibility of
resistance strains forming from monotherapy. Based on WHO guidelines, Pauci-bacillary

Chung
8
patients at adult age take Dapsone (100mg) daily and Rifampicin (600mg) monthly for six
months. For Multi-bacillary adult patients, they must take Dapsone (100mg) daily, Rifampicin
(600mg) monthly, 50 mg of Clofazimine daily, and 300 mg of Clofazimine monthly for 12
months (WHO, 1998).
On a cellular basis, Dapsone inhibits the production of folic acid that is needed for
growth in M. leprae by inhibiting dihydropteroate synthase. This prevents the incorporation of
para-aminobenzoic acid into dihydropteric acid. Dihydropteric acid is the predecessor of folic
acid (Atrix Laboratories Inc., 2005). In regards to Rifampicin, the drug inhibits bacterial DNAdependent RNA polymerase activity (Sanofi-Aventis, 2010). While the exact mechanism of how
Clofazimine works as a bactericidal for M. leprae, it is thought to target and bind to
mycobacterial DNA, disrupting the cell cycle. It is also hypothesized that Clofazimine binds and
inhibits bacterial potassium transporters (Wishart, 2006).
Mycobacterium lepromatosis
The diffuse form of lepromatous leprosy is characterized by large scattered cutaneous
lesions that ulcerate, blood clot in a deep artery or vein, and the pathogenic bacilli present in the
walls of blood vessels. Moreover, there is inflammation in the vessels along with diffuse nonnodular infiltration of the skin that has been compared to myxedema (Prem anand et al., 2014).
The diffuse form of lepromatous leprosy is often mainly found in western Mexico and in the
Caribbean countries (Hans et al., 2008). Han et al. (2008) performed an autopsy on the tissue of
two Mexican immigrants who died from diffuse lepromatous leprosy. They found that the
microorganism responsible for the DLL in both patients was not M. leprae but a new
microorganism because the microbe had a 2.1% divergence in the 16s rRNA gene, and 6-14%
mismatches in other genes compared to M. leprae. They called it Mycobacterium lepromatosis.

Chung
9
Along with these two cases in Mexico, Han et al. (2008) found two other DLL cases in
Singapore where M. lepromatosis was responsible. Han et al. (2008) hypothesizes that some
characteristic of M. lepromatosis causes the diffuse form of lepromatous leprosy. It appears to be
very similar to M. leprae,as it prefers cooler temperatures and cannot be cultivated. However,
there may be shorter doubling time than M. leprae, which is 14 days (Han et al., 2008).
Currently, there is little clinical significance to determine which microorganisms is responsible
for the leprosy because it can be treated with the same drug therapy that is used for M. leprae.
However, research must be done to further the knowledge about M. lepromatosis, M. leprae, and
the epidemiology of leprosy (Scollard, 2016).
Epidemiology of Leprosy:
As mentioned earlier, leprosy cases have essentially been eliminated in industrialized
societies like the UK and the U.S.A, but it is still present in countries such as Brazil and India. In
countries still affected by leprosy, there has been a significant decline of case due to the many
campaigns launched to decrease and eliminate leprosy. A large portion responsible for this
eradication is the World Health Organization. WHO has continuously fought the elimination of
leprosy, making treatment and diagnoses more available. In the beginning of 2015, the global
prevalence rate was 211, 973 new cases. By the end of 2015, the global prevalence rate reached
176, 176 new cases or 0.2 cases per 10,000 people. It is important to note that these new cases
are highly concentrated (94% of the new cases) in 14 countries that had more than 1,000 cases,
showing its high endemicity in certain areas (World Health Organization, 2016). Figure 1 shows
the approximate number of cases found in each country. Also, it must be considered that real
prevalence rates may be higher than reported because the criteria for prevalence rates dictates
whether or not a case may be accounted for. For example, the reported prevalence rates may have

Chung
10
excluded recurrent cases and treatment dropout cases (Lastria & Morgado de Abreu, 2014).
Despite the overall prevalence rates declining, WHO has remained diligent in combatting leprosy
in highly affected areas. Recently, WHO has launched a new global campaign focused on
training health care professionals on treating leprosy, increasing treatment seeking, and visible
disabilities caused by leprosy. This initiative is called The Global Leprosy Strategy 2016-2020:
Accelerating towards a leprosy-free world (World Health Organization, 2016). Hopefully, this
will be a successful initiative in eradicating leprosy in humans worldwide.
Conclusion: M. leprae & M. lepromatosis in Animals
To reiterate, researchers have found a greater increase of squirrels infected with M.
leprae and M. lepromatosis. They found M. leprae in Brownsea Island, England, while they
found M. lepromatosis in the British Isles, England, Scotland, and Ireland. The most important
finding, however, was finding M. lepromatosis in the British Isles because it was completely
eradicated from there many years ago. This unexpected discovery may imply how a
microorganism can persist in the environment despite eradication (Avanzi et al., 2016). This
discovery also has many implications and questions. If there is a greater increase of these bacilli
in squirrels, it may be possible that squirrels can transmit their infection onto humans. This can
be problematic for WHOs initiative to completely eradicate leprosy worldwide by 2020.
Therefore, further research must be done in order to learn more about the M. leprae and M.
lepromatosis in these squirrels, along with continual research on the new species M.
lepromatosis.

Chung
11
References
Atrix Laboratories Inc. Microbiology Review. Federal Drug Administration, 2005. Web.
Avanzi, C., J. Del-Pozo, A. Benjak, K. Stevenson, V. R. Simpson, P. Busso, J. Mcluckie, C.
Loiseau, C. Lawton, J. Schoening, D. J. Shaw, J. Piton, L. Vera-Cabrera, J. S. VelardeFelix, F. Mcdermott, S. V. Gordon, S. T. Cole, and A. L. Meredith. Red Squirrels in the
British Isles Are Infected with Leprosy Bacilli. Science 354.6313 (2016): 744-47. Web.
Bhat, Ramesh Marne, and Chaitra Prakash. Leprosy: An Overview of Pathophysiology.
Interdisciplinary Perspectives on Infectious Diseases 2012 (2012): 1-6. Web.
Brophy, Peter J. Microbiology: Subversion of Schwann Cells and the Leper's Bell. Science
296.5569 (2002): 862-63. Web.
Byrd, Sally R., Robert Gelber, and Luiz E. Bermudez. Roles of Soluble Fibronectin and 1
Integrin Receptors in the Binding of Mycobacterium Leprae to Nasal Epithelial Cells.
Clinical Immunology and Immunopathology 69.3 (1993): 266-71. Web.
Chapter 5: Pathogenesis. Government of India: Ministry of Health & Family Welfare. Web.
http://nlep.nic.in/pdf/Ch%205%20Pathogenesis.pdf
Cole, S. T., K. Eiglmeier, J. Parkhill, K. D. James, N. R. Thomson, P. R. Wheeler, N. Honor,
T. Garnier, C. Churcher, D. Harris, K. Mungall, D. Basham, D. Brown, T. Chillingworth,
R. Connor, R. M. Davies, K. Devlin, S. Duthoy, T. Feltwell, A. Fraser, N. Hamlin, S.
Holroyd, T. Hornsby, K. Jagels, C. Lacroix, J. Maclean, S. Moule, L. Murphy, K. Oliver,
M. A. Quail, M.-A. Rajandream, K. M. Rutherford, S. Rutter, K. Seeger, S. Simon, M.
Simmonds, J. Skelton, R. Squares, S. Squares, K. Stevens, K. Taylor, S. Whitehead, J. R.
Woodward, and B. G. Barrell. Massive Gene Decay in the Leprosy Bacillus. Nature
409.6823 (2001): 1007-011. Web.

Chung
12
Hansen's Disease (Leprosy)-Signs and Symptoms. Centers for Disease Control and Prevention.
Centers for Disease Control and Prevention, 29 Apr. 2013. Web.
Lastoria, Joel Carlos, and Marilda Aparecida Milanez Morgado De Abreu. Leprosy: Review of
the Epidemiological, Clinical, and Etiopathogenic Aspects Part 1. Brazilian Annals of
Dermatology 89.2 (2014): 205-18. Web.
Porter, Ronald. Topic 7: Taxonomy-Diversity Overview. Honors Microbiology 201. The
Pennsylvania State University-UP, Pennsylvania. 4 Oct. 2016.
Prem Anand, P., Neetu Oommen, S. Sunil, M.s. Deepa, and Mythri Potturu. Pretty Leprosy:
Another Face of Hansens Disease! A Review. Egyptian Journal of Chest Diseases and
Tuberculosis 63.4 (2014): 1087-090. Web.
Sanofi-Aventis. Rifadin Federal Drug Administration, Nov. 2010. Web.
Scollard, David M. Infection with Mycobacterium Lepromatosis. American Journal of
Tropical Medicine and Hygiene 95.3 (2016): 500-01. Web.
Scollard, David M. Pathology and Pathogenesis of Leprosy. International Textbook of Leprosy.
Tapinos, Nikos, Makoto Ohnishi, and Anura Rambukkana. ErbB2 Receptor Tyrosine Kinase
Signaling Mediates Early Demyelination Induced by Leprosy Bacilli. Nature Medicine
12.8 (2006): 961-66. Web.
Telis, Gisela. Leprosy Reprograms Body's Cells. Science. American Association for the
Advancement of Science, 12 July 2013. Web.
Wishart, David S. DrugBank: A Comprehensive Resource for in Silico Drug Discovery and
Exploration. Nucleic Acids Research 34 (2006) Web.
World Health Organization. Leprosy (Fact sheet). (2016). Retrieved from
http://www.who.int/mediacentre/factsheets/fs101/en/

Chung
13
World Health Organization. Microbiology of M.leprae. World Health Organization. World
Health Organization. Web.
World Health Organization. "WHO Model Prescribing Information: Drugs Used in Leprosy:
Treatment of Leprosy." Essential Medicines and Health Products Information Portal.
World Health Organization, 1998. Web.

Chung
14
Figure 1: Geographical Distribution of New Leprosy Cases, 2015
Source: http://www.who.int/lep/epidemiology/en/

Chung
15

Figure 2: Differences in the Types of Leprosy

Source: https://www.hindawi.com/journals/ipid/2012/181089/

Chung
16
Figure 3: Bacteriological Index-Scoring for Slit-Skin Smear Test

Source: http://www.internationaltextbookofleprosy.org/chapter/pathology