Hansens Disease

History
Definition:
Leprosy is a chronic systemic
disease caused by Mycobacterium leprae
manifesting as development of specific
granulomatous or neurotrophic lesions in the
skin, mucous membrane, eyes nerves, bones
and viscera.

Oldest infection known to mankind

Synonyms: Hansens disease, Kushtha roga

Transmission of Leprosy
Respiratory route: inhalation of bacilli-laden
droplets

Cutaneous: skin to skin contact

}
GIT : ingestion of food Not
Yet
Intradermal : inoculation by tattoos Proven
Epidemiological factors
Occurs at all age groups
Peak age of onset : Between 10 20 years
Males > Females
Children most susceptible
Immune status ( host resistance)
Overcrowding
Low socioeconomic status
Immunity and Leprosy
Host resistance Clinical manifestation
Excellent No infection
Good Subclinical infection with
spontaneous regression
Fair Indeterminate, pure neuritic,
tuberculoid
Poor Mid-borderline,
borderline-lepromatous
Very poor Lepromatous
Mycobacterium Leprae
Obligate, intracellular, acid-fast bacillus
Affinity for skin, nerves and muscle tissue
Found in macrophages, histiocytes and
Schwann cells.
Non cultivable
Grown in animal models
Closely resembles M.tuberculosis, but less
acid-fast.
Multiplies in 11-13 days.
Classification
The Ridley Jopling classification
Indeterminate
Tuberculoid
Borderline: borderline-tuberculoid,
mid-borderline,
borderline-lepromatous
Lepromatous

Pure neural, Maculoanaesthetic - Indian

classification
Tuberculoid (TT)
Single or few, asymmetrical, well-defined,
erythematous or copper-coloured patches
Sensations - Absent
Nerves - thickened, presence of feeding
nerves, abscesses
Skin smears - Negative
Lepromin test - Strongly positive
Course - Relative benign and stable, with good
prognosis.
Borderline leprosy
Common type of leprosy
Subdivided into BT, BB & BL.
Course - Unstable with variable prognosis ,
may progress to sub-polar LL leprosy.
Most prone to reactions.
Lepromin test -Negative ,weakly positive in BT.
Borderline Tuberculoid (BT)
Few asymmetric, hypopigmented or skin
coloured macules, plaques with ill defined
margins
Presence of satellite lesion near the advancing
margin of patch
Sensory impairment - Marked
Nerve involvement - Marked and asymmetrical
Midborderline leprosy (BB)
Unstable form, reactions frequent
Annular lesions with characteristic punched out
appearance (inverted saucer shaped)
Sensory impairment - Moderate.
Nerve involvement - Marked and asymmetrical.
Borderline lepromatous leprosy (BL)
Multipleshiny macules, papules, nodules and
plaques with sloping edges
Sensory impairment - Slight
Nerve involvement - Widespread and less
asymmetrical.
Glove & stocking hypoaesthesia
Lepromatous leprosy
Hypopigmented, erythematous or coppery,
shiny macules, papules, nodules
Lesions symmetrically distributed, small,
multiple, shiny with normal or mild sensory loss
Leonine facies: Infiltration of skin with nodules,
loss of eyebrows and eyelashes
Nerve involvement symmetrical; glove &
stocking anaesthesia
Lepromin test - Negative
Leonine facies
Pure Neuritic leprosy
Neuritic manifestations -Tingling, heaviness
and numbness, paresis, hypotonia, atrophy,
claw hand and toes, wrist-drop, foot-drop.
No skin lesion.
Other changes-Anhidrotic, dry glossy skin,
blisters, neuropathic ulcers, decalcification,
bone resorption.
Pure Neuritic leprosy
Lepromin test -Slightly positive.
Course-Spontaneous regression or
progression to TT leprosy.
Silent neuritis (silent neuropathy)
Sensory or motor impairment without skin
signs of reversal reaction or ENL ,tenderness,
paraesthesiae or numbness.
Special forms of Leprosy
Lucio Leprosy:
Rare form of lepromatous leprosy, described in
Mexico. Diffuse widespread infiltration of skin,
loss of body hair, loss of eyebrows &
eyelashes, and widespread sensory loss.
Lepra Bonita (Pretty leprosy)
Elderly persons with diffuse infiltration of face
smoothes out wrinkles, giving youthful
appearance.
Histoid leprosy:
BL patients with irregular or poor treatment
compliance
Drug resistant cases
Other features
Nasal stuffiness / crusting
Epistaxis
Hoarseness of voice
Gynaecomastia
Saddle nose
Bone resorption
Lymphadenopathy
Diagnosis
Cardinal signs of leprosy
Sensory impairment in affected areas
Enlargement of peripheral nerves associated
with signs of peripheral nerve damage
Finding acid-fast bacilli in the lesions
Clinical examination
Type and number of skin lesions
Sensory impairment
Motor examination
Nerve examination
Sweating
Loss of hair
Clinical examination: Sensory
Touch
Tested with wisp of cotton,nylon thread or feather.

Temperature
Tested with two test tubes one containing hot
water and other cold

Pain
Tested by pin prick
Clinical examination : Motor
Testing of motor power- Done clinically

Electro-diagnosis - Employed in very early

cases. Electrical stimulator using faradic and
galvanic current used to test muscle power.
Nerves
Supra/ infraorbital Ulnar
Greater auricular
Clavicular Median
Radial Lateral popliteal

Sup. Radial cut Posterior tibial

Anterior tibial

Sural
Investigations for M. Leprae
Bacteriological examination
Skin smears:
Made by slit and scrape method from the most
active looking edge of skin lesion and stained
with Ziehl-Neelsen method.

Reading of smears:
Bacteriological index- Indicates density of leprosy
bacilli (live & dead) in the smears and ranges
from 0 to 6+
Morphological index- It is the percentage of
presumably living bacilli in relation to total
number of bacilli in the smear
Investigations
Histopathological examination
Nerve biopsy
Sweat function test
Lepromin test
Animal Models: Armadillo, Thymectomised,
irradiated nude mice, Korean chipmunk etc.
MDT-WHO
Paucibacillary leprosy (6 months)
- Cap. Rifampicin (600 mg) monthly, supervised
- Tab. Dapsone (100 mg) daily
Multibacillary leprosy (1 year)
- Cap. Rifampicin (600mg) monthly, supervised
- Cap. Clofazimine (300mg) monthly, supervised
- Tab. Dapsone (100mg) daily
- Cap. Clofazimine (50mg) daily
Blister packets for MDT
Easy to use, handy and of convenient size
Provide complete treatment
Improve clinical attendance
Drugs are better protected against
moisture,heat and accidental damage
Ensures quicker dispensing of the drugs
Can be dispensed by non medical person
Lepra Reactions
Acute episodes or bouts of exacerbations
occurring in course of chronic disease
Sudden increase in activity of existing lesions,
appearance of fresh lesions with or without
constitutional symptoms
Type I reaction - all borderline cases (BT,
BB,BL)
Type II reaction - BL & LL cases
Precipitating factors
Physiological conditions like pregnancy
Drugs: anti-leprosy drugs, iodides
Severe physical or mental stress
Infections
Type I Reaction
Sub-types

- Upgrading (Reversal)
- Downgrading
Type IV hypersensitivity reaction.
Existing lesions worsen/New lesions may appear
Neuritis / Nerve abscesses
Systemic disturbances: Unusual
Type I reaction - complications
Neuritis
Dactylitis, edema of hands & feet, inflammation
of small joints of fingers
Corneal anesthesia, Conjunctivitis
Sudden occurrence of claw hand, foot-drop,
facial palsy
Type II Reaction
Occurs in BL and LL cases
Type III hypersensitivity reaction
Erythema Nodosum Leprosum-crops of painful,
recurrent, erythematous, papulonodular lesions.
Fever and malaise
Iridocyclitis, episcleritis, epididymo-orchitis,
arthritis, neuritis, lymphadenitis
Treatment of Lepra reactions
Principles of treatment
Early initiation of treatment for reaction

Continuation / initiation of MDT

Removal of precipitating factor

Rest, physical and mental

Treatment modalities
Analgesics
Corticosteroids
Antimalarials
Clofazimine
Thalidomide
Miscellaneous colchicine, zinc, cetrizine,
antimonials
Supportive management for eye
complications, splints etc.
Thank you