Leprosy in Indonesia

Fadel Muhammad Garishah, MDDepartment of General Medicine

Overview of Leprosy

Leprosy is a disease caused by Mycobacterium leprae, a bacterium which primarily affects the skin and peripheral nerves.

Mode of transmission is considered to be air-borne, through droplets discharged from the respiratory tract of untreated infectious cases

The disease causes stigma and those affected can be victims of discrimination and often displacement.

Physical and neurological damage may be irreversible even if cured.

Epidemiology

In 2011, the Ministry of Health Republic of Indonesia reported 20.023 new leprosy cases or 8.3 in 100,000 population

Mycobacterium leprae

• Mycobacteria genus

• Acid-Fast Bacili

• Difficult to be cultured; Inoculated in Armadillo skin

Spectrum of Disease

Immunity Profile to Disease Outcome

Leprosy

Lepromatous

Borderline

Tuberculoid

HumoralImmunity

CellularImmunity

Treatment

Leprosy

Paucibacillary (PB)

Multibacillary (MB)

Paucibacillary (PB): the number of M. leprae in the body is small (less than 1 million) and a skin smear test is negative. The patient presents five or fewer skin lesions. Most cases of leprosy are PB.

Multibacillary (MB): M. leprae can multiple in the body almost without any check and is thus present in high numbers. The bacillus has likely spread to almost all areas of skin and peripheral nerves. A skin smear test is positive and the patient presents more than five skin lesions.

Bacterial Index

Acid Fast Bacilli Bacterial Index> 1000 > immersion field 6 +100 – 1000/field 5 +10 – 100/field 4 +1 – 10 3 +1 – 10/10 field 2 +1 – 10/100 1 +0/100 0

Skin Lesion: Hypopigmented Hypoesthesia Maculae

Disability

Diagnostic

Hypopigmented or reddish patches with definite loss of sensation

Thickened peripheral nerves Acid-fast bacilli on skin smears or biopsy material

Pharmacology

Dapsone (Bactericidal) by preventing of formation of folic acid, inhibiting bacterial growth.

Rifampicine Inhibits DNA-dependent bacterial RNA polymerase.

Clofazimine (Lamprene) Inhibits mycobacterial growth, binds preferentially to mycobacterial DNA.

After 6 months MDT Tx

However, damaged nerves and tissues cannot regrow. Thus, if left untreated for too long, disfigurment from leprosy can be permanent, unless it can be repaired with reconstructive surgery.

PB Single Lesion

Rifampicin 600 mg Ofloxacin 400mg Minocycline 100 mg

Single Dose

PB >5 Lesions

6 – 9 months Day 1 Rifampicin 600mg and Dapson 100 mg Day 2 – 28 Dapson 100 mg

MB

12-18 months Day 1: Rifampicin 600 mg, Dapson 100 mg/

Clofazimine 300 mg Day 2 -28: Dapson 100 mg, Clofazimine 50mg

Leprosy Reactions

Reversal reactions Erythema Nodosum Leprosum

Reversal Reaction

Mild: analgesics, sedatives, Chloroquin base 150mg TID 3-5 days

Severe: Prednison/prednisolon/analgesics, sedatives

Prednisolon 10 mg TID or

Week 1 and 2 : 40 mg/day Week 3 and 4: 30 mg/day Week 5 and 6: 20 mg/day Week 7 and 8: 15 mg/day Week 9 and 10: 10 mg/day Week 11 and 12: 5 mg/day

Prednison 40-60 mg/day

2 weeks I 30 mg/day (1x 6 tab) 2 weeks II 20 mg/day (1x4 tab) 2 weeks III 15 mg/day (1x3 tab) 2 weeks IV 10 mg/day (1x2 tab) 2 weeks V 5mg/day (1x1 tab)

Erythema Nodosum Leprosum

Thalidomide 100-400mg/day Prednisolon

30-40 mg/day 1-2 weeks Decrease 5-10 mg/2 weeks

Clofazimine 300mg (3x100mg) 1 months 4-6 weeks, no more than 3 months Decrease 2 x 100 mg/ day 1 months 1 x 100mg/day 1 months 50 mg/day