Educational ExcursionThe Leprosy Mission

NepalPrepared By:-

Sandeep Paudel

Contents

• Objective of Excursion• Introduction• History and background of leprosy• History of TLM-N• Leprosy in Nepal• Classification of Leprosy• Cardinal Signs• Lab Diagnosis• Treatment

Objective of Excursion

• To find out current scenario of Leprosy in Nepal and identification and laboratory diagnosis of causative agent

Introduction

• Leprosy is a chronic infectious disease caused by an acid-fast, rod-shaped bacillus, Mycobacterium leprae.

• M. leprae multiplies very slowly and the incubation period of the disease is about five years.

• Symptoms can take as long as 20 years to appear. • Leprosy is not highly infectious. • Leprosy is transmitted via droplets, from the nose and

mouth, during close and frequent contacts with untreated cases.

Cont…

• Untreated, leprosy can cause progressive and permanent damage to the skin, nerves, limbs and eyes.

• The disease mainly affects the skin, the peripheral nerves, mucosa of the upper respiratory tract and also the eyes.

• Leprosy is curable and treatment provided in the early stages averts disability.

History and background of leprosy

• Leprosy was recognized in the ancient civilizations of China, Egypt and India.

• The earliest documented account of leprosy is around 1550B.C on Egyptian papyrus.

• Throughout history, the badly affected have often been hated by their communities and families (stigmatization).

• Although leprosy was treated differently in the past, the first advance in treatment occurred in the 1940s with development of the drug Dapsone, which arrested the disease.

• But duration of the treatment was many years, even a lifetime, making it difficult for patients to follow.

History of TLM-N• The Leprosy Mission began work in Nepal in 1957, opening

Anandaban Hospital on a quiet hill side near Lele in Lalitpur District, some 18km south from the centre of Kathmandu.

• At that time leprosy was a very visible health problem in Nepal, the only recognised treatment being limited in its effect.

• The developing work included out-patient as well as in-patient services.

• Over the years major developments have included the addition of a Training Centre, the development of Mycobacterial Research Laboratory and the start of Community-Based Rehabilitation programmes.

Leprosy in Nepal• The number of people being diagnosed with leprosy in Nepal is

greatly reduced from earlier years, nevertheless, it continues to be a health issues, in particular in the Terai area neighbouring India.

• In 2015 the Government Leprosy Control Division has reported the number of new case diagnoses in the last year as 3253.

• The General Health Services run by the Government now extend throughout Nepal and are primarily responsible for diagnosis and treatment with the standard multiple drug therapy.

• Leprosy is most common in the poorest sectors of local communities. As in many countries, persistent traditional attitudes towards leprosy in Nepal mean that people developing the initials signs of leprosy fear the consequences, personal and social as well as physical.

• Caste and gender-based prejudices further exacerbate the situation.

Cont….• Delay in diagnosis and treatment, for any reason, places the

person affected at risk of developing irreversible nerve impairments affecting sensation and movement.

• TLM Nepal is involved in training Government General Health Service Medical Officers and other staff in the diagnosis and treatment of leprosy and also provides technical support.

• Through Anandaban Hospital it provides specialist services in reconstructive surgery and treatment for people experiencing complications due to leprosy.

• These are accessed locally and by referral from Government centres across Nepal.

Classification of Leprosy

• Two types of classifications: • Skin smear result classification • Clinical classification

SKIN SMEAR RESULTS CLASSIFICATION

1. Paucibacillary leprosy (PB) – few Bacilli; Two to five skin lesions with negative skin smear results at all sites 2. Multibacillary leprosy (MB); Any form of leprosy in which the patient shows positive smears at any site

CLINICAL CLASSIFICATION

1. Indeterminate leprosy (IL)2. Tuberculoid leprosy (TT)3. Lepromatous leprosy (LL)4. Borderline leprosy (BL): Borderline tuberculoid leprosy (BT) Borderline borderline leprosy (BB) Borderline lepromatous leprosy (BL)

CARDINAL SIGNS• Numbness : hands & feet• Painful and/or tender nerves• Burning sensation in the skin• Painless swelling or lumps in

the face and earlobes • Loss of eyebrows and or

eyelashes.

(a) Nodules on the face (b) skin patch on the face

(c) an enlarged nerve in the neck

DIAGNOSIS

• Diagnosis of leprosy is most commonly based on the clinical signs and symptoms. These are easy to observe by any health worker after a short period of training.

• Only in rare instances there is a need to use laboratory and other investigations to confirm a diagnosis of leprosy.

LAB DIAGNOSIS

1. Specimens2. Acid fast staining3. Skin and nerve biopsy4. Animal inoculation5. Lepromin test

1. SPECIMENSNasal mucosa, skin lesions, ear

lobules. Skin and nerve biopsy.

Edges of the lesion.Slit and scrape

method:• Pinch the site tight• Incise• Scrape & collect

material• Smear on a slide

SKIN:

SKIN BIOPSY:Active edges of the patches NERVE BIOPSY :From thickened nerves

2. ACID FAST STAINING Ziehl-Neelson method Decolourising agent = 5% sulphuric acid Lepra cells confirm the diagnosis

of lepromatous leprosy.

i. Bacteriological index (B.I) :

Number of total bacilli in a tissue.B.I is calculated by totalling the

grades and divided by no. of smears.Minimum of 4 skin lesions,a nasal

swab & both the ear lobes are to be examined.

Percentage of uniformly stained bacilli out of the total number of bacilli counted.

For assessing the progress of patients on chemotherapy.

ii. MORPHOLOGICAL INDEX(M.I) :

• For histological confirmation of tuberculoid bacilli ( as they cannot be demonstrated in direct smear)

• Skin biopsy is also useful in diagnosis and accurate classification of leprosy lesion.

3. SKIN AND NERVE BIOPSY

Obligate intracellular parasite. Lacks many necessary genes for

independent survival.

WHY CAN’T WE CULTIVATE Mycobacterium leprae

IN AN ARTIFICIAL CULTURE MEDIUM???

4. ANIMAL INOCULATION

Nine banded armadillo Injection of ground tissue from

lepromatous nodules or nasal scrapings from leprosy patient into the foot pad of mice.

Typical granuloma at the site of inoculation within 6 months.

5. LEPROMIN TEST• Delayed type of hypersensitive reaction.• First described by Mitsuda in 1919.• Lepromins used as antigens may be of

human origin (lepromin H) or armadillo derived (lepromin A).

Procedure : Carried out by the intradermal

injection of 0.1 ml of lepromin.

1)Early reaction of Fernandez

2)Late reaction of Mitsuda

Biphasic response:

Early reaction of Fernandez

Erythema & induration

Develops in 24-48 hrs & usually remains for 3-5 days

Late reaction of Mitsuda

Appears 1-2 weeks after the injection, reaching a

peak in 4 weeks.

Appears in the form of nodule that may ulcerate. Takes few

weeks to heal.

USES OF LEPROMIN TEST:a) Classification of leprosy: - Positive in tuberculoid leprosy- Negative in lepromatous leprosyb) Assessment of prognosis:- Positive lepromin test indicates a good

prognosis.- Negative lepromin test indicates a bad

prognosis.

c) Assessment of resistance:- To assess the resistance of an individual to

leprosy.- Resistance is indicated by positive

lepromin test.

TREATMENT • Multidrug therapy (MDT) treatment has been made available by

WHO free of charge to all patients worldwide since 1995, and provides a simple yet highly effective cure for all types of leprosy.

• The drugs used in WHO-MDT are a combination of: • Multi Bacillary (MB) leprosy :-Rifampicin + Clofazimine + Dapsone • Paucibacillary (PB) leprosy :- Rifampicin + Dapsone • Among these Rifampicin is the most important anti leprosy drug

and therefore is included in the treatment of both types of leprosy.

• 1 dose of Rifampicin can kills 99.97% bacteria