DIAGNOSIS AND TREATMENT OF LEPROSY - … · infection by lepra bacilli. LEPROMIN TEST ......

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Transcript of DIAGNOSIS AND TREATMENT OF LEPROSY - … · infection by lepra bacilli. LEPROMIN TEST ......

DIAGNOSIS AND TREATMENT OF LEPROSY

DR.RAGHU MOHAN 2ND YEAR PG DVL KIMS, NARKET PALLY

INTRODUCTION

ν Chronic granulomatous infectious disease. ν Caused by Mycobacterium leprae ν Mainly involves the peripheral nerves and skin ν Other organs may involve:

Mucosa of mouth Upper respiratory tract Eyes Bones, Muscles Testes etc. Commonly involves every organ except : CNS, Ovary and Lungs.

Historical aspect of leprosy

One of the Oldest and most dreaded disease known to Mankind. Earliest description from India in 600BC

Kustha Roga & attributed to punishment or curse of God Prophet Mohammed’s apparent dread of leprosy in his statement: “Escape from the leprous the way you escape from a lion”

• Sir Gerhard Henrik Armauer Hansen in 1873 in Norway discovered M Leprae . •Hence referred to as Hansen’s disease.

DIAGNOSIS

ν HISTORY ν CLINICAL EXAMINATION ν BACTERIOLOGICAL

EXAMINATIONS ν BIOPSY ν HISTAMINE TEST ν IMMUNOLOGICAL TEST ν FOOT-PAD CULTURE

History should include the following points : νPatients Bio data : name, age, sex, address νPresenting complaints νFamily history of leprosy νContact with leprosy cases νPrevious history of treatment for leprosy, if any

CLINICAL EXAMINATION

Physical examination should include : νA thorough inspection of the body surface(skin). νPalpation of commonly involved superficial nerves: 1.Ulnar N. near the medial epicondyle. 2.Greater Auricular N as it turns over SCM muscle.

3.Lateral Popliteal N. 4.Dorsal branch of Radial N. ν

Testing for : • Loss of sensation : heat, cold, pain, touch . • Paresis or paralysis of muscles of hands and feet.

Nerve palpation

Tuberculoid Leprosy (TT)

Borderline Tuberculoid leprosy (BT)

Borderline Borderline Leprosy (BB)

Borderline lepromatous leprosy (BL)

Lepromatous leprosy (LL)

BACTERIOLOGICAL EXAMINATION

This includes : ν Skin Smears : ν Nasal Smears or blows :

BACTERIAL INDEX

ν Bacterial index is an objective way of monitoring benefit of treatment.

ν According To Ridley’ Logarithmic Scale , it Ranges From 0 To 6+ and is based on the No. of bacilli seen in an average microscopic field.

ν BI 0 stands for no bacilli in any of 100 oil immersion field.

BACTERIAL INDEX

BACTERIAL INDEX

BACTERIAL INDEX

MORPHOLOGICAL INDEX

ν The MI is calculated after examining 200 pink-stained free standing bacilli.

ν The percentage of solid staining bacilli in a stained smear is referred to as MI.

ν It is a valuable indicator of the patient’s ν response to treatment during the first

few months and helps to signal drug resistance.

BIOPSY ν Usually resorted to when there is high

clinical suspicion.

It also gives information about the bacterial content of skin.

HISTAMINE TEST

ν Reliable test for detecting at an early stage peripheral nerve damage due to leprosy.

ν Method : carried out by injecting 0.1ml of a 1:1000 solution of histamine phosphate into hypopigmented patches or in areas of anesthesia.

ν Result : in normal person it gives rise to a wheal surrounded by erythematous flare.

ν In case of leprosy where the nerve supply is destroyed, flare response is lost.

IMMUNOLOGICAL TESTS

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• LEPROMIN TEST- Test for cell mediated immunity. • Phenolic glycolipid-1:This is a specific serologic test based on the detection of antibodies to phenolic glycolipid-1. •Polymerase chain reaction (PCR): PCR and recombinant DNA technology have allowed for the development of gene probes with M leprae–specific sequences.

LEPROMIN TEST

Method : it is performed by injecting 0.1ml of lepromin into inner aspect of the forearm. The reaction is read at 48 hours and 21 days.

Two types of reaction have been described :

EARLY REACTION(FERNANDEZ REACTION) : an inflammatory reaction develops within 24 to 48 hours and this tends to disappear in 3 to 4 days. If the diameter of the red area is more than 10mm the test is considered positive. It is a delayed type hypersensitivity reaction to soluble constituents of lepra bacilli and indicates whether or not a person has been sensitized by exposure to and infection by lepra bacilli.

LEPROMIN TEST

•LATE REACTION(MITSUDA REACTION) : It is characterized by the appearance of a nodule which becomes apparent in 7 to 10 days and reaches its maximum in 3 to 4 weeks. The test is read at 21 days. If the nodule is more than 5 mm it is considered positive. • It is induced by the bacillary component and indicates cell mediated immunity. ♣In the first six months of life most children are lepromin negative ♣BCG vaccination is capable of converting lepra reaction from negative to positive.

VALUE OF LEPROMIN TEST : νUseful tool for evaluating the immune status of leprosy patients. νAid to classify the type of disease. νEstimating the prognosis νStrongly positive in a typical tuberculoid case and getting weaker towards the lepromatous end, the typical lepromatous case being lepromin negative indicating failure of CMI. The greatest drawback being high false positive and false negative cases hence not used as a diagnostic test.

FOOT-PAD CULTURE

ν Only certain way of identifying M. Leprae. ν 10 times more sensitive at detecting the bacilli

than slit skin smear. ν Time consuming : requires 6 to 9 months. ν Used for : 1.Detecting drug resistance. 2.Evaluating the potency of anti-leprosy drugs. 3.Detecting the viability of bacilli during

treatment.

TREATMENT MULTIDRUG CHEMOTHERAPY

• In the absence of effective of primary prevention by a leprosy vaccine, leprosy control is based on effective multidrug chemotherapy(secondary prevention). OBJECTIVES : ¬To interrupt transmission of infection ¬Early detection and treatment of cases to prevent deformities ¬To prevent drug resistance

MULTIDRUG CHEMOTHERAPY

In multidrug regimens only bactericidal drugs are used : νFirst line drugs : rifampicin, dapsone, clofazimine, ethionamide /prothionamide. νSecond line drugs : quinolones, minocycline, clarithromycin.

: 600mg once monthly under supervision : 100mg daily self administered : 300mg once monthly under supervision

50mg daily self-administered

MULTIDRUG CHEMOTHERAPY

WHO RECOMMENDED REGIMENS OF CHEMOTHERAPY : MULTIBACILLARY LEPROSY

♣Rifampicin ♣Dapsone ♣clofazimine

Where clofazimine is unacceptable due skin coloration it may be substituted by 250 to 375mg daily dose of ethionamide or prothionamide. The above regimen needs to taken for 12 months within 18 months

PAUCIBACILLARY LEPROSY :

The above regimen needs to be taken for 6months within 9 months

Treatment regimen for children 10-14 years

MULTIBACILLARY LEPROSY ♣Rifampicin ♣Dapsone ♣clofazimine

: 450mg once monthly under supervision : 50mg daily self administered : 150mg once monthly under supervision

50mg every other day self-administered

PAUCIBACILLARY LEPROSY ♣Rifampicin ♣Dapsone

: 450mg once a month under supervision : 50mg daily self administered.

MULTIDRUG CHEMOTHERAPY

MULTIDRUG CHEMOTHERAPY

Important points : ♣MDT is not contraindicated in patients with HIV infection. ♣MDT is safe during pregnancy. ♣Drugs are excreted in breast milk but no reports of adverse reaction except for mild discoloration of infants skin by clofazimine ♣Leprosy is exacerbated during pregnancy, it is important that MDT is continued

Drugs Rifampicin : highly bactericidal, a single 1200mg dose kills 99 percent of viable organisms Toxic effects includes anorexia, nausea, vomiting, abdominal discomfort and orange discoloration of body secretions. It is hepatotoxic Dapsone : weakly bactericidal. Adverse effects include hemolytic anemia, methemoglobinemia, agranulocytosis, hepatitis, neuropathy, psychosis and rarely DDS syndrome-fever, maculopapular rash, enlarged lymph nodes, hepatitis and exfoliativedermatitis.

• Clofazimine :

• Less effective than dapsone but has added advantage of preventing lepra reaction.

• More expensive but less toxic which includes dark red discoloration of skin, mucus membranes, sweat and urine.

Ethionamide/Prothionamide : highly bactericidal killing 98 percent of viable bacilli in 3 to 4 days.

Relatively more expensive and more toxic.

Thank You

THANK YOU