Case Of Lepromatous Leprosy Research Articles

Paranasal sinus computed tomography findings in patients treated for lepromatous leprosy

Nasal and paranasal sinus involvement is common in lepromatous leprosy and is of considerable epidemiological significance. The aim of this study was to investigate paranasal sinus abnormalities in treated lepromatous leprosy cases and to evaluate the findings in comparison with those of previous studies. Thirty-eight patients who had been treated for lepromatous leprosy were included. All patients had been treated with dapsone and rifampicine for six months, and followed with dapsone, rifampicine and clofamizine for a minimum of two years. All patients received a clinical examination, a coronal computed tomography (CT) examination of the paranasal sinuses and ethmoidal sinus endoscopy, in order to investigate the involvement of the paranasal sinuses in the leprosy. Ethmoidal sinus biopsies were taken in 18 of the 21 cases of ethmoidal sinus involvement noted on CT scan. Twenty-three patients had sino-nasal symptoms. Endoscopic examination showed different pathologies in 21 of these patients. Abnormalities in the paranasal CT images were observed in 27 patients. The ethmoidal, maxillary, frontal and sphenoid sinuses were affected in 21, 18, three and two patients, respectively. Various degrees of nasal septum perforation were noted in 18 cases. In six of the 18 patients biopsied, the biopsy specimen showed involvement by lepromatous leprosy. These findings suggest that although these lepromatous leprosy patients had been treated, persistent infection was still commonly encountered. Paranasal sinus CT examination is a useful method for the evaluation of patient response to treatment and follow up; however, a CT scan alone cannot determine whether the leprosy is active.

Lèpre lépromateuse révélée par un œdème des mains

We reported a case of lepromatous leprosy in a Tunisian woman revealed by a potentially misleading clinical picture involving isolated infiltration of the hands. A 37 year-old woman consulted in October 2000 for bilateral edema of the hands associated with paraesthesia that had been present for one month. Screening for Hansen's bacilli confirmed the diagnosis of multibacillary leprosy. Daily therapy with triple anti-leprosy treatment was initiated. The occurrence of edema, which is classically described as a symptom of a reactional state, can occur during the course of leprosy. Where it is a presenting symptom, this unusual heralding sign can be a source of diagnostic error and delay.

CLINICAL COURSE OF ERYTHEMA NODOSUM LEPROSUM: AN 11-YEAR COHORT STUDY IN HYDERABAD, INDIA

Erythema nodosum leprosum (ENL) or type 2 lepra reactions complicate lepromatous leprosy and borderline lepromatous leprosy. We report an 11-year retrospective case record analysis of 481 outpatients with borderline lepromatous and lepromatous leprosy at the Dhoolpet Leprosy Research Center in Hyderabad, India.. The overall prevalence of ENL was 24%, 49.4% among cases of lepromatous leprosy (LL) and 9% among cases of borderline lepromatous (BL) leprosy. Logistic regression analysis identified LL (odds ratio [OR] = 8.4, 95% confidence interval [CI] = 4.6-15.4, P < 0.001) and BL with a bacterial index > or = 4+ (OR = 5.2, 95% CI = 2.1-12.9, P = 0.001) as major risk factors. The average patient with ENL was male, 34.7 years of age, and had multiple episodes of ENL (mean = 3.1) over an 18.5-month period. Three types of ENL were identified: single acute ENL, multiple acute ENL (repeated discrete episodes), and chronic ENL (continuous episodes). Acute single ENL is rare, accounting for only 8% of cases. Chronic ENL accounted for 62.5% of the cohort. Chronic ENL was of longer duration and more severe. An age > or = 35 years was a risk factor for developing chronic ENL. Patients with chronic ENL were more compliant with multi-drug therapy, especially during the first six doses of multi-drug therapy. Distinguishing these different types of ENL would be useful for patient management and developing improved treatment of these debilitating reactions. Improved strategies for treatment and management of these reactions need to be developed.

Variable nucleotide tandem repeat (VNTR) typing of two palaeopathological cases of lepromatous leprosy from Mediaeval England

Using ancient DNA methods, we have examined in detail two archaeological cases of leprosy from Mediaeval England. The first was a child skeleton with rhino-maxillary changes typical of lepromatous leprosy (LL). The second case was the skeleton of a male adult who showed both typical rhino-maxillary changes and osteitis/periostitis on the leg and foot bones. Bone powder was sampled from both cases and DNA extracts were prepared. These were subjected to a series of polymerase chain reactions (PCRs) specific for regions on the Mycobacterium leprae genome. The repetitive element RLEP was used for confirmation of M. leprae DNA and then three polymorphic regions were successfully amplified and sequenced to determine the number of variable nucleotide tandem repeats (vntr) at these loci. These were the microsatellite regions ML2344 and ML2172 and the minisatellite region ML0058. Genotyping data from the strains preserved within the skeletal remains were compared with those obtained for a reference strain of M. leprae. Variation at these three loci was found between both burials and the reference strain, indicating that vntr typing of LL cases from the archaeological record is a useful way of confirming disease and an additional means of authenticating aDNA data. This demonstrates the feasibility of targeting multiple loci for phylogenetic studies of leprosy strains from archival sources.

Dos casos de lepra en Valladolid

Leprosy is still a major health problem on a worldwide level, and although it does not reach endemic levels on our continent, it seems that there is an upward trend due to the number of imported cases diagnosed each year. We present two cases of lepromatous leprosy diagnosed in Valladolid within a five-month period. The last reported case of this disease in our community was over 20 years ago.

Penile tuberculoid leprosy in a five year old boy

A 5-year-old contact of a lepromatous leprosy patient with a tuberculoid lesion on the anterior aspect of the shaft of the penis is reported. The child was clinically suspected to have borderline tuberculoid leprosy during a survey of contacts of leprosy patients, which on histopathology revealed features of subpolar tuberculoid leprosy. The father of the child was recently detected as a case of lepromatous leprosy and was started on multibacillary regime of WHO multidrug therapy. The reason for the localization of the lesion to the shaft of the penis is also suggested. Skin as a route of transmission of tuberculoid leprosy is also emphasized.

Leprous osteitis presenting as bone cyst and erosions

A 30-year-old man presented to the Hansen outpatient department with swelling and ulceration of toes for 2 months and swelling of the right fifth and fourth fingers and the left second finger for 1 month. In addition to skin lesions of lepromatous leprosy (subpolar type), there was nontender, non-fluctuant swelling of the right fifth and fourth fingers and left second finger. Skin over the right fifth finger showed sinus-like openings with associated purulent discharge. He also had swelling and ulceration of second left toe. Slit-skin smear (SSS) showed a bacterial index of 6+ from the ear lobes and cutaneous nodules, 4+ from the patch, and 3+ from normal skin. Modified Ziehl-Neelsen staining of the discharge extruding from the sinuses on the right fifth finger also showed abundant acid-fast bacilli. Radiography of the hands and feet showed lytic lesions in the distal epimetaphyseal region o proximal phalanx of the right fifth finger and left second finger and erosion of distal end of proximal phalanges of both second toes. Histopathological examination of biopsy specimen from the patch (back) showed features of lepromatous leprosy, and Fite-Faraco stain for tissue acid-fast bacteria (AFB) was strongly positive. Fine-needle-aspiration cytology (FNAC) from the lytic lesion in the bone also showed predominantly foamy macrophages with strongly positive staining for AFB with a few interspersed lymphocytes, epithelioid cells and Langhans giant cells. On the basis of these features, a clinical diagnosis of subpolar lepromatous leprosy with leprous osteitis was made. In today's clinical era of improved case detection and prompt treatment with effective multidrug regimens, advanced bone changes are rarely encountered. We describe this case of lepromatous leprosy that developed cavitating lesions of the phalanges of the hand, seen on x-ray as well-defined bone cyst and erosions.

Response ofMycobacterium habanavaccine in patients with lepromatous leprosy and their household contacts. A pilot clinical study

Single dose vaccination was carried out with Mycobacterium habana vaccine, 31 lepromatous leprosy cases receiving 1.5 mg (1.5 mg = 6.27 x 10(8) bacilli) and 36 household contacts randomly receiving 1.5, 2.0, 2.5 mg vaccine intradermally. Duration of study was 18 weeks. Vaccination induced lepromin conversion in 100% of lepromatous leprosy cases and lepromin negative household contacts and augmentation of lepromin reactivity in 100% of lepromin positive household contacts, which was stable for the 15 weeks duration of follow-up. The maximum augmentation in lepromin reactivity was obtained with 1.5 mg of vaccine, which is probably the supramaximal dose. Overall, post-vaccination, those without prior BCG vaccination scars showed higher mean values of lepromin augmentation. Local vaccination site changes included induration, ulceration, itching, pain and uncomplicated regional lymphadenopathy, all of which remitted spontaneously by 15 weeks. Systemic side-effects noted were pyrexia, ENL and jaundice, and were seen with no greater frequency than that reported in other vaccine trials. Overall, systemic side-effects were easily controlled and were not accompanied by clinically detectable nerve or ocular damage. The safety profile investigations revealed an increase in the mean values of Hb%, RBC count and PCV in household contacts and of PCV in lepromatous patients, post-vaccination. Alterations in the liver function tests were also observed in patients of lepromatous leprosy. Thus, M. habana vaccine appears to be useful in stimulating specific CMI against M. leprae as evidenced by increased lepromin reactivity.

THERAPEUTIC HYPERBARIC OXYGENATION AS AN ADJUNCT TO MULTIDRUG THERAPY IN HANSEN'S DISEASE

Hansen's disease is a chronic infection caused by Mycobacterium leprae. Current therapy for this disease is with the WHO recommended Multi Drug Therapy (MDT) with DDS, rifampicin and clofazimine. Hyper Baric Oxygen Therapy (HBOT) has been used to treat many medical conditions including infections with a great deal of success. It's efficacy on various species of mycobacteria and other bacteria have been studied in vitro and in vivo and it is found to be an effective antimicrobial agent under specified conditions. HBOT has been used to treat Hansen's disease, including drug resistant lepromatous leprosy cases with good results. However there is a paucity of literature on this form of therapy. We have treated twenty cases of Hansen's disease with HBOT prior to exhibiting MDT as per the WHO schedule. There has been a marked regression in skin signs especially decrease in erythema and flattening of raised lesions. This correlated well with the histopathological picture which showed a reduction in the inflammatory exudate.

Pathological findings of the liver in Hansen's disease

In leprosy patients, granulomatous lesion are often observed, not only in skin and nerve, but also other visceral organs such as liver, kidney, spleen and cardiovascular system. But for the development of drug therapy, there are very few cases we can see the acid-fast bacilli in the lesion these days. We have reviewed the histopathological lesions in the liver of leprosy patients who had been treated for long term, based on autopsy findings of 31 cases, including 24 cases with lepromatous leprosy (LL) and 7 cases with tuberculoid leprosy (TL). Except one case of LL with progressive stage, most of them diagnosed as retrogressive or quiescent stage. Morphologically, acid-fast bacilli and granuloma were seen in a few cases of Hansen's disease. In addition, no suggestive changes of drug and virus induced liver injury were recognized. However, sclerotic change of portal vein was remarkably encountered in the tuberculoid leprosy.

Primary resistance to single and multiple drugs in leprosy--a mouse footpad study.

Skin biopsy homogenates obtained from three cases of lepromatous leprosy with no prior history of antileprosy treatment were tested in the mouse footpad for the sensitivity of Mycobacterium leprae to multiple drugs. One of the inocula was sensitive to all the three drugs tested using the highest concentration each of DDS 0.01 g%, RFP 0.03 g% and CLF 0.01 g%. The 2nd inocula showed growth in the presence of 0.01 g% DDS only. While the 3rd inocula (Pt. KU) tested resistant to all the three drugs in the first, i.e. man to mouse, as well as in the second passage, i.e. mouse to mouse.

Autoantibodies in leprosy sera.

Our objective was to assess the prevalence of autoantibodies in patients with leprosy. Forty-one cases of lepromatous leprosy were studied. For the detection of autoantibodies we used the Elisa technique using the following purified antigens in an Elisa assay: dsDNA, ssDNA, histone, mitochondria, RNA, RNP, SS-A, SS-B, Sm, Scl-70, Anca C, Anca P and the cardiolipin complex. As a "cut off" point we used values shown on previous studies to differentiate normal from elevated values. Antibodies to SS-B, mitochondria and cardiolipin were the most prevalent in our study. Antimitochondrial antibodies distinct from those seen in primary biliary cirrhosis and antiphospholipid antibodies with variable ligand activity to B2GIP are frequent in the sera of leprosy patients.

Human thyroid gland releases interleukin-6(IL-6) in vitro

Leprous neuropathy, which is due to infection of nerve cells by Mycobacterium leprae, still affects millions of people in many developing countries. The clinical and pathological manifestations are determined by the natural resistance of the host to invasion of M. Leprae. Failure of early detection of leprosy often leads to severe disability in spite of eradication of mycobacterium at a later date. In the lepromatous type, bacilli are easily found in the skin and in nerve cells including Schwann cells, endothelial cells, and macrophages. In the tuberculoid type, a strong cell-mediated immune reaction leads to formation of granulomas and destruction of cells harboring bacilli and neighboring nerve fibers. In many cases, treatment of patients with the multibacillary leprosy is complicated by reversal reaction and further nerve damage. Nerve lesions lead to a symmetrical, pseudo-polyneuritic pattern in most cases of lepromatous leprosy, which is usually associated with typical skin lesions, but pure neuritic forms occur in up to 10% of patients with lepromatous leprosy. In the pure neuropathic cases, only nerve biopsy permits diagnosis. The multifocal pattern is more common in tuberculoid leprosy. Treatment is currently based on multidrug therapy with dapsone, rifampicin, and clofazimine. The use of corticosteroids can reduce or prevent nerve damage in reversal reactions. It is important to remember that sequelae, especially sensory loss, are extremely common, which can lead to secondary trophic changes due to repeated trauma in painless areas.

A morphological study of nerve biopsies from cases of multibacillary leprosy given multidrug therapy.

Nerve biopsies were examined from 17 cases of lepromatous leprosy given WHO-recommended multidrug therapy (MDT) for 2 years. The pathological changes were assessed qualitatively and quantitatively to judge the effectiveness of MTD. The nerves varied very considerably in the severity of their lesions. Some regenerating fibres were seen in most of the nerves. In a few cases, the nerves were almost entirely populated by regenerated fibres, confirming that MTD was effective in halting the disease process within the nerve. Mycobacterium leprae showed morphological features of degenerate bacilli. Some pathological features of the lepromatous lesion are described.

Serum tumor necrosis factor and interleukin 1 in leprosy and during lepra reactions

Tumor necrosis factor—α (TNF), one of the mediators of septic shock, has a role in the immunopathological complications of several infections. However, its role in leprosy is yet unclear. In this study, serum TNF and IL-1 levels in 64 patients spread over the spectrum of leprosy [lepromatous leprosy (LL), 30; borderline lepromatous, 12; borderline borderline, 8; and borderline tuberculoid-tuberculoid leprosy, 14] were measured at the time of admission. Elevated levels of TNF ranging from 15 to 4500 pg/ml were detected in lepromatous leprosy cases (399 ± 189) and low levels ranging from 15 to 160 pg/ml were detected in the tuberculoid form of leprosy. Patients undergoing type 1 and type 2 lepra reactions also exhibited high TNF levels of 15–2100 pg/ml. Of the 14 clinically healthy individuals studied, 3 showed TNF levels of 15, 50, and 58 pg/ml. Interleukin 1-β (IL-1) levels were found to be significantly higher in LL cases (70–5000 pg/ml) (328 ± 184) in comparison to other groups or normal controls (9 ± 3). The coefficient of correlation between TNF and IL-1 levels was statistically significant in LL and reaction cases ( r = 0.96, P < 0.001). These patients were followed up as outpatients for a period of 1 year. It was observed that 4 out of 8 patients with TNF levels >100 pg/ml went into lepra reactions between 2 and 6 months after entry into the study, whereas only 5 out of 56 with <100 pg/ml went into mild lepra reactions (χ 2 = 9.7, P < 0.01). Determination of TNF and IL-1 levels thus seems to have a prognostic significance in terms of lepra reaction in patients.

Mast cells in histoid lepromatous lesions

Ten patients with histoid lesions among the lepromatous leprosy cases, of both sexes in the age group of 35-65 years, were included in this study. Skin biopsy from the nodule with surrounding healthy skin of histoid lesion was taken. The biopsies were fixed in Susa solution and processed for light microscopy. 5-7µ thick sections were cut and stained with haematoxylin and eosin, Toluidlne blue and Fite Faraco. Observations were made on the dermis to locate the mast cells and bacili. Proliferation of mast cells and their degranulation were seen in the histoid nodule as compared to surrounding normal healthy skin where the cells were mainly intact. The study further investigates the role of mast cells in the histopathogenesis of the disease.

Hepato-protective role of indigenous drug LIV-52 in lepromatous leprosy

The present study incorporates a study of 42 cases of lepromatous leprosy for hepatic involvement and role of indigenous herbal preparation in protecting the liver in leprosy. Liver was enlarged in 32 cases which was tender in 8 patients. Alteration in liver function irrespective of extent and duration of the illness (3 months to 10 years with mean duration of illness = 2 years 5 months) was mainly seen as uniform elevation of serum proteins (6.2-9.2 gms%, mean = 7.5 gms%) with hypoalbuminaemia (2.0-4.4 gms%, mean = 2.9 gms%). Highest level of serum bilirubin of 1.6 mg% was detected in 6 cases, emphasising the presence of leprous hepatitis. Raised level of serum transaminases (SGOT = 65.2 IU, SGPT = 78.7 IU) were proportionate to the liver and muscle involvement. Presence of characteristic granulomata in the liver around the central vein, periportal area and even distribution at various locations in the liver lobules were the most significant changes in 12 out of 15 liver tissues. Acid fast M. leprae were demonstrated in 12 patients. The present work emphasises the detection of hepatic involvement in the early stage of the disease and hepato-protective role of indigenous drug Liv-52 in lepromatous leprosy which usually lead to dreaded mutilated complications in the body.

Histopathological findings of serial preparation including the total length of nerve or Extrimitas thracica in leprosy (author's transl)

Most reports on the histological changes in the peripheral nerves in leprosy have been made from the study of biopsy specimens. A study of bigger nerves, in their entire length, including the spinal cord, has been made occasionally as this is possible only at autopsy. We have undertaken a detailed study of the peripheral nerves in lepromatous leprosy by which made an addition to modified embedding method of their entire length. In addition, a detailed histological examination of the spinal cord was also undertaken. Histological examination of peripheral nerves of the upper extremities including the plexus and the roots of origin from the spinal cord dissected from three autopsy cases showed a greater degree of destruction of the axis cylinders and myelin sheaths in a spindle-like from and moderate destruction of them in proximal parts. Lepra bacilli, besides being present all along the peripheral nerves were found to be concentrated in a spindle-like from part.The examination of the spinal cords in three cases of lepromatous leprosy both histopathologically as well as by the staining method for the bacilli by Harada, failed to reveal acid fast organisms.It is concluded, therefore, that the lepra bacilli travel along the peripheral nerves to the roots, but fail to enter the spinal cord and it degenerates only secondarily.

Peripheral arteriographic studies in leprosy

There is a considerable controversy regarding the frequency and significance of vascular lesions in leprosy. Twenty-six cases of leprosy below the age of 40 years, without any local or systemic arterial disease and normal looking hands were subjected to brachial arteriography. One patient had posterior tibial arteriography also. The diagnosis of leprosy was confirmed by histology or bacteriological staining techniques. Biopsy material was studied from the involved areas and similar material was obtained from nine matched control subjects at autopsy. Skin thermometry and reflex vasodilatation was studied in eight cases. Arteriographic abnormalities such as occlusion, narrowing, tortuosity, dilatation, irregularity and incomplete filling were seen in more than two vessels in the hand in 50%, and in the digits in 75% of the cases. The ulnar artery was more frequently involved than the radial. Superficial and deep palmar arches were equally affected. Marked increase in arcuate vessels was noticed in nearly three-quarters of the patients, and in some, arcuate vessles were serving as collaterals. Histologically all sizes of vessles, including the capillaries, showed changes in nearly half the cases. Reflex vasodilation was lost in three cases of dimorphous leprosy and impaired or absent in three out of five cases of lepromatous leprosy. There was no predilection for any form of leprosy to show arterial changes more than the other. This study clearly demonstrates that the arterial involvement in leprosy is very frequent and must be playing an important role in causing mutilation and deformities of hands and feet.

Pregnancy and Leprosy

Jafari, K., Stepto, R. C. and Petrys, R. (Dept. of Obstetrics and Gynecology, Cook County Hospital, Chicago, Ill., USA). Pregnancy and leprosy.Int J Gynaecol Obstet 13: 222–224, 1975.A case of lepromatous leprosy in a patient with pregnancy is reported. Literature was reviewed. Fetal and maternal outcome and the modality of the treatment is discussed.