Multibacillary Disease Research Articles

Clinical Profile of Leprosy in Post-elimination Era in a Tertiary Care Hospital

Introduction Leprosy is a chronic disease that primarily affects peripheral nerves and skin. It has a long incubation period and clinical presentations are variable leading to deformities and social stigma. Leprosy was eliminated in Nepal in 2010 AD. This study was undertaken to determine the demographic and clinical profile of Leprosy in the past three years. MethodsA retrospective observational study was conducted in the Department of Dermatology and Venereology, Tribhuvan University Teaching Hospital. Records of all the newly diagnosed leprosy patients attending the Out-Patient Department from April 2021 to March 2023 were reviewed retrospectively and analyzed. ResultsThere were 109 newly diagnosed leprosy cases among which majority were males. The maximum clinical diagnosis was lepromatous leprosy and 100 (91.74%) cases were multibacillary. Type 1 lepra reaction was seen in 11 (10.09%) patients and 12 (11%) patients had type 2 lepra reaction. Slit skin smear was positive in 75 (68.80%) patients. On clinical examination, peripheral nerves were palpable in 92 (84.4%) patients with ulnar nerve being the most common palpable peripheral nerve. Type 1 deformity was present in 55 (50.45%) patients and 18 (16.51%) patients had type 2 deformity. Claw hand was the most common type 2 deformity observed. ConclusionThough leprosy has been eliminated in Nepal, there are still considerable cases of Leprosy. Higher number of cases with multibacillary disease and increasing number of Lepra reaction is an alarming sign.

A hospital-based cross-sectional study of clinico-epidemiological aspects of childhood leprosy with disability in the post-elimination era

Background Childhood leprosy is an important indicator of active foci of transmission in the community in the post-elimination era. Childhood leprosy cases with disabilities are still prevalent, but are often undertreated or misdiagnosed due to diminishing awareness and the available studies on the same are limited. Aims and objectives To study the clinical presentation, WHO grading, duration, relation with lepra reaction, smear positivity and neurological correlation of childhood leprosy cases with disability. Materials and methods A cross-sectional study was conducted in the dermatology department of a tertiary care center including all recent cases of childhood leprosy (less than or equal to 13 years) with WHO grade 1 and grade 2 disability from October 2018 to June 2020. Results Disability among childhood leprosy cases was detected in 18 (32.1%) out of 56 children. The most common type of disability observed was visible muscle wasting (26.7%). Based on WHO disability grading, 3 children (16.6%) had grade 1 disability and 15 children (83.4%) had grade 2 disability. Children with borderline tuberculoid lesions had maximum disability (17.8%). All had thickened peripheral nerves with increased incidence of lepra-reaction (27.7%) and slit skin smear positivity (38.8%). None of the children with disability had a second dose of BCG or rifampicin prophylaxis, even if leprosy cases were reported in the family earlier. Conclusion Development of deformity was dependent on various factors including increasing age, delay in accessing health care, multiple skin lesions, multibacillary disease, smear positivity, multiple nerve involvement, and lepra reaction at the time of presentation. Active school surveys and campaigns are needed for early detection of leprosy and prevention of disability, with appropriate distribution of post-exposure prophylaxis.

Looking into Array of Clinical Presentations of Patients with Leprosy and their Clinico-epidemiological Profile: A Retrospective Study

Introduction: The prevalence of leprosy in India has decreased to <1 per 10,000 population by 2016 after the introduction of Multidrug Therapy (MDT) in 1982; still wide variations in Prevalence Rates (PR) continue to exist across the states and regions in the country. Aim: To determine the current clinical profile of leprosy and study various presenting features of patients with leprosy at a tertiary care hospital in North India. Materials and Methods: A retrospective study, based on seven years data, was conducted on patients diagnosed and registered in the leprosy clinic of a tertiary care hospital in North India, from January 2013 to December 2019. Data regarding their demographic details, presenting complaints, clinical features, associated complications and treatment administered was analysed and was entered into Microsoft Excel and presented as tables. Results: A total of 181 patients of leprosy were registered over a period of seven years. There were 133 males and 48 females with M:F ratio of 2.77:1. Of the total patients registered, 3.86% were children (≤14 years) and 97.8 % patients were immigrants from the adjoining states. The most common clinical type was Multibacillary (MB) leprosy in 88.95% patients whereas most frequent morphological type was Borderline Tuberculoid (BT) leprosy (72.93%). Thirty-three (18.23%) patients presented with leprosy reaction (Type 1 reaction in 16.6% and Type 2 reaction in 1.66%). World Health Organisation (WHO) grade 2 deformities (G2D) were diagnosed in 3 (1.66%) patients, with claw hand being the most common deformity (1.10%). Anaesthetic to hypoaesthetic patches were the most common presenting feature (64.1%). Conclusion: Despite statistical elimination, MB disease and leprosy reactions are commonly seen as presenting manifestations. It highlights the need for high quality leprosy services including good referral system for an active case detection. Varied clinical presentations of leprosy should be contemplated while examining patients that can assist in an early and better case detection that will prevent delay in therapy and associated deformities and also decrease the transmission of disease in the community.

Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental study

SummaryBackgroundIndirect financial costs and barriers to health-care access might contribute to leprosy treatment non-adherence. We estimated the association of the Brazilian conditional cash transfer programme, the Programa Bolsa Família (PBF), on leprosy treatment adherence and cure in patients in Brazil.MethodsIn this quasi-experimental study, we linked baseline demographic and socioeconomic information for individuals who entered the 100 Million Brazilian Cohort between Jan 1, 2007, and Dec 31, 2014, with the PBF payroll database and the Information System for Notifiable Diseases, which includes nationwide leprosy registries. Individuals were eligible for inclusion if they had a household member older than 15 years and had not received PBF aid or been diagnosed with leprosy before entering the 100 Million Brazilian Cohort; they were excluded if they were partial receivers of PBF benefits, had missing data, or had a monthly per-capita income greater than BRL200 (US$50). Individuals who were PBF beneficiaries before leprosy diagnosis were matched to those who were not beneficiaries through propensity-score matching (1:1) with replacement on the basis of baseline covariates, including sex, age, race or ethnicity, education, work, income, place of residence, and household characteristics. We used logistic regression to assess the average treatment effect on the treated of receipt of PBF benefits on leprosy treatment adherence (six or more multidrug therapy doses for paucibacillary cases or 12 or more doses for multibacillary cases) and cure in individuals of all ages. We stratified our analysis according to operational disease classification (paucibacillary or multibacillary). We also did a subgroup analysis of paediatric leprosy restricted to children aged up to 15 years.FindingsWe included 11 456 new leprosy cases, of whom 8750 (76·3%) had received PBF before diagnosis and 2706 (23·6%) had not. Overall, 9508 (83·0%) patients adhered to treatment and 10 077 (88·0%) were cured. After propensity score matching, receiving PBF before diagnosis was associated with adherence to treatment (OR 1·22, 95% CI 1·01–1·48) and cure (1·26, 1·01–1·58). PBF receipt did not significantly improve treatment adherence (1·37, 0·98–1·91) or cure (1·12, 0·75–1·67) in patients with paucibacillary leprosy. For patients with multibacillary disease, PBF beneficiaries had better treatment adherence (1·37, 1·08–1·74) and cure (1·43, 1·09–1·90) than non-beneficiaries. In the propensity score-matched analysis in 2654 children younger than 15 years with leprosy, PBF exposure was not associated with leprosy treatment adherence (1·55, 0·89–2·68) or cure (1·57, 0·83–2·97).InterpretationOur results suggest that being a beneficiary of the PBF, which facilitates cash transfers and improved access to health care, is associated with greater leprosy multidrug therapy adherence and cure in multibacillary cases. These results are especially relevant for patients with multibacillary disease, who are treated for a longer period and have lower cure rates than those with paucibacillary disease.FundingCONFAP/ESRC/MRC/BBSRC/CNPq/FAPDF–Doenças Negligenciadas, the UK Medical Research Council, the Wellcome Trust, and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior–Brazil (CAPES).

Trends of leprosy and multibacillary infection in the state of Georgia since the early 1900s.

Few investigations to date have analyzed the epidemiology of Hansen’s disease (leprosy) in the United States, and in particular, if birth location is related to multibacillary versus paucibacillary leprosy. We collected data on 123 patients diagnosed with leprosy in Georgia from the National Hansen’s Disease Program from 1923—January 2018. A logistic regression model was built to examine the relationship between country of origin (U.S.-born or immigrant) and the type of leprosy. While the model showed no significant relationship between country of origin and type of leprosy, being Asian or Pacific Islander was associated with a higher odds of multibacillary disease (aOR = 5.71; 95% CI: 1.25–26.29). Furthermore, since the early 1900s, we found an increasing trend of leprosy reports in Georgia among both domestic born and immigrant residents, despite the overall decrease in cases in the United States during the same time period. More research is therefore necessary to further evaluate risk for multibacillary leprosy in certain populations and to create targeted interventions and prevention strategies.

Aspectos epidemiológicos da hanseníase em menores de 15 anos, diagnosticados em um Centro de Referência do Sul do Brasil, entre 2007 e 2017


 Introdução: A Hanseníase (Doença de Hansen) é uma doença infectocontagiosa, que apresenta tropismo pela pele e nervos periféricos, cujo diagnóstico tardio pode causar sequelas físicas e emocionais. A Hanseníase em crianças é considerada um dos principais indicadores da tendência da doença e sugere intensa circulação do Mycobacterium leprae. Métodos: Um estudo retrospectivo, observacional e analítico foi conduzido com dezoito crianças diagnosticadas e tratadas no Ambulatório de Dermatologia Sanitária de Porto Alegre, Brasil. As informações clínicas e sociodemográficas foram obtidas através do Sistema de Informação de Agravos de Notificação (SINAN). Resultados: Durante o período de 2007-2017, 478 indivíduos foram diagnosticados como novos casos de Hanseníase em nosso Serviço; dentre esses, 18 (3,76%) eram crianças menores de 15 anos de idade, e sete foram diagnosticadas somente no ano de 2017. Dentre as 18 crianças, 15 (83,3%) eram multibacilares, e somente uma apresentou grau 2 de incapacidade. Aproximadamente 11% da amostra desenvolveram reações hansênicas durante o período de acompanhamento; 61,1% tinham entre 10 e 14 anos de idade. Contatos domiciliares foram identificados em 77,8% dos pacientes. Conclusão: Este estudo mostra que, apesar da situação endêmica ser menos preocupante no Sul do Brasil em relação às demais regiões brasileiras, o aumento da incidência de casos de Hanseníase em 2017 em indivíduos menores de 15 anos pode indicar uma mudança na tendência da doença e do indicador de detecção de casos novos da Hanseníase no Rio Grande do Sul, Brasil.

Mu-opioid receptor expression in multibacillary leprosy

During the clinical course of multibacillary leprosy disease, mainly in Lepromatous Leprosy (LL) patients, acute and systemic inflammatory episodes known as Erythema Nodosum Leprosum (ENL) may be present.

Clinico-epidemiological study of leprosy from a North Indian tertiary care hospital

<p class="abstract"><strong>Background:</strong> Leprosy was eliminated as a public health problem in India in 2005. Yet, more than 60% of all new cases of leprosy are reported from India.</p><p class="abstract"><strong>Methods:</strong> A retrospective analysis of the records of patients attending the leprosy clinic of the Dermatology Out Patient Department was done for a period of one year from May 2017 to April 2018. The data was analysed for clinical and epidemiological characteristics of the patients.<strong></strong></p><p class="abstract"><strong>Results:</strong> A total of 225 patients visited the leprosy clinic during the study period. Almost half of all patients (47.1%) were aged between 21-40 years. Among the patients were 32 children (14.2%) below 16 years. There were 60 patients (26.6%) suffering from paucibacillary disease and 158 patients (70.2%) had multibacillary disease. Seven patients (3.2%) presented with other forms of leprosy like historic leprosy and pure neuritic leprosy. Borderline lepromatous leprosy was found to be the commonest subtype seen in 86 patients (38.2%). There were 152 males (67.6%) and 73 females (32.4%). The male female ratio was 2.08:1. A total of 118 patients (52.4%) were from rural background and 107 (47.6%) hailed from urban areas. Multibacillary disease was seen in 83.6% of the total females compared to 63.8% of males.</p><p class="abstract"><strong>Conclusions:</strong> Leprosy may be down but is not yet out. The high proportion of children diagnosed with leprosy is a warning regarding the active transmission of the disease in the community. Continued efforts are required to prevent the disease from making a resurgence.</p>

Regulatory T cells: Friends or foe in human Mycobacterium leprae infection?

Regulatory T cells (Tregs) are known to control immune responses by suppressing the antigen-presenting and effector T cells. Some mechanisms adopted by Tregs in combating Mycobacterium infections have been proposed. Nevertheless, in M. leprae infection, also known as leprosy or Hansen’s disease, the role of Tregs has not been completely elucidated. Using multicolor flow cytometry, we evaluated the expression of different cell surface and intracellular molecules present in Tregs from peripheral blood samples of leprosy patients. Before initiating treatment, thirteen new cases of leprosy were grouped according to the Ridley–Jopling classification in to the paucibacilary (PB) or multibacilary (MB) group. Fifteen non-infected individuals (NI) were included as control subjects. Tregs were higher in the MB group than in the NI group. Tregs also co-expressed high amounts of PD1 and PDL-1, indicating that these cells could induce apoptosis of effector cells and simultaneously prevent their own apoptosis. Our data showed that compared to the NI group, Tregs from the PB group expressed higher levels of CD95L, which may be associated with other apoptotic pathways that may decrease Tregs in these patients. Correlation analysis reinforced that PD1 and CD95L are efficient apoptosis' pathway that decreased levels of Tregs in the NI and PB groups. We also observed significant differences in cytokine expression of Tregs from the PB and MB groups. Compared to the NI group, Tregs from the MB group showed higher IL-17 expression; however, compared to the PB group, the expression of IL-10 in Tregs from the MB group was lower, suggesting inefficient control of inflammation. Therefore, we concluded that different pathways were involved in Treg-induced suppression of leprosy. Moreover, Treg-mediated regulation of inflammation via IL-10 and IL-17 expression in leprosy patients was inefficient. Thus, we propose that during M. leprae infection, Tregs may impair the immune responses elicited against this bacillus, favor bacterial replication, and aid in persistence of a disseminated multibacillary disease.

A study of untreated leprosy affected children reporting with Grade 2 disability at a referral centre in West Bengal, India

Setting: An observational study of children diagnosed with leprosy and Grade 2 disability at a referral centre in West Bengal, India. Methods: A descriptive study was conducted of 21 children, diagnosed as new cases of leprosy with Grade 2 disability (G2D), and registered for treatment at The Leprosy Mission Hospital, Purulia, West Bengal, India. The socio-demographic and medical details were obtained from the patients charts. In-depth interviews were carried out with both the children and their parents to inquire about the factors responsible for the delay in diagnosis. Results: During a 3-year study period (2013–15), 1938 people were diagnosed as new active cases of leprosy at our referral centre; among the registered patients, 319 (16.5%) were children aged between 4 and 15 years, of whom 159 (50%) were diagnosed with multibacillary disease and 21 (6.6%) were reported with G2D. The disability proportion was lower in children compared with adults and higher in MB children compared with PB children. Paralysis of the intrinsic muscles of the hand was seen in 15 children and of these, 10 children had right hand ulnar paralysis and three had bilateral ulnar-median paralysis. Several children had noticed a patch as the first symptom and 15 had a leprosy-affected parent. Conclusion: This study shows that there is still a problem of children developing G2D before the diagnosis of leprosy is made, and points to some of the social factors responsible for delayed reporting and prompt starting of MDT. Better communication and innovative methods of persuading the families to report early need to be tested and urgently implemented.

Pathways and Genes Associated with Immune Dysfunction in Sheep Paratuberculosis

Multibacillary and paucibacillary paratuberculosis are both caused by Mycobacterium avium subspecies paratuberculosis. Multibacillary lesions are composed largely of infected epithelioid macrophages and paucibacillary lesions contain T cells but few bacteria. Multibacillary disease is similar to human lepromatous leprosy, with variable/high levels of antibody and a dysfunctional immune response. Animals with paucibacillary disease have high cell-mediated immunity and variable levels of antibody. This study aims to characterize the immunological dysfunction using TruSeq analysis of the ileocaecal lymph node that drains disease lesions. Immune dysfunction is highlighted by repression of TCR/CD3 genes, T cell co-receptors/co-stimulators, T cell activation and signal-transduction genes. Inflammation was an acute phase response and chronic inflammation, with little evidence of acute inflammation. The high levels of immunoglobulin and plasma cell transcripts is consistent with the anti-MAP antibody responses in paratuberculosis sheep. Also notable was the overwhelming reduction in mast cell transcripts, potentially affecting DC activation of the immune response. This study also shows that there were no fundamental differences in the gene expression patterns in multibacillary and paucibacillary disease, no shift in T cell genes from Th1 to Th2 pattern but rather an incremental decline into immune dysfunction leading to multibacillary pathology.

Multibacillary leprosy by population groups in Brazil: Lessons from an observational study.

BackgroundLeprosy remains an important public health problem in Brazil where 28,761 new cases were diagnosed in 2015, the second highest number of new cases detected globally. The disease is caused by Mycobacterium leprae, a pathogen spread by patients with multibacillary (MB) leprosy. This study was designed to identify population groups most at risk for MB disease in Brazil, contributing to new ideas for early diagnosis and leprosy control.MethodsA national databank of cases reported in Brazil (2001–2013) was used to evaluate epidemiological characteristics of MB leprosy. Additionally, the databank of a leprosy reference center was used to determine factors associated with higher bacillary loads.ResultsA total of 541,090 cases were analyzed. New case detection rates (NCDRs) increased with age, especially for men with MB leprosy, reaching 44.8 new cases/100,000 population in 65–69 year olds. Males and subjects older than 59 years had twice the odds of MB leprosy than females and younger cases (OR = 2.36, CI95% = 2.33–2.38; OR = 1.99, CI95% = 1.96–2.02, respectively). Bacillary load was higher in male and in patients aged 20–39 and 40–59 years compared to females and other age groups. From 2003 to 2013, there was a progressive reduction in annual NCDRs and an increase in the percentage of MB cases and of elderly patients in Brazil. These data suggest reduction of leprosy transmission in the country.ConclusionPublic health policies for leprosy control in endemic areas in Brazil should include activities especially addressed to men and to the elderly in order to further reduce M. leprae transmission.

Variations in T cell transcription factor gene structure and expression associated with the two disease forms of sheep paratuberculosis

Two different forms of clinical paratuberculosis in sheep are recognised, related to the level of bacterial colonization. Paucibacillary lesions are largely composed of lymphocytes with few bacteria, and multibacillary pathology is characterized by heavily-infected macrophages. Analysis of cytokine transcripts has shown that inflammatory Th1/Th17 T cells are associated with development of paucibacillary pathology and Th2 cytokines are correlated with multibacillary disease. The master regulator T cell transcription factors TBX21, GATA3, RORC2 and RORA are critical for the development of these T cell subsets. Sequence variations of the transcription factors have also been implicated in the distinct disease forms of human mycobacterial and gastrointestinal inflammatory diseases. Relative RT-qPCR was used to compare expression levels of each transcript variant of the master regulators in the ileo-caecal lymph nodes of uninfected controls and sheep with defined paucibacillary and multibacillary pathology. Low levels of GATA3 in multibacillary sheep failed to confirm that multibacillary paratuberculosis is caused simply by a Th2 immune response. However, high levels of TBX21, RORC2 and RORC2v1 highlights the role of Th1 and Th17 activation in paucibacillary disease. Increased RORAv1 levels in paucibacillary tissue suggests a role for RORα in Th17 development in sheep; while elevated levels of RORAv4 hints that this variant might inhibit RORα function and depress Th17 development in multibacillary sheep.Electronic supplementary materialThe online version of this article (doi:10.1186/s13567-016-0368-3) contains supplementary material, which is available to authorized users.

A Clinico-Epidemiological Study of Leprosy in an Urban Leprosy Centre of West Bengal

A Clinico epidemiological study of 208 patients of leprosy who sought medical advice at the Leprosy OPD of School of Tropical Medicine, Kolkata, during January 2016 – April 2016 is reported. Among all the cases, 94.2% were new cases, 3.8% were defaulters and 1.9% were having a relapse after completion of treatment. Around 59% of them had borderline tuberculoid type. An important finding was that prevalence of BL & LL cases before the age of 50 years is about 15.8% but beyond this age the prevalence rises to 47.6%. Depending on slit skin smear report 146 (70.2%) cases were multibacillary leprosy. The disease was found 2.3 times more often in males than in females and was found mainly in the age group 11-70 years. Lepra reactions were seen in 17 (8.17%) cases, of which 10 had type 1 reaction (58.8%) and 7 type 2 reaction (41.2%). Another significant finding was the occurrence of lepra reactions (both type I & II) in multibacillary type of leprosy (n=14) than in paucibacillary type. Among the 146 patients with multibacillary disease 42 (28.76%) developed deformity and most (80.95%) would have more severe and permanent deformities.

Delayed Diagnosis, Leprosy Reactions, and Nerve Injury Among Individuals With Hansen's Disease Seen at a United States Clinic.

Background. Hansen's disease (HD), or leprosy, is uncommon in the United States. We sought to describe the characteristics of patients with HD in a US clinic, including an assessment of delays in diagnosis and HD reactions, which have both been associated with nerve damage. Methods. A retrospective chart review was conducted on patients seen at an HD clinic in the southern United States between January 1, 2002 and January 31, 2014. Demographic and clinical characteristics were summarized, including delays in diagnosis, frequency of reactions, and other complications including peripheral neuropathy. Results. Thirty patients were seen during the study time period. The majority of patients were male (73%) and had multibacillary disease (70%). Brazil, Mexico, and the United States were the most frequent of the 14 countries of origin. Hansen's disease "reactions", severe inflammatory complications, were identified among 75% of patients, and nerve damage was present at diagnosis in 36% of patients. The median length of time between symptom onset and diagnosis was long at 12 months (range, 1-96), but no single factor was associated with a delay in diagnosis. Conclusions. The diagnosis of HD was frequently delayed among patients referred to our US clinic. The high frequency of reactions and neuropathy at diagnosis suggests that further efforts at timely diagnosis and management of this often unrecognized disease is needed to prevent the long-term sequelae associated with irreversible nerve damage.

The association between neuropathic pain and disability grades in leprosy

To detect neuropathic pain in people who have had leprosy and correlate this association with the WHO Degree of Physical Disability classification (DPD-WHO). Data were collected from medical records, interviews and physical examinations of patients treated in 2013 in a regional referral service that attends 102 municipals. Clinical and general data, the DPD-WHO classification and the Douleur Neuropathique 4 Questionnaire (DN4) were utilised to determine the profile and to diagnose neuropathic pain. Of 84 treated patients, 37 (44.1%) had leprosy-related pain at the time of the interview. The mean age was 53 years, 51.4% were women; 75.7% had multibacillary disease and 72.9% had some kind of reactional episode. Of the 37 patients with pain, 22 (59.5%) had neuropathic pain and 15 (40.5%) had nociceptive pain. The most frequently reported symptoms related to neuropathic pain, apart from numbness (64.9%), were tingling and touch hypoesthesia (56.8%). Of 22 patients with neuropathic pain, 20 had some physical disability; 14 (63.6%) had Grade I disability, six (27.2%) Grade II, and two (9.3%) Grade zero disability. An association was found between neuropathic pain and degree of disability (P-value < 0.05). Of the patients who reported pain related to leprosy, 59.5% had neuropathic pain. The DN4 seems to be suitable for determining the presence of neuropathic pain in leprosy. There is an association between the degree of disability and neuropathic pain, i.e. patients with neuropathic pain tend to have a physical disability too.

Variations in IL-23 and IL-25 receptor gene structure, sequence and expression associated with the two disease forms of sheep paratuberculosis.

The immunopathology of paucibacillary and multibacillary sheep paratuberculosis is characterized by inflammatory T cell and macrophage responses respectively. IL-23 and IL-25 are key to the development of these responses by interaction with their complex receptors, IL-23R/IL-12RB1 and IL-17RA/IL-17RB. In humans, variations in structure, sequence and/or expression of these genes have been implicated in the different pathological forms of tuberculosis and leprosy, and in gastrointestinal inflammatory disorders such as Crohn’s disease. Sequencing has identified multiple transcript variants of sheep IL23R, IL12RB1 and IL17RB and a single IL17RA transcript. RT-qPCR assays were developed for all the identified variants and used to compare expression in the ileo-caecal lymph node of sheep with paucibacillary or multibacillary paratuberculosis and uninfected animals. With IL-23 receptor, only the IL12RB1v3 variant, which lacks the receptor activation motif was differentially expressed and was significantly increased in multibacillary disease; this may contribute to high Th2 responses. Of the IL17RB variants only full length IL17RB was differentially expressed and was significantly increased in multibacillary pathology; which may also contribute to Th2 polarization. IL17RA expression was significantly increased in paucibacillary disease. The contrast between the IL17RA and IL17RB results may indicate that, in addition to Th1 cells, Th17 T cells are also involved in paucibacillary pathology.Electronic supplementary materialThe online version of this article (doi:10.1186/s13567-016-0314-4) contains supplementary material, which is available to authorized users.

The decline of leprosy in the Republic of Korea; patterns and trends 1977–2013

Though the World Health Organization declared the 'elimination of leprosy as public health problem' in 2000, the disease remains endemic in many countries. Current trends in incidence of infection and disease are unclear. Data on leprosy prevalence between 1977-2013 and data on new leprosy cases detected in the Republic of Korea between 1989-2013 were analysed by age, sex, clinical types, mode of detection, family history, disability grading and geographical distribution. Both prevalence and incidence have declined greatly. There has been a shift to an increased proportion of multibacillary disease, and older age groups, consistent with a dramatic decrease in infection transmission in recent decades. An increase in proportion of cases with family history of disease is consistent with these declines. There is evidence that declines in infection and disease have been greater in the north of the country, as revealed in patterns by place of birth over time. Cases in immigrants now form a substantial proportion of leprosy disease in the Republic of Korea. Leprosy has declined dramatically in the Republic of Korea in recent decades, and transmission of M. leprae may have effectively stopped. There remains a burden of care for individuals whose disease developed in the past, and there may be some additional newly detected cases among immigrants and among older individuals who acquired autochthonous infections decades ago.

Tuberculous Pericarditis is Multibacillary and Bacterial Burden Drives High Mortality

BackgroundTuberculous pericarditis is considered to be a paucibacillary process; the large pericardial fluid accumulation is attributed to an inflammatory response to tuberculoproteins. Mortality rates are high. We investigated the role of clinical and microbial factors predictive of tuberculous pericarditis mortality using the artificial intelligence algorithm termed classification and regression tree (CART) analysis. MethodsPatients were prospectively enrolled and followed in the Investigation of the Management of Pericarditis (IMPI) registry. Clinical and laboratory data of 70 patients with confirmed tuberculous pericarditis, including time-to-positive (TTP) cultures from pericardial fluid, were extracted and analyzed for mortality outcomes using CART. TTP was translated to log10 colony forming units (CFUs) per mL, and compared to that obtained from sputum in some of our patients. FindingsSeventy patients with proven tuberculous pericarditis were enrolled. The median patient age was 35 (range: 20–71) years. The median, follow up was for 11.97 (range: 0·03–74.73) months. The median TTP for pericardial fluid cultures was 22 (range: 4–58) days or 3.91(range: 0·5–8·96) log10CFU/mL, which overlapped with the range of 3.24–7.42 log10CFU/mL encountered in sputum, a multi-bacillary disease. The overall mortality rate was 1.43 per 100 person-months. CART identified follow-up duration of 5·23months on directly observed therapy, a CD4+ count of ≤199.5/mL, and TTP≤14days (bacillary load≥5.53 log10 CFU/mL) as predictive of mortality. TTP interacted with follow-up duration in a non-linear fashion. InterpretationPatients with culture confirmed tuberculous pericarditis have a high bacillary burden, and this bacterial burden drives mortality. Thus proven tuberculosis pericarditis is not a paucibacillary disease. Moreover, the severe immunosuppression suggests limited inflammation. There is a need for the design of a highly bactericidal regimen for this condition.

Factors associated with the worsening of the disability grade during leprosy treatment in Brazil

To analyse factors associated with the worsening of physical disabilities during the treatment of leprosy in Brazil in cases that were newly diagnosed in 2009. This epidemiological study performed as a retrospective cohort investigated the factors associated with the worsening of the physical disability grade during the treatment of paucibacillary and multibacillary leprosy cases. Logistic regression with a confidence interval of 95% was used to analyse the variables associated with the worsening of disability grade. The cases with the greatest odds for worsening physical disability grade were patients from the south (odds ratio [OR] = 2.60) and southeast regions (OR = 1.74); with multibacillary disease (OR = 3.48); who were illiterate (OR = 2.26); and with reactive episodes (OR = 2.42). The factors associated with higher odds of worsening physical disability during treatment demonstrate failure to apply appropriate remedial measures to prevent disabilities, and greater attention should be given to patients with the most severe disease.