Slit Skin Smear Research Articles

A Pilot Study on Hypogonadism in Male Leprosy Patients in Rural Tertiary Care Hospital in Central India

Background: Leprosy is a chronic granulomatous infectious disease caused by Mycobacterium leprae. Besides the skin and peripheral nerves, it also involves many internal organs. Testicular involvement is mainly seen in leprosy. Hypogonadism in males with leprosy can occur due the involvement of testis. Aim: The aim was to evaluate the gonadal function impairment in males with leprosy and to analyze the relation of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone to the activity, duration, and disease classification in Central India. Patients and Methods: This was a prospective observational pilot study. We evaluated 30 patients of leprosy. They were subjected to careful history taking, dermatological and genital examination, assessment of FSH, LH, and testosterone levels, and slit skin smear for acid-fast bacilli. Diagnosis of leprosy was confirmed histopathologically. The collected data were encoded and entered electronically in a computer excel worksheet 2010 version. The statistical analysis was performed using SPSS version 17.0 for Windows. Pearson correlation coefficient was used to establish relationship between different variables. P ≤ 0.05 was considered statistically significant. Results: A positive correlation was found between FSH and LH hormones which was highly significant, whereas there was a negative correlation between testosterone and FSH and LH levels. There was a positive correlation between age, duration of disease, and reaction in leprosy with those of FSH and LH levels. There was a positive correlation between disease activity bacillary index (BI) and FSH, LH and a negative correlation between BI and testosterone. Conclusion: It is recommended that lepromatous leprosy patients should be routinely screened for hypogonadism using FSH, LH, and testosterone levels.

Epidemiological and Clinical Pattern of Leprosy in a Tertiary Care Centre in Bareilly, Uttar Pradesh, India- A Retrospective Study

Introduction: Leprosy also known as Hansen’s Disease (HD), is a chronic infectious granulomatous disease caused by Mycobacterium leprae. It affects the skin and peripheral nerves. It is characterised by the formation of nodules or macules that enlarge and spread with loss of sensation due to nerve involvement which can progress to paralysis and eventually lead to deformities. Aim: To describe the clinical and epidemiological pattern of leprosy patients in a tertiary care hospital in Bareilly, Uttar Pradesh, India. Materials and Methods: This retrospective study was conducted at a tertiary level, Military Hospital in Bareilly, Uttar Pradesh, India, from June 2022 to August 2022. Medical records of 263 Leprosy patients, who were diagnosed as HD clinically and histopathologically were part of the study. All their data pertaining to the history, onset, time of detection, clinical features in the form, type and number of patches, presence of peripheral nerve thickenings, investigations which included skin slit smear for Acid Fast Bacilli (AFB) (Lepra) and histopathological examination, duration of drug therapy, reactions encountered and the disabilities were collected. Results: A total of 263 case records of leprosy patients (225 males (85.55%) and 38 females (14.45%), mean age of 35.36±13.79 years) were analysed. Majority of the cases were Borderline Tuberculoid (BT) Hansen’s 113 (42.96%). Average time taken by the patients before reporting to the Leprosy centre from onset of symptoms was 18 months. The most common clinical manifestation was multiple light coloured numb patches in 169 patients. A total of 245 patients had peripheral nerve thickening with Ulnar nerve 205 (77.95%) being the most commonly affected nerve. A total of 98 patients had Type-1 reaction and 13 had Type-2 reaction. The Grade-2 disability was seen in 22 cases with claw hand deformity being the commonest 10 (45.45%). Conclusion: In present study, majority patients were male with the most common clinical manifestation being multiple numb patches all over the body. The most common type of leprosy which presented was BT HD.

Hansen’s Disease- Lepromatous Type

A 36-year-old male presented with multiple skin-colored nodules involving both the ears and madarosis for last one year. There was no history of any other lesion elsewhere. Examination revealed lesions over the ear, ala of nose and diffusely infiltrated superciliary region (Panel A, B) and a normal sensory and motor system. Slit skin smear from the ear nodules revealed multiple acid-fast bacilli with globi formation and bacillary index of 6+ and morphological index (MI) of 35% (Panel C). He was diagnosed as Hansen’s disease-lepromatous type (LL) which is usually characterized by infiltrative lesions and nodules especially over face and edema of hands and feet.

1427. Correlation of Dermoscopic and Histopathologic Patterns in Leprosy-a Pilot Study

Abstract Background Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae. It is diagnosed based on clinical features and confirmed on the histological findings and peripheral slit skin smear staining. Dermoscopy is a handy easily accessible tool to diagnose this granulomatous disease and classify patients based on the immunological and clinical response. Methods A total of 50 patients in different poles of leprosy were evaluated as a single spot observational analysis. The clinical and histological findings were correlated with the characteristic dermoscopy findings. A Lepromatous leprosy showing xerosis and scaling along leg as part of glove and stocking distribution of lesions Dermoscopic pattern in lepromatous leprosy showing partial loss of hair follicles, dry xerotic skin, and white characteristic scaling (Heine Delta® 20 T dermatoscope; 16×; polarizing) Results The dermoscopy findings correlated with the clinical and histological findings. Tuberculoid poles of leprosy classically showed loss of hair and skin pigment along with absence of white dots as sweat glands in dermoscopy. Lack of blood vessel changes ruled out any lepra reaction. Lepromatous pole of leprosy on the other hand showed characteristic xerosis and white scaling on dermoscopy in the background of hypotrichosis and hypopigmentation. leprosy reactions were characterized by blood vessel changes and arborizing blood vessels were characteristic in erythema nodosum leprosum and a diffuse erythema was a clue towards diagnosing type I lepra reaction. Interestingly clofazimine induced pigmentation was picked up characteristically on dermoscopy as a ‘honey comb pattern’. Borderline tuberculoid leprosy with a hypoaesthetic patch on the left side of face with a thickened greater auricular nerve Dermoscopic pattern in borderline tuberculoid leprosy showing white areas with loss of hair follicles. In between yellow globules can be seen which was the hallmark apart from white areas demonstrating hypopigmentation. Absence of blood vessels rules out lepra reaction (Heine Delta® 20 T dermatoscope; 16×; polarizing) Conclusion Dermoscopy is certainly a handy tool in aiding the diagnosis of leprosy, lepra reactions and course of therapy. Characteristic patterns during the course of leprosy would certainly facilitate a quick and definitive diagnosis of patients suffering from leprosy. Also patient drug compliance particularly to Clofazimine can also be picked up objectively on Clofazimine. Multiple erythematous plaques on the back depicting type 1 lepra reaction Dermoscopic features of type I lepra reaction showing characteristic diffuse erythematous background and branching telangiectatic vessels along with sparse hair follicles and scaling (Heine Delta®20 T dermatoscope; 16×; polarizing) Disclosures All Authors: No reported disclosures.

PP102 Selecting The Sequence Of Diagnostic Tests For Leprosy In Brazil

IntroductionHansen’s disease, or leprosy, is a chronic bacterial infection that affects the nerves, skin, eyes, and nose lining. In 2019, there were 202,256 new cases reported globally, and nearly 28,000 new cases are diagnosed each year in Brazil. The best way to prevent the spread of Hansen’s disease is early diagnosis and treatment of infected individuals. Most diagnoses are done clinically, but only the microscopic analysis of slit-skin smears is funded in Brazil. Serologic and polymerase chain reaction (PCR) tests have also been developed to aid in the diagnosis. The goal of this study was to identify the most cost-effective strategy for increasing the diagnosis of Hansen’s disease in Brazil.MethodsWe examined the impact of the following four strategies using a decision tree model: (i) slit-skin smear only; (ii) PCR test only; (iii) serologic testing followed by slit-skin smear for positive samples; and (iv) serologic testing followed by slit-skin smear for positive samples and PCR test for negative serologic tests and negative slit-skin smears. The accuracy of the tests was determined using a systematic review and meta-analysis and validated by experts. The costs were calculated from the Brazilian health system perspective. Univariate and probabilistic analyses were also conducted.ResultsSerologic testing or PCR followed by slit-skin smear was dominated in the economic model (more false-negative samples and more costly). The addition of serologic testing and PCR to the diagnostic sequence made the strategy more expensive than slit-skin smears alone, but it significantly reduced the percentage of false negative results (from 7.3 to 2.9%) at an estimated cost of USD 533.61 per incremental diagnosis. Disease prevalence was the most important variable in the sensitivity analysis.ConclusionsThis is the first cost-effectiveness model undertaken for Hansen’s disease. The results indicate that incorporating serology and PCR testing into the Brazilian health system could be an appealing option for reducing the spread of Hansen’s disease in Brazil.

Squamous cell carcinoma associated with an active cutaneous leishmaniasis in immunocompetent patient: case presentation of an unlikely association and literature—review

BackgroundAssociation between leishmaniasis and malignancy can be classified into four categories: leishmaniasis mimicking malignancy, leishmaniasis co-existing with malignancy, malignancy developing in patients with leishmaniasis scar, and leishmaniasis developing in patients with malignancy. In immunocompetent patients, the main form of association is cutaneous squamous cell carcinoma (cSCC) developing within cutaneous leishmaniasis scar years after cutaneous leishmaniasis is cured. Association of active cutaneous leishmaniasis and cSCC is exceptional, we are aware of two more cases.Case presentationA 30-year-old man presented with 2 years history of an unhealed wound on the dorsum nasi. As there still exist few sites of leishmaniasis in Morocco, systematic screening for leishmania was performed. Leishmania bodies were identified on slit skin smear by Giemsa staining. The patient received local antibiotic and on-site injections of 4 cc of meglumine antimonate for 2 months without any improvement. The lesion volume has increased significantly, a biopsy revealed an invasive squamous cell carcinoma. After staging assessment, the patient underwent a complete removal of the nasal tumor with a 1-cm margin, associated with right modified radical neck dissection. Histopathological examination confirmed the diagnosis of SCC with no lymph nodes metastasis. Nasal reconstruction was performed 2 weeks later using a frontal flap. Oncology meeting board advised adjuvant radiation on the tumor. The patient is followed up regularly and remains free of disease for a year now.ConclusionAlthough many cancers are related to infection (viral or parasitic), there is no proven link between leishmaniasis and malignancy. However, there are many etiopathogenic theories based on pathology finding that involve chronic inflammation inducing dysplasia, mitotic abnormalities, and expression of p53.

Clinicoepidemiological Profile of Childhood Leprosy in a Tertiary Care Hospital of North Karnataka

Abstract Background: Childhood leprosy is an indicator of ongoing transmission of the disease. The prevalence rate of pediatric leprosy is considered an important epidemiological index for determining the level of transmission of the disease. Our aim was to estimate the proportion of leprosy cases among children aged 0–14 years in our tertiary care hospital. Methods: A retrospective study was carried out for a period of 4 years from January 2017 to December 2020. Secondary data were collected from leprosy records pertaining to childhood leprosy (aged between 0 and 14 years). Only new cases presented during the period were included. Details of the patients such as age, sex, family history, number and site of lesions, nerve involvement, reactions, and deformities were noted. Slit-skin smear and biopsy findings were tabulated and descriptive analysis was done. Results: Fifty-five cases (9.54%) of childhood leprosy were diagnosed. Majority of the cases were in the age group of 10–14 years. The most common leprosy type was borderline tuberculoid found in 42 patients (76.36%). Forty-nine patients (89.09%) had paucibacillary (PB) and 6 (10.91%) had a multibacillary type. The most common presenting symptom was patch (61.8%). Eleven patients had a family history. Clinicopathological correlation was observed in 50 (90%) patients. Lepra reactions were seen in six (10.9%) patients and two deformities in three patients. Conclusion: The proportion of pediatric leprosy cases was 11.61% in 2017 and decreased to 6.45% in 2020. PB type is the most common type. To achieve zero childhood leprosy cases, thorough follow-up and contact tracing of adult leprosy patients, early diagnosis of childhood leprosy to prevent disabilities is the need of the hour.

Diagnosis and Treatment of Multibacillary Leprosy Borderline Lepromatous Type: A Case Report

Background: Leprosy is a chronic granulomatous infectious disease caused by Mycobacterium leprae. This disease has a high transmission ability and can cause physical disability and have an impact on the social life of the sufferer because of the negative stigma about leprosy. This study aims to describe the examinations performed in the diagnosis and treatment of patients with multibacillary leprosy, borderline lepromatous type.
 Case presentation: A 43-year-old woman with a chief complaint of redness on the arm since 1 year ago. The patches are not itchy, painless, stiff, and numb. Since 3 months ago, the patient complained of red patches increasing and spreading to the trunk and legs. Dermatological examination found in the facial region et truncus anterior et posterior et superior, and inferior extremities bilateral showing multiple erythematous plaques, well-demarcated with scales in several parts. Sensory function examination revealed a decrease in lesions on the face, superior and inferior extremities, and anterior and posterior trunks. Negative AFB examination and biopsy results support the diagnosis of borderline lepromatous type (BL) multibacillary leprosy (MB).
 Conclusion: Clinical findings in the form of hypopigmented lesions that feel numb is a cardinal signs of leprosy. Asymmetrical distribution of lesions with a number of more than 5 lesions accompanied by impaired nerve function in the form of decreased sensibility is a characteristic of MB leprosy. Histopathological features support the diagnosis of MB type BL leprosy even though the results of the skin slit smear examination were negative.

Morbus Hansen Multibacillary Type Mid Borderline: A Case Report

Background: Morbus Hansen (MH) is a granulomatous infectious disease caused by an obligate intracellular pathogenic bacterium, Mycobacterium leprae (M. leprae). Cardinal signs of Hansen's morbus (MH) include patches of numb skin, thickening of the peripheral nerves, and acid-fast bacteria (AFB) on a skin smear or biopsy. This case report aims to establish the diagnosis of mid borderline (BB) MH with clinical and histopathological examination.
 Case presentation: A 44-year-old woman presented with red patches on her face and body 1 month ago. Madarosis and multiple erythematous plaques confluent, poorly demarcated, raised edges, atrophic center with some smooth shiny and some rough surfaces found in the facial region and superior extremities et al. bilateral inferior with bilateral auricular infiltrates. A sensory examination of the lesion showed decreased sensitivity to pain and temperature. Skin-slit smear examination showed AFB with bacterial index (IB) +2 and morphological index (IM) 30%. On histopathological examination with hematoxylin and eosin staining, Grenz zone appeared, epithelioid granuloma affecting the epidermis, no lymphocytes, and no giant Langhans cells were found, and nerves were surrounded by lymphocytes and granulomas. On fite-faraco staining, BTA was obtained with IB +3 and IM 30%. The diagnosis of MH type BB was established, and the patient was given multidrug therapy (MDT) multibacillary (MB).
 Conclusion: Morbus Hansen type BB has a typical histopathological picture of granulomas composed of mature epithelioid cells, Grenz zone, AFB, enlarged and swollen nerves surrounded by lymphocytes or infiltrated with granulomas without damage. After 3 months of therapy, there was a decrease in IB and IM on AFB examination.

Interleukin-17A in Egyptian leprosy patients: a clinical, genetic, and biochemical study

BackgroundLeprosy represents a long-term communicable disease resulting from Mycobacterium leprae infection. IL-17A is one of the pro-inflammatory cytokines that protects humans against many fungal and bacterial pathogens. ObjectiveTo investigate IL-17A (rs2275913) gene polymorphism and its circulating level in leprosy patients, and to correlate the detected results with different clinical aspects of leprosy in the investigated patients. Methods60 patients with leprosy, and 29 age and sex-matched volunteers were investigated for IL-17A serum level and IL-17A single nucleotide polymorphism (SNP) by ELISA and RFLP-PCR respectively. ResultsIL-17A serum level was significantly higher in leprosy patients than in controls (p=0.034), and in TL than LL (p=0.017). IL-17A (rs2275913 A/G) G allele and GG genotype were associated significantly with LL (p=0.005and 0.001 respectively). IL-17A (rs2275913 A/G) AG genotype carriers demonstrated the highest IL-17A serum levels; however, its lowest levels were found in IL-17A (rs2275913 A/G) AA genotype carriers (p=0.005). Grade 2 disability (p=0.030) and positive slit skin smear (SSS) (p=0.005) were significantly associated with IL-17A (rs2275913 A/G) GG genotype. Study limitationsThe small number of studied subjects. ConclusionsIL -17A may have a pivotal role in leprosy pathogenesis. IL-17A (rs2275913) GG genotype plus G allele might be related to the development of LL in the Egyptian population.

Effectiveness of intralesional sodium stibogluconate for the treatment of localized cutaneous leishmaniasis at Boru Meda general hospital, Amhara, Ethiopia: Pragmatic trial.

Cutaneous leishmaniasis (CL) is generally caused by Leishmania aethiopica in Ethiopia, and is relatively hard to treat. Sodium stibogluconate (SSG) is the only routinely and widely available antileishmanial treatment, and can be used systemically for severe lesions and locally for smaller lesions. There is limited data on the effectiveness of intralesional (IL) SSG for localized CL in Ethiopia and therefore good data is necessary to improve our understanding of the effectiveness of the treatment. A pragmatic (before and after Quazi experimental) study was done to assess the effectiveness of intralesional SSG among localized CL patients at Boru Meda general hospital, Northeast Ethiopia. Patients who were assigned to intralesional SSG by the treating physician were eligible for this study. Study subjects were recruited between January and August 2021. Infiltration of intralesional SSG was given weekly to a maximum of six doses. However, when a patient's lesions were already cured before getting 6 doses, treatment was not conintued, and patient were only asked to come for lesion assessment. Skin slit smears (SSS) were taken each week until they became negative. Outcomes were assessed at day 90, with patients who had 100% reepithelization (for ulcerative lesions) and/or flattening (for indurated lesions) defined as cured. Multi-level logistic regression was done to assess factors associated with cure. A total of 83 patients were enrolled, and final outcomes were available for 72 (86.75%). From these 72, 43 (59.7%, 95% confidence interval 0.44-0.69) were cured at day 90. Adverse effects were common with 69/72 patients (95.8%) reporting injection site pain. Factors associated with cure were age (OR 1.07 95% CI: 1.07-1.27), being male (OR 1.79, 95% CI: 1.10-2.25), size of the lesion (OR 0.79, 95% CI: 0.078-0.94) and skin slit smear (SSS) result +1 grading (OR 1.53, 95% CI: 1.24-1.73) and +2 grading (OR 1.51, 95% CI: 1.41-3.89) compared to the SSS grade +6. Our findings revealed that intralesional sodium stibogluconate resulted in a cure rate of around 60%, with almost all patients experiencing injection site pain. This emphasizes the need for local treatment options which are more patient-friendly and have better cure rates.

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.

Slit-skin smear for the classification of leprosy; are we wasting time and resource?

Leprosy is a chronic neglected tropical disease, classified into two groups: multibacillary (MB) and paucibacillary (PB) leprosy based on the number of skin lesions and nerve involvement. A positive skin slit smear (SSS) result automatically puts a patient in the MB category. Although guidelines do not recommend routine use of SSS for classification and diagnosis of leprosy, it is performed for most patients in Ethiopia. However, the added value of performing SSS for the classification of leprosy on top of clinical classification is unclear. A cross sectional study was done using routine laboratory and clinical data from September 2018 to January 2020 at Boru Meda General Hospital, Ethiopia. All newly diagnosed leprosy cases were included. Descriptive statistics were performed to calculate frequencies and proportions. We included 183 new leprosy patients in our study, of which 166/183 (90.7%) were MB patients and 17/183 (9.3%) were PB patients. All clinical PB cases and 150/166 (90.4%) clinical MB patients had SSS done. All PB patients had negative SSS result and 68 (45.3%) clinical MB patients had a positive result. Based on the SSS, no patient with a clinical classification of PB was reclassified to MB. SSS microscopy was performed routinely for all leprosy cases without changing the classification and management of patients in Boru Meda Hospital. Therefore, we recommend restricted and rational use of the SSS for PB cases in which SSS could change management.

Utility of a Mycobacterium leprae molecular viability assay for clinical leprosy: An analysis of cases from the Philippines, Ethiopia, and Nepal

Mycobacterium leprae is a slow-growing species of mycobacteria that cannot be cultured in axenic media. This presents a number of challenges for monitoring treatment efficacy and advancing new drugs and regimens for treating leprosy. We previously developed a molecular viability assay (MVA) which measures expression of hsp18 and esxA transcripts to determine viability of M. leprae directly from infected tissue. The objective of the current study was to determine the utility of the MVA for practical use on clinical specimens. Leprosy cases from the Philippines (N = 199), Ethiopia (N = 40), and Nepal (N = 200) were diagnosed by clinical examination, slit-skin smears (SSS) from index sites, and/or histopathology. Biopsy specimens for MVA were collected from an active lesion and stored in 70% ethanol. DNA and RNA were extracted from the tissue, and M. leprae were enumerated on the DNA fraction via RLEP qPCR. Based on this count, DNased RNA was normalized to the equivalent of 3x103M. leprae per reverse transcription reaction, and hsp18 and esxA transcripts were amplified by PCR on the resulting cDNA. There was a strong correlation between RLEP enumeration on the specific biopsy specimen for MVA and the average SSS bacterial index (BI) in all three cohorts (p < 0.001). The MVA could be performed on most biopsies with an average SSS BI ≥ 2 and showed a decrease in M. leprae viability with increasing duration of leprosy multidrug therapy (R2 = 0.81, p < 0.001). The MVA also detected viable M. leprae in relapse patients where it showed significant correlation with the mouse footpad assay (p = 0.018). The MVA is a M. leprae-specific, sensitive, and relatively quick test. Clinically, the MVA would likely be most useful to monitor treatment, confirm suspected relapse cases, and determine efficacy of new leprosy drugs in clinical trials.

Bacilloscopy and polymerase chain reaction of slit-skin smears and anti-phenolic glycolipid-I serology for Hansen's disease diagnosis.

The bacilloscopy of the slit-skin smear (SSS) is the exclusive laboratory test associated with dermato-neurological evaluation for Hansen’s disease (HD) diagnosis; however, it is negative in the majority of PB or primary neural forms. Thus, a PCR technique involving different sequences and target genes has been performed with an aim to increase the sensitivity and specificity of M. leprae identification, especially in patients with low bacillary loads. Additionally, serological assays based on antibody response reflect infection levels and indicate that this could be a simpler, less invasive technique for estimating M. leprae exposure. Serological tests and PCR have been shown to be more sensitive and accurate than the SSS. Our study aimed to measure accuracy and performance among the SSS and PCR of dermal scrapings stored on filter paper and APGL-I serology for diagnosis in HD. A cross-sectional study analyzing the medical records (n = 345) of an HD outpatient-dermatology clinic from 2014 to 2021 was conducted. Accuracy performance parameters, correlation, and concordance were used to assess the value among the SSS, PCR, and APGL-I exams in HD. The SSS presented 24.5% sensitivity, 100% specificity, 37.4% accuracy, and the lowest negative predictive value (21.5%). The PCR assay had 41, 100, and 51% sensitivity, specificity, and accuracy, respectively. PCR and APGL-I serology increased the detection of HD cases by 16 and 20.6%, respectively. PCR was positive in 51.3% of patients when the SSS was negative. The SSS obtained moderate concordance with PCR [k-value: 0.43 (CI: 0.33–0.55)] and APGL-I [k-value: 0.41 (CI: 0.31–0.53)]. A moderate positive correlation was found between the APGL-I index and the bacillary index (r = 0.53; P < 0.0001). Thus, the use of the SSS is a low sensitivity and accuracy method due to its low performance in HD detection. The use of PCR and serological tests allows for a more sensitive and accurate diagnosis of patients.

Diagnostic Accuracy Of Slit Skin Smear and FNAC in Diagnosis of Cutaneous Leishmaniasis Taking Histopathology as Gold Standard

Aim: To assess the efficacy of slit skin smear and fine-needle aspiration cytology (FNAC) for diagnosing cutaneous leishmaniasis while keeping histopathological analysis as a gold standard. Place and duration of study: From 6th Jan 2020 to 6th Jan 2021 at Bakhtawar Amin Medical &amp; Dental College, Multan. Study design: A Cross-Sectional Study Methodology: In this study, a total of 180 patients were observed. In the slit skin smear technique, the Smear was fixed and stained with Leishman or Giemsa stain. For the FNAC technique, hematoxylin and eosin (H &amp; E) stained smear slides were prepared which were examined under light power. For FNAC, the stained slides were examined under low (10x) and high power (40x) to examine cell mass and product formation and then under oil immersion lens (100x) for identifying the morphology of the parasite. Results: The diagnostic accuracy of slit skin smear was 44.44% and that of fine-needle aspiration cytology was 88.33%. Conclusion: Fine needle aspiration cytology has better diagnostic accuracy as compared to slit skin smear in diagnosing cutaneous leishmaniasis. Keywords: slit skin smear, fine needle aspiration cytology, cutaneous leishmaniasis, histopathology.

Approach of Persisters Relapse in a Smear-negative Leprosy after Second MB-MDT Completion: An Arduous Case Report

Introduction: Many infectious disease intervention programs, including leprosy, are cautious about the establishment of relapse and drug resistance. This case report reports on a male patient who has had two relapses and had undergone twice MB-MDT treatment as well.&#x0D; Case Report: A 31 year-old male, came with the main complaint of new hypopigmented patches appeared on the body since 4 months ago, which arose from his second MB-MDT treatment. He started his first MB-MDT treatment in 2019 and second MD-MDT in 2020. Slit skin smear yielded negative results and histopathological examination showed no signs of leprosy. Serological anti-PGL-1 antibody tests yielded very high IgM (3.163) and normal IgG (2) levels. PCR amplification examination showed positive, but DNA sequencing targeting rpoB, folP, and gyrA genes showed no mutations. He was diagnosed with persisters relapse in a borderline-lepromatous leprosy and was treated with rifampicin 600 mg/day for 2 weeks; combination of minocycline 100 mg/ day, clarithromycin 500 mg/ day, and clofazimine 50 mg/ day for 6 months; and methylprednisolone 32 mg/ day for the neuritis. No new lesions appeared during current treatment and he is also showing gradual improvement of foot drop in his left leg.&#x0D; Discussion: The fact of a very high IgM levels after 2 courses of MB-MDT indicated that there is still bacteria that continued to induce antibody formation, thus supporting the persisters bacilli hypothesis in this case. Positive results of PCR amplification conclude that there is still M. leprae bacilli in skin tissues, which may be hidden in deeper tissues. We have to make a more proactive approach considering this was his second times of relapse, and knowing the fact that MB-MDT was consumed religiously in the two previous treatment.&#x0D; Conclusion: In an arduous case like this, proactive step must be taken. Whenever possible, the use of whole genome sequencing is strongly advised.&#x0D; Keywords: leprosy, persisters bacilli, relapse, drug resistance

Sensitivity of different DNA extraction methods and PCR to detect resistance in patients with leprosy stratified by the bacilloscopic index

IntroductionAntimicrobial resistance in leprosy is an emerging problem, and the quantitative impact of low bacilloscopic indexes (BIs) on the sensitivity of molecular tests is unknown. We aimed to evaluate the sensitivity of gene sequencing for the detection of mutations related to antimicrobial resistance in Mycobacterium leprae in patients with low BIs using an analytical model. MethodsPatients with leprosy were included and divided into two groups depending on their BIs (≥ 2+ and < 2+). The sensitivities of the two DNA extraction methods were compared after amplifying and sequencing the repetitive element (RLEP), folP1, rpoB and gyrA in M. leprae. ResultsWe included 56 patients with leprosy: 35 had BIs less than 2+ (22 had negative slit-skin smear [SSS] results) and 21 patients had BIs greater than or equal to 2+. The sensitivity of the amplification of the RLEP target and the gene sequencing of folP1, rpoB and gyrA was 50 to 70% lower in patients with a BI less than 2+ and was significantly reduced in patients with lower BIs for all targets (p < 0.001). One patient had a mutation in the folP1 gene, and 14 patients had mutations in the gyrA gene, but no mutations related to antimicrobial resistance were found. ConclusionsWe can conclude that the sensitivity of molecular tests is directly related to the BI, but these tests can still detect up to 20% of the targets in patients with BIs < 2+. New strategies to improve the sensitivity for detecting antimicrobial resistance in leprosy patients and reasonable clinical criteria for follow-up and the introduction of alternative treatments must be developed.

Ofloxacin resistance in multibacillary new leprosy cases from Purulia, West Bengal: a threat to effective secondary line treatment for rifampicin-resistant leprosy cases

Purulia is one of the high-endemic districts for leprosy in West Bengal (the eastern part of India). The annual new case detection rate (ANCDR) of leprosy in West Bengal is 6.04/100000 (DGHS 2019-20). Our earlier report provided evidence of secondary drug resistance in relapse cases of leprosy. The aim of the current study was to observe primary drug resistance patterns for dapsone, rifampicin, and ofloxacin amongst new leprosy patients from Purulia, West Bengal in order to better understand the emergence of primary resistance to these drugs. In the present study, slit-skin smear samples were collected from 145 newly diagnosed leprosy cases from The Leprosy Mission (TLM) Purulia hospital between 2017 and 2018. DNA was extracted from these samples and the Mycobacterium leprae genome was analyzed for genes associated with drug resistance by polymerase chain reaction (PCR), followed by Sanger sequencing. Wild-type strain (Thai-53) and mouse footpad-derived drug-resistant strain (Z-4) were used as reference strains. Of 145 cases, 25 cases showed mutations in genes associated with resistance to rifampicin, dapsone, and ofloxacin (as described by the World Health Organization, rpoB, folP, and gyrA, respectively) through Sanger sequencing. Of these 25 cases, 16 cases showed mutations in ofloxacin, two cases showed mutations in combinations of ofloxacin and rifampicin, four cases showed a mutation only in rifampicin, one case showed mutations in combinations of rifampicin and dapsone, and two cases showed mutations only in dapsone. Results from this study indicated the emergence of resistance to antileprosy drugs in new cases of leprosy. As ofloxacin is the alternate drug for the treatment of rifampicin-resistant cases, the emergence of new cases with resistance to ofloxacin indicates that ofloxacin-resistant M. leprae strains are actively circulating in this endemic region (i.e., Purulia, West Bengal), posing challenges for the effective treatment of rifampicin-resistant cases.

Clinical profile of patients with pure neuritic leprosy: 20 years’ experience at a tertiary referral centre from North India

Introduction Pure neuritic leprosy (PNL) is characterized by enlargement of peripheral nerves, sensory loss without any cutaneous lesions, skin slit smear negativity and a variable lepromin test and histopathology. Methods This was a retrospective analysis of the clinical records of all the leprosy patients enrolled in the Leprosy Clinic, during the years 1999–2019. The patient records fulfilling the diagnostic criteria of PNL were considered for analysis. Results A total of 1225 patients registered leprosy cases, out of which 41 (3.3%) patients were diagnosed with PNL. Mean age was 31 years and 80% patients were male. Multiple nerves were affected in 25 (61%) patients and one nerve was found to be affected in only 16 (39%) patients. Grade 2 deformities were seen in 26 (63%) patients. All patients were treated with multi-drug therapy - 25 patients received the multibacillary regimen and 16 received the paucibacillary regimen; 27 (66%) patients completed the treatment as prescribed. Conclusion Leprosy is the most common treatable cause of peripheral neuropathy. Therefore, early detection of leprosy neuropathy is important for preventing deformities and disabilities. It may be advisable to treat all PNL cases with the multibacillary multidrug therapy in view of higher rate of deformities.