Borderline lepromatous leprosy:A case report

Rationale:Lepromatous leprosy can have many atypical presentations,obscuring early diagnosis.We present a case of lepromatous leprosy,presenting with atypical features,which made a diagnostic dilemma.Patient concerns:A 48-year-old man presented with bilateral lower limb oedema and scaly“ichthyosis like”skin rash in both hands and feet,hepatosplenomegaly and pancytopenia,over a course of three months,without any classical features of leprosy.A skin biopsy revealed an unexpected diagnosis of borderline lepromatous leprosy.Diagnosis:Lepromatous leprosy.Interventions:Multi-drug regimen treatment with rifampicin,dapsone and clofazimine for lepromatous leprosy.Outcomes:The patient made a good clinical recovery.Lessons:In endemic settings,clinicians should be aware of similar atypical manifestations of leprosy to face the global challenge of eradicating this chronic deforming disease.

Erythema nodosum leprosum in a patient with lepromatous leprosy:A case report

Rationale:Lepromatous leprosy is a skin condition.Erythema nodosum leprosum(ENL)aids in its diagnosis.ENL is a type-2 immune response,whereas lepra ENL is characterized by a hypersensitivity reaction and an exaggerated immune response through a different pathway.Patient's Concern:A 40-year-old male patient,previously diagnosed with lepromatous leprosy,displayed painful skin lesions on his extremities.Diagnosis:Type-2 lepra reaction,specifically erythema nodosum leprosum.Interventions:The patient was initially treated with 100 mg dapsone daily and then with fusidic acid,prednisone,and other MDT agents,after development of dapsone resisitance.After type-2 lepra reaction was lessened in just two weeks,the regimen was adjusted to prednisolone(up to 2 g daily),thalidomide(300 mg daily),minocycline(1.5 g daily),ofloxacin(1 g twice daily),and pentoxifylline(400 mg three times daily)over a six-month period.Outcomes:The treatment effectively reduced the type-2 lepra reaction and improved the patient's skin lesions and overall health.Lessons:Healthcare providers should maintain a high level of awareness regarding the symptoms and medical history associated with ENL to facilitate timely diagnosis and appropriate management strategies.It is critical to tailor treatment to each patient’s symptoms and responses for successful management.Consistent monitoring of inflammatory markers and regular follow-up appointments play vital roles in preventing complications and ensuring positive outcomes for patients with ENL.

Exploring the Pathways of Leprosy Patients from Their Communities to a Diagnosis in the Districts of Mayuge, Yumbe and Kasese-Uganda

Background: Leprosy is known to cause disability that leads to severe outcomes like stigma, discrimination, mental health problems and participation restriction. Furthermore, in cases of infectious leprosy, longer delays increase the risk for the spread of the disease. Despite being preventable and curable, a significant proportion of new leprosy patients (39%) in 2019 had grade 2 (Described as Visible disability) at the time of diagnosis signifying late presentation. The aim of this study was to describe patient journeys from first symptoms suggestive of leprosy to a diagnosis and individual and community level factors associated with health seeking behavior of leprosy patients. Methods: This was a cross-sectional explorative study implemented in Kasese, Mayuge and Yumbe districts .A structured questionnaire was used to collect quantitative data. Qualitative assessment included patients, family members, health workers, voluntary health teams and the district health team. Descriptive statistics were presented in terms of percentages, frequency tables, pie Charts and graphs for easy interpretation and discussion. Results: The results indicate that 53% of the respondents identified as female. The median age of the respondents being 34 years, with a range of 1 to 76 years (Mean: 44.7, Mode: 65, Standard-Deviation: 19.6, Kurtosis: 0.6). The most common first symptom noticed by respondents was skin lesions (65%) followed by deformities (18%) (P value = 0.05%) occurring mostly in the feet (P-value = 0.48). Majority (52%) of the patients had taken more than 24 months (SD 18.72 OR 2.75) for a diagnosis to be made with a maximum delay of over 60 months. The most common cause of delay in seeking health care was lack of knowledge on leprosy (P value=Conclusions: There was a delay of 2 years in seeking health care for the majority of the patients. Key barriers to early diagnosis were lack of knowledge and infrastructure. Community sensitization and strengthening capacity building are needed to achieve early diagnosis of leprosy and proper management.

Feasibility of Integrating Leprosy Post-Exposure Prophylaxis with Single-Dose Rifampicin (LPEP) into Routine Leprosy Control Program in Bukedi and Teso Regions in Uganda

Background: World Health Organization recommends the implementation of contact tracing and Leprosy Post Exposure prophylaxis (LPEP) to interrupt the chain of transmission. To accelerate the uptake of this recommendation, a cross-sectional study among contacts of leprosy patients was conducted to investigate the feasibility of integrating leprosy systematic contact tracing and post-exposure prophylaxis (PEP) into the routine leprosy control program. Methods: This was a mixed methods cross-sectional study. The study was implemented in Kumi, Ngora, Serere, Soroti, Budaka and Kibuku Districts. Results: The 45 enrolled index patients (97.8% of the registered) identified a total of 135 contacts, of which 134 (99·2%) consented and were screened. Among them, one new leprosy patient was identified and started on treatment with multidrug therapy (MDT). All the eligible contacts, received the prophylactic treatment with Single Dose Rifampicin (SDR). Overall, SDR was administered to 133(98.5% of the listed contacts) with no adverse event reported. Factors associated with successful contact investigation and management included: Involvement of index patients, health care workers during the contact screening and SDR A administration, counselling of the index patients and contacts by the health care works, LPEP being administered as Directly observed Therapy (DOT) among others. Results Interpretation: The integration of leprosy post-exposure prophylaxis with administration of SDR and contact tracing is feasible, generally accepted by the patient, their contacts and health workers and can be integrated into the National Leprosy control programmes with minimal additional efforts once contact tracing has been established. Therefore, we recommend integration of administration of SDR in to the routine leprosy control program.

Type 2 reaction associated sensorineural hearing loss in a drug resistant lepromatous leprosy patient: A case report

Rationale:Leprosy,a chronic granulomatous disease often present clinically as erythema nodosum leprosum,a type 2 reaction.The involvement of cochlear part of audiovestibular system is a rarity.Patient concerns:A 26-year-old male patient with lepromatous leprosy developed bilateral sensorineural hearing loss(SNHL)during type 2 reactional episode.Diagnosis:Recurrent erythema nodosum leprosum in rifampicin-resistant lepromatous leprosy.Interventions:Corticosteroids and second-line multidrug therapy.Outcomes:The patient improved significantly and was further referred for management of psychosocial impact due to sensorineural hearing loss.Lessons:The hearing impairment is a rare complication of type 2 reaction.Any patient with suspected cranial nerve involvement should essentially be screened by tuning fork tests for early detection of hearing impairment and offer timely intervention as required.All high bacteriological index cases should be investigated for antimicrobial resistance in high endemic areas.

FINAL REPORT ABOUT STAGE II COLLABORATION PROJECT ON LEPROSY REHABILITATION

To undertake the pilot experiments of prevention of disability (POD) in 14 different geographical areas to serve as examples for future development of rehabilitation work in China and in Asia. Methods.According to the principles and national criterion, 27 000 people affected by leprosy were selected and assessed using disability record forms at beginning and followed up regularly for observing changes of different indicators. Results. A total of 197 neuritis cases were detected and treated with prednisolone out of 1 407 new or active cases. Self care training of eyes, hands and feet were conducted for 10 500 disabled people affected by leprosy. Comprehensive therapy was given to 1 804 cases having complicated ulcers of which 1 055 cases have got their ulcers healed. Out of 706 prostheses, 613 were given to patients with satisfactory results. Surgical treatment was given to 269 cases and 251 have shown good progress. Conclusion. Most of patients have got benefit from the project in function or appearance which is very helpful for their going back to the society and agreed by foreign experts during the final evaluation. The experiences from the project can be implemented in the whole country.

TRENDS OF CASE DETECTION AND OTHER INDICATORS OF LEPROSY IN CHINA DURING 1985-2002

Objective To analyze the trends of case detection and other indicators of leprosy in China during 1985-2002. Methods Data reported by each province were collected by China National Leprosy Database in Nanjing P.R.China. All data about registered cases were put into computer for analysis. Results From 1985 to 2002, a total of 49 477 leprosy new cases had been detected. Among them, 69.5% were multi- bacillary cases and 25.4% had grade 2 disability. The child cases aged below 15 years accounted for 3.74% of total cases. Totally, 5824 cases and 303 cases relapsed after dapsone (DDS) mono-therapy and multidrug therapy (MDT), respectively. Case detection showed a marked reduction from 0.47/100 000 in 1985 to 0.18/100 000 in 1993 although there were several spurts due to operational factors. From 1994, case detection showed no significant decline. The grade 2 disability among new patients decreased from 31.4% in 1985 to 23.4% in 2002. The child case detection rate among new cases fluctuated between 2.70%-3.56% from 1999 to 2002. The incidence of relapse declined after the introduction of DDS mono-therapy. However, it increased after the introduction of MDT. Conclusion China experiences in leprosy control show that it will take a long time with continuing present leprosy control activities to bring down the case detection and other indicators to a very low level even after reaching the elimina- tion goal of leprosy.

Culture Circle as a Teaching Approach in the Education of Teenager Health Multipliers on Leprosy Awareness

Objective: The study aims to evaluate the use of a teaching method proposed by Paulo Freire, Culture Circles, in the education of teenagers multipliers on leprosy awareness. Methods: It is an action-research study with a qualitative approach developed in a public school in Pernambuco, Brazil. Five Culture Circles were conducted involving the participation of 26 teenagers. The followings were used as data collection tools: observation, field notes, photography and filming. Results: The educational intervention on health addressed the following topics: 1) Definition and transmission of leprosy;2) Characteristics and diagnosis of leprosy;3) Treatment of leprosy;4) Aesthetics, prejudice and mental health related to leprosy;and 5) Planning of educational activities for teenagers as health multipliers on leprosy awareness. The educational action on health provided this age group to perceive themselves, act as political subjects in the development of Culture Circles, and act as protagonists in the dissemination of knowledge on leprosy. Conclusions: This study highlights that the application of active methodologies, such as Culture Circles, is able to encourage the engagement of young people in community empowerment and bring together health professionals and the school community in an intersectoral work in order to develop action strategies involving the promotion of health in the context of neglected diseases such as leprosy.

Clinical characteristics predicting erythema nodosum leprosum(ENL) among patients with multibacillary leprosy(MBL) in Sarawak

Objective:To determine the clinical features predicting erythema nodosum leprosum(ENL) in a non endemic leprosy area.Methods:Twenty newly diagnosed patients with MBL attending the skin clinic,Sarawak General Hospital from 1992 to 2007 were analyzed.They were divided into 2 groups,one with ENL and one without. Analysis of the presenting clinical features was done to determine the risk factors for ENL.Chi square and student t test was used for statistical analysis.Level of significance was set at 0.05.Results:ENL was present in 40%patients,all with lepromatous leprosy(LL).Clinical features that were seen more frequently in patients developing ENL include earlobe thickening(100%cf.25%,P =0.00),loss of the lateral third of the eyebrows(75%cf.16.7%,P=0.02) and mean bacteriology index(BI)(5.1 cf.2.9,P=0.03) and mean morphological index(MI)(17.8 cf.7.0,P =0.02).Number of thickened nerves(mean 2.5 cf. 1.4,P = 0.12),number of skin lesions(mean 19.4 cf.10.9,P = 0.15) and duration of illness(mean 15. 3 cf.12.8 months,P =0.68) did not predict ENL development.Conclusion:Finding LL patients with thickened earlobes,loss of lateral third of the eyebrow,high BI and MI should alert treating clinician to the possibility of ENL in a non endemic leprosy area.

EFFECT OF THREE-YEAR MULTIDRUG THERAPY IN MULTIBACILLARY LEPROSY PATIENTS

The feasibility and effects of a 3-year treatment using rifampicin(RFP),clofazimine(B663)and dapsone(DDS)in multibacillary leprosy patients in Yangzhou Prefecture and DongtaiCounty(1983-1986)are reported.Among 591 active multibaeillary leprosy patients in thetwo areas,569 (96.30%)were treated with this regimen.of 303 cases available for analysis,196(64.7%)cases showed negative skin smears and clinical inactivity.The rest showeddifferent degrees of improvement.The average reduction of BI was 0.78.The intensityand frequency of ENL and neuritis decreased markedly with treatment.The main side-effects were pigmentation and ichthyosiform changes of the skin,but these did not influencetreatment.

Limbal leproma in lepromatous leprosy

Dear Sir, W e are writing to you to present an unusual case of leproma growing at the limbus of a lepromatous leprosy patient. This the first report of ocular leprosy in Brunei, where leprosy is extremely rare. Leprosy, otherwise known as Hansen’s disease, is a chronic granulomatous communicable infection caused by Mycobacterium leprae and its genetic variant (Mycobacterium lepromatosis) [1]. A leproma is a superficial, ci

Leprosy without typical skin involvement but with concurrent tuberculosis: a case report

Leprosy is characterized by skin lesions and peripheral nerve damage. It may take a long time before the diagnosis can be confirmed if the patients have no typical skin involvements. Here we report an unusual case. A 40-year-old male with lepromatous leprosy showed a gradual onset of bilateral symmetrical neuropathies without characteristic skin manifestations seven years after onset and with pulmonary tuberculosis simultaneously. He was misdiagnosed as having Guillani-Barr6 syndrome and systemic necrotizing vasculitis for 10 years until the skin biopsy was performed. This case indicates that the risk of leprosy exists, though new cases being detected have significantly declined over the last 50 years; neurologists need to pay more attention to leprosy with various manifestations .

Theoretical Assessment of the Transmission Dynamics of Leprosy

Leprosy is a communicable disease which can cause hideous deformities to the afflicted and social stigmatization to them and their families. The continued high endemicity of leprosy in pockets of Sub-Saharan Africa is a source of bafflement to researchers. In this paper, we investigate non-compliant behavior by patients on treatment and possible inadequacy of the prescribed treatments as the reason for the persistence of the disease in the region. We construct theoretical, deterministic mathematical models of the transmission dynamics of leprosy. These models are modified to encapsulate non-compliance and inadequate treatment. The models are then analyzed to gain insight into the qualitative features of the equilibrium states, which enable us to determine the basic reproduction number. We also employ analytical and numerical techniques to investigate the impact of non-compliance and inadequate treatment on the transmission dynamics of the disease. Our results show that, as long as there is treatment, leprosy will eventually be eliminated from the region and that the disposition under investigation only serves to slow the rate at which the disease is eradicated.

A Clinco-Bacteriological Study of Leprosy in Paediatric Age Group

Clinico-bacteriological study was done in 51 leprosy patients below 14 years of age. Majority of the patients were males in the age group of 11-14 years. Nearly 84% had not received any prior treatment because of lack of awareness and financial constraints. Only 11.76% had a positive contact history. Skin lesions were present in all cases and 84.3% had lesions mainly on the exposed areas of the body and their number was found to increase significantly with advancing age (p < 0.005). These lesions were hypo-pigmented patches in 88% cases. 88% of cases had hypo-anesthesia and nerve thickening was observed in 24% cases. The most common type of skin lesion was borderline tuberculoid (BT) in 53% cases. Positivity of the skin smears increased significantly as the number of the skin lesions per patient increased (p 0.001). Multibacillary cases were seen in 15.6% of cases and found only in the age group of 10-14 years of age. No statistically significant association between BCG vaccination and prevention of leprosy was seen.

Assessment of Risks of Cardiovascular Diseases among Leprosy Patients Settlement at Ossiomo-Ogan Rehabilitation Center, Edo State, Nigeria

Background/Aim: Quality of life is reduced in people living with leprosy as a result of its impact on human activities. Lipid profile means pattern of lipids in the blood, which is routinely done to assess cardiovascular risk. The aim of this study is to assess the risk of cardiovascular diseases among the leprosy patients settlement at Ossiomo-Ogan, Edo state. Method: Blood samples were collected from a total number of one hundred and eight (108) (57 leprosy patients and 51 controls) subjects. The lipid profiles of the participants were determined using standard methods. Results: Significantly (p < 0.001) higher mean serum levels of total cholesterol, triglycerides, HDL and LDL in leprosy patients compared with the healthy controls were obtained. There is significant positive correlation between artherogenic index and levels of total cholesterol (r = 0.663;p < 0.001);triglyceride (r = 0.901;p < 0.001);HDL (r = 0.284;p = 0.003);and LDL (r = 0.626;p < 0.001) in leprosy patients. However, all the control subjects and 54 (94.7%) of the leprosy patients had low cardiovascular disease risk, while 3 (2.8%) indicated moderate CVD risk. None of the participants had high risk of developing cardiovascular disease. Conclusion: In this study, lipid profile levels of leprosy patients significantly increased despite moderate level of BMI. This study also showed significant positive correlation between the anthrogenic index of plasma and all the lipid profile. Many of the leprosy patients are not conscious of their diet which was tilted towards heavy carbohydrate and fatty meals. None of the participants is at high risk of cardiovascular diseases but the risk may increase with further elevation of the lipid profiles. Efforts should be made by all stakeholders to improve on the awareness of leprosy disease and encourage the sufferers to live decent lives.

Serum Levels of Prostate Specific Antigen Parameters among Male Patients with Lepromatous Leprosy in Edo State, Nigeria

Aim: This study is aimed at determining the total PSA (tPSA), free PSA (fPSA) concentrations and free to total PSA ratio (f/tPSA) and their utility in prostate cancer (PCa) risk stratification among male lepromatous leprosy patients in Edo state, Nigeria. Methods: Forty participants and thirty controls participated in this study. A structured questionnaire was administered to each participant to elicit details such as their personal data, age, sex, residence, medications, alcohol consumption, smoking habit, length of time of diagnosis, sexual activities, as well as the history of any other underlying diseases. Blood samples were collected from the participants. Total and free PSA concentrations in the samples were measured using ELISA method. Results: Significantly (p = 0.042) higher serum fPSA among the leprosy patients (0.22 ± 0.12 ng/ml) compared with the healthy controls (0.17 ± 0.09 ng/ml). There were no significant (p = 0.055) difference in the mean tPSA between the leprosy patients (2.69 ± 2.25 ng/ml) compared with the control (1.95 ± 0.69 ng/ml). Similarly, no significant (p = 0.548) difference was observed in PSA ratio between the control (0.08 ± 0.04) and the leprosy patients (0.09 ± 0.03). Conclusion: Our study indicated no significant differences in tPSA and f/tPSA between the leprosy patients and their healthy control. Elevated tPSA as well as f/tPSA levels that fell within the high risk zones of PCa were more prevalent among patients aged ≥ 70 years, not married, who rarely had sexual intercourse and those with longer disease duration.

Polymorphisms of the Toll-Like Receptor-2 Gene in Patients with Leprosy and Their Healthy Contacts

Leprosy is an immunopathology caused by M. leprae;its evolution depends on immunological and genetic aspects of the host. The objective was verifying the relationship between SNPs 2029 and 2258 of the TLR-2 gene and leprosy. Blood samples from 127 individuals were analyzed: 45 patients, being 34 multibacillary (MB) and 11 paucibacillary (PB) and 82 contacts, in the municipalities of the State of Pará-Brazil. SNPs 2029 and 2258 of the TLR-2 gene were genotyped by sequencing on the ABI 3130 Genetic Analyzer (Applied Biosystems), analyzed using Fisher’s exact test. Distribution of SNP 2029 genotypes: all MB individuals presented the C/C genotype and the mutant (C/T) genotype was observed in contacts and PB. Alleles: all MB individuals presented only C allele and the mutant allele (T) was observed in contacts and PB. SNP 2258 genotypes: 79 contacts had G/G genotype and only 3 had G/A genotype, the MB group had only G/G genotype and the PB group was predominant G/G, with only 1 G/A genotype. Alleles: all MB individuals had allele G and the mutant allele (A) was observed in contacts and PB. The association between the SNPs and the susceptibility or protection to leprosy was not observed.

Human Rights and Social Stigma Review for Leprosy Patients in Korea

Leprosy is a chronic disease caused by a low multiplying bacillus, Mycobacterium leprae, which primarily affects the skin and the extremities. Multidrug therapy (MDT) and Bacillus Calmette-Guérin (BCG) vaccinations are effective at treatment of the disease, but social misconceptions about the disease inhibit efficient health care for affected individuals. In South Korea, leprosy patients face social, economic, and political discrimination. Korean leprosy patients are isolated into Sorokdo island and face challenges such as difficulty receiving education and limited job opportunities. Leprosy cognitively, emotionally, and socially impacts patients’ lives, and represents a serious social inequality issue. To raise awareness, dispel myths about the disease, and to end patient discrimination that destroys families, we conducted case studies based on scientific journals. The paper specifically focuses on difficulties faced by Korean leprosy patients, and subsequent initiatives by the government to aid patients. To reach the WHO’s target of health and wellbeing for all by 2030, we need to educate the masses about leprosy and address relevant social inequality issues.

Three-dimensional models of antigens with serodiagnostic potential for leprosy:An in silico study

BACKGROUND Leprosy is a disease caused by Mycobacterium leprae(M.leprae),an intracellular pathogen that has tropism and affects skin and nervous system cells.The disease has two forms of presentation:Paucibacillary and multibacillary,with different clinical and immunological manifestations.Unlike what occurs in the multibacillary form,the diagnostic tests for the paucibacillary form are nonspecific and not very sensitive,allowing the existence of infected individuals without treatment,which contributes to the spread of the pathogen in the population.To mitigate this contamination,more sensitive diagnostic tests capable of detecting paucibacillary patients are needed.AIM To predict the three-dimensional structure models of M.leprae antigens with serodiagnostic potential for leprosy.METHODS In this in silico study,satisfactory templates were selected in the Protein Data Bank(PDB)using Basic Local Alignment Search Tool to predict the structural templates of ML2038,ML0286,ML0050,and 85B antigens by comparative modeling.The templates were selected according to general criteria such as sequence identity,coverage,X-ray resolution,Global Model Quality Estimate value and phylogenetic relationship;Clustal X 2.1 software was used in this analysis.Molecular modeling was completed using the software Modeller 9v13.Visualization of the models was made using ViewerLite 4.2 and PyMol software,and analysis of the quality of the predicted models was performed using the QMEAN score and Z-score.Finally,the three-dimensional moels were validated using the MolProbity and Verify 3D platforms.RESULTS The three-dimensional structure models of ML2038,ML0286,ML0050,and 85B antigens of M.leprae were predicted using the templates PDB:3UOI(90.51%identity),PDB:3EKL(87.46%identity),PDB:3FAV(40.00%identity),and PDB:1F0N(85.21%identity),respectively.The QMEAN and Z-score values indicated the good quality of the structure models.These data refer to the monomeric units of antigens,since some of these antigens have quaternary structure.The validation of the models was performed with the final three-dimensional structure-monomer(ML0050 and 85B antigens)and quaternary structures(ML2038 and ML0286).The majority of amino acid residues were observed in favorable and allowed regions in the Ramachandran plot,indicating correct positioning of the side chain and absence of steric impediment.The MolProbity score value and Verify 3D results of all models indicated a satisfactory prediction.CONCLUSION The polarized immune response against M.leprae creates a problem in leprosy detection.The selection of immunodominant epitopes is essential for the development of more sensitive serodiagnostic tests,for this it is important to know the three-dimensional structure of the antigens,which can be predicted with bioinformatics tools.

Foot and Ankle Muscles Activation and Plantar Sensory Deficit in Leprosy and Its Implication to Foot Deformity and Walking Capacity

Objective: To observe extrinsic foot muscle activity ratio and sensory disturbance in Leprosy and its implication to foot deformity and walking capacity. Design: Cross sectional study in Singkawang, West Kalimantan. Materials and Methods: Thirty-three leprosy patients without walking aids and/or orthotic prosthetic were enrolled using consecutive sampling. Foot deformity score was calculated and muscle activity was measured using surface EMG. Muscle activation ratio was calculated in Tibialis anterior-to-Gastrocnemius (TA/GA) and Tibialis Anterior-to-Peroneal (TA/PE). Walking capacity was assessed using Timed up and Go test. Results: Significant differences of foot ulcer (p = 0.001) and foot deformities (p = 0.001) were found in plantar sensory deficit group. There was strong correlation between foot deformities and decreased TA/GA ratio (p = 0.001, r = ﹣0.787) and decreased TA/PE ratio (p = 0.001, r = ﹣0.663). There were significant differences of TA/GA ratio (p = 0.00) and TA/PE ratio (p = 0.09) based on the foot ulcer, and no significant difference of Timed Up and Go Test result within plantar sensory deficit group (p = 0.427). No significant correlation was found between walking capacity and TA/GA ratio (p = 0.055), and TA/PE ratio (p = 0.165). Conclusion: Plantar sensory deficit and decreased extrinsic muscle activation ratio during gait had been proven to affect foot impairment, but have not been proven to inhibit walking capacity.