Avaliação do desempenho de um teste rápido imunocromatográfico no diagnóstico de hanseníase em uma região endêmica no norte do Brasil / Evaluation of the performance of a rapid immunochromatographic test in the diagnosis of leprosy in an endemic region in northern Brazil

Introdução: A hanseníase é de grande importância para a saúde pública, devido à sua epidemiologia e a seu poder incapacitante. A eficiência no diagnóstico desta doença é limitada. O objetivo deste estudo foi o de analisar o desempenho de um teste rápido imunocromatográfico para hanseníase multibacilar (MB) e paucibacilar (PB), em amostras positivas e negativas pela baciloscopia de raspado dérmico em pacientes diagnosticados com hanseníase, comparando analiticamente com os critérios da Organização Mundial da Saúde (OMS). Métodos: O estudo foi realizado no município de Ji-Paraná/RO, entre 2015 e 2016, sendo avaliados 140 indivíduos. A análise comparativa entre os métodos foi realizada pelo cálculo de sensibilidade e especificidade utilizando o software SPSS®. Foi estimado o índice de Kappa (k) para avaliação da concordância entre os métodos. Valores de p <0,05 foram considerados significativos. Resultados: O índice de concordância entre o teste rápido e a classificação da OMS foi de k= 0,94 (p <0,01). Quando comparado a baciloscopia de indivíduos com hanseníase PB e o teste rápido, foi verificada concordância não significante (k= 0,01; p= 0,59). Comparando a concordância entre a baciloscopia de indivíduos com hanseníase MB e o teste rápido, foi detectado um índice de k= 0,64 (p <0,01). Além disso, sensibilidade de 94% e especificidade de 98% foram detectadas para hanseníase PB. Para hanseníase MB a sensibilidade foi de 95% e a especificidade de 98%. Conclusão: O teste rápido avaliado é uma ferramenta útil, rápida e eficaz no auxílio do diagnóstico da hanseníase. (AU)

Introduction: Leprosy is of great importance for public health because of its epidemiology and disabling power. Efficiency in the diagnosis of this disease is limited. The objective of this study was to evaluate the performance of a rapid immunochromatographic test for multibacillary (MB) and paucibacillary (BP) leprosy, in positive and negative samples by skin smear examination in patients with leprosy, and to compare the rapid test analytically with World Health Organization (WHO) criteria. Methods: The study was conducted in the municipality of Ji-Paraná/RO, Brazil, between 2015 and 2016. In total, 140 individuals were evaluated. For a comparative analysis of the methods, sensitivity and specificity were calculated using SPSS® software. The Kappa (k) index was used to evaluate agreement between the methods. A p-value < 0.05 was considered significant. Results: Regarding agreement between the rapid test and WHO classification, k index was 0.94 (p < 0.01). When skin smear of individuals with BP leprosy was compared to the rapid test, agreement was non-significant (k = 0.01; p = 0.59). For agreement between skin smear of individuals with MB leprosy and the rapid test, a k index of 0.64 (p < 0.01) was detected. In addition, for PB leprosy sensitivity was 94% and specificity was 98%, while for MB leprosy sensitivity was 95% and specificity was 98%. Conclusion: The rapid test is a useful tool, fast and effective in aiding the diagnosis of leprosy. (AU)

Utility of immunoglobulin isotypes against LID-1 and NDO-LID for, particularly IgG1, confirming the diagnosis of multibacillary leprosy

BACKGROUND Leprosy remains a health problem in many countries, with difficulties in diagnosis resulting in delayed treatment and more severe disabilities. Antibodies against several Mycobacterium leprae antigens have, however, shown value as diagnostic and/or prognostic markers. OBJECTIVES The objective of this study was to evaluate serum immunoglobulin (Ig) IgM and IgG subclass reactivity against three M. leprae specific antigens: NDO-HSA, a conjugate formed by natural octyl disaccharide bound to human serum albumin; LID-1, the fusion protein product of the ml0405 and ml2331 genes; and NDO-LID, a combination of LID-1 and NDO. METHODS Sera from healthy controls, paucibacillary (PB) and multibacillary (MB) leprosy patients, and their respective household contacts, were evaluated for the presence of antigen-specific IgM, IgG, and IgG subclass antibodies by enzyme-linked immunosorbent assay (ELISA). The sensitivity and specificity of each ELISA were evaluated by receiver operating characteristic (ROC) curve analysis. FINDINGS Our data confirm that serum IgM antibodies against NDO-HSA and IgG antibodies against LID-1, as well as IgG/M antibodies against NDO-LID, are markedly increased in MB patients. For the first time, our data reveal a selective increase in IgG1 and IgG3 antibodies against LID-1 and NDO-LID in MB patients, demonstrating that these antibody isotypes are suitable for differentiation between MB and PB patients. ROC curve analysis indicates an improved capacity for diagnosing MB leprosy patients using the detection of IgG antibodies, particularly the IgG1 isotype, specific to LID-1 and NDO-LID over the performance levels attained with NDO-HSA. CONCLUSIONS Our findings indicate that serological tests based on the detection of antigen-specific IgG1 antibodies are a useful tool to differentiate MB from PB patients, and indicate the enhanced performance of the LID-1 and NDO-LID antigens in the serodiagnosis of leprosy.

Salivary anti-PGL-1 IgM may indicate active transmission of Mycobacterium leprae among young people under 16 years of age

Abstract Considering that the main route of Mycobacterium leprae transmission is the upper respiratory tract, detection of salivary antibodies can be a useful tool for diagnosing early infection. The study aimed to analyze salivary anti-PGL-1 IgA and IgM antibodies in 169 children aged 4-16 years old, who lived nearby or inside the house of multibacillary or paucibacillary leprosy patients in two endemic cities in Alagoas State - Brazil. Salivary anti-PGL-1 antibodies were quantified by modified ELISA method. The frequency of contact and clinical form of the index case were significantly associated with salivary antibody levels. High frequency of IgM positivity strongly suggests active transmission of M. leprae in these communities. We suggest in the present work that salivary anti-PGL IgA and IgM are important biomarkers to be used for identifying communities with probable active transmission of M. leprae.

Analysis of clinical data and T helper 1/T helper 2 responses in patients with different clinical forms of leprosy

Abstract INTRODUCTION: Currently, there are no laboratory tests or sensitive and specific molecular markers for the early diagnosis of leprosy. The aim of this study was to analyze the clinical characteristics of patients with leprosy and investigate their immunological profile, comparing this with the type of lesion and the presence or absence of a Bacillus Calmette-Guérin (BCG) vaccination scar. METHODS: Statistical analyzes were performed by employing comparative tests (Pearson´s chi-square) to evaluate the variables in different clinical forms, considering significance at the 5% level. RESULTS: The study identified a predominance of lepromatous leprosy (26.9%) in patients aged between 34-53 years. Caucasians predominantly had borderline tuberculoid (BT) clinical forms (42%); a predominance of males with borderline lepromatous (19%) and lepromatous leprosy (26.9%) forms was observed; and the presence of BCG vaccination scars (27.5%) and lower limb nerves were more affected (38%) predominantly in the BT clinical form. Significant differences were identified, which included hypochromic lesions predominantly in the BT clinical form (24%); diffuse-type lesions predominantly in the tuberculoid (TT) clinical form (28%); ill-defined lesion border dominance in lepromatous leprosy (LL) clinical forms (30%); an irregular lesion limit predominantly in LL clinical forms (32%); and a predominant Th1 immune response in the BT clinical form (41.7%). CONCLUSIONS: The evaluation of the immunological profile in leprosy patients may contribute to the more detailed diagnosis and possibly better characterization of the prognosis for these individuals.

Diagnostic challenges of single plaque-like lesion paucibacillary leprosy

The diagnosis of single-lesion paucibacillary leprosy remains a challenge. Reviews by expert dermatopathologists and quantitative polymerase chain reaction (qPCR) results obtained from 66 single-plaque biopsy samples were compared. Histological findings were graded as high (HP), medium (MP) or low (LP) probability of leprosy or other dermatopathy (OD). Mycobacterium leprae-specific genes were detected using qPCR. The biopsies of 47 out of 57 clinically diagnosed patients who received multidrug therapy were classified as HP/MP, eight of which were qPCR negative. In the LP/OD (n = 19), two out of eight untreated patients showed positive qPCR results. In the absence of typical histopathological features, qPCR may be utilised to aid in final patient diagnosis, thus reducing overtreatment and delay in diagnosis.

Epidemiological situation of leprosy in Salvador from 2001 to 2009

Mycobacterium leprae was first described as the bacillus that causes leprosy, a chronic granulomatous infectious disease, in 1873 by Amauer Hansen. Leprosy is part of a group of 10 neglected diseases and Bahia has endemic levels of this illness, varying between high and very high. The detection of 52 new cases of leprosy in children under 15 years old in Salvador in 2006 is alarming, and suggests an early contact with the disease. The aim of this review is to analyze the epidemiological situation, the detection rate and evaluate the clinical and epidemiological profile of leprosy in Salvador, in the period 2001-2009. A retrospective cross-sectional study was performed using secondary data collected at Notifiable Diseases Information System Database (SINAN) through the notification of patients with leprosy. Over these nine years 3,226 patients were reported, with a predominance of: females (51.5%), and clinical multibacillary forms in the general population (51.7%), but when we analyze those under 15 years old, paucibacillary forms (tuberculoid + indeterminate) prevailed. The tuberculoid form was the most diagnosed type of presentation. The annual detection rate in Salvador remained at a very high level of endemicity during the studied period and for those under 15 years old it ranged between high and very high. Grade 2 disabilities both at the time of diagnosis and at discharge after cure, varied between low and medium. Based on these data we conclude that the high levels of leprosy detection rates in the general population, plus the variation between high and very high levels in those under 15 years old, associated with the medium level of grade 2 disabilities at the time of diagnosis and discharge, demonstrate the need for improvement on the existing services, investment in active case finding and training of the healthcare professionals in Salvador.

Diagnóstico da hanseníase paucibacilar com lesão única / Leprosy diagnosis with single plaque skin lesions

Introdução: Apesar do recente declínio dos coeficientes de detecção de casos novos, a hanseníase permanece endêmica no Brasil e em outros países do mundo. O diagnóstico da doença se baseia nos aspectos clínicos, embora o índice baciloscópico e a histopatologia sejam usados como suporte para o diagnóstico. Nas formas paucibacilares, bacilos são raramente detectados e o exame histopatológico pode ser inconclusivo. Neste estudo,analisamos os aspectos clínicos e histopatológicos de pacientes com suspeita de hanseníase paucibacilar e estabelecemos a contribuição do PCR no manejo clínico destes casos.Pacientes e Métodos: Foram estudados 66 pacientes com lesão cutânea única em placa,atendidos no Ambulatório Souza Araújo (ASA) da Fundação Oswaldo Cruz, Rio de Janeiro,Brasil, no período de janeiro de 2008 a dezembro de 2011. Dois patologistas independentes,que não tinham informações sobre a história clínica dos pacientes, realizaram a reanálisehistopatológica. Os pacientes foram classificados como Alta (A), Média (M) e Baixa (B)probabilidade do diagnóstico de hanseníase ou outras dermatoses (O). O DNA foi extraído defragmentos de biópsias de pele e os níveis de M. leprae Ag85B e 16S rDNA foram estimadosusando a amplificação por PCR quantitativo (qPCR). Resultados: O qPCR foi positivo em 46/66 (69.7 por cento) das amostras de pele. Dos 66 pacientes, 57 (86.3 por cento) tinham recebidotratamento com poliquimioterapia (PQT) baseado nos aspectos clínicos e histopatológicos. Aassociação entre o resultado do PCR e a variável tratamento mostrou que entre os 19pacientes classificados como L+O, 2 pacientes com PCR positivo não tinham recebidotratamento e 6 pacientes com PCR negativo tinham sido tratados com PQT por 6 meses.Conclusão: Concluímos que o qPCR é uma ferramenta útil para o diagnóstico e o manejoclínico dos pacientes com suspeita de hanseníase paucibacilar, nos casos em que ahistopatologia não é conclusiva...

Background: Despite recent decline in detection rates, leprosy remains endemic in Brazil andin others countries around the world. Frequently, the disease diagnosis is based only onclinical aspects, although the bacteriological index in skin smears and histopathologicalexamination are used to support conclusions. In paucibacillary forms, bacilli are rarelydetected, and histopathological examination may not be conclusive. In this study, we analisedthe clinics and histopathological aspects of patients suspected of paucibacillary leprosy andtry to establish the contribution of PCR to the clinical management of these cases. Methods:We evaluated 66 patients with single-plaque skin lesions who attended the Leprosy OutpatientUnit of Oswaldo Cruz Foundation, Rio de Janeiro, Brazil, between 2008 and 2011. Twoindependent pathologists who were blinded to the patients’ clinical details performedpathological reanalysis of slides. Patients were classified as High (H), Medium (M), and Lowprobability (L) for the diagnosis of leprosy or another dermatosis (O). DNA was extractedfrom the fragments of skin biopsies, and the levels of M. leprae Ag85B and 16S rDNA wereestimated using qPCR amplification. Findings: The qPCR was positive in 46/66 (69.7 percent) ofskin samples. Out of 66 patients, 57 (86.3 percent) received multidrug therapy (MDT) based onclinical and histopathological examination. The association between previous treatment andqPCR results showed that among 19 patients classified as L+O, 2 qPCR-positive patientswere not treated, whereas 6 patients with negative qPCR results were treated with MDT for 6months. Conclusion: In conclusion, qPCR is a useful tool to diagnosis and clinicalmanagement in suspected cases of paucibacilary leprosy in cases with inconclusivehistopathology...

High rates of undiagnosed leprosy and subclinical infection amongst school children in the Amazon Region

Leprosy in children is correlated with community-level factors, including the recent presence of disease and active foci of transmission in the community. We performed clinical and serological examinations of 1,592 randomly selected school children (SC) in a cross-sectional study of eight hyperendemic municipalities in the Brazilian Amazon Region. Sixty-three (4%) SC, with a mean age of 13.3 years (standard deviation = 2.6), were diagnosed with leprosy and 777 (48.8%) were seropositive for anti-phenolic glycolipid-I (PGL-I). Additionally, we evaluated 256 house-hold contacts (HHCs) of the students diagnosed with leprosy; 24 (9.4%) HHC were also diagnosed with leprosy and 107 (41.8%) were seropositive. The seroprevalence of anti-PGL-I was significantly higher amongst girls, students from urban areas and students from public schools (p < 0.0001). Forty-five (71.4%) new cases detected amongst SC were classified as paucibacillary and 59 (93.6%) patients did not demonstrate any degree of physical disability at diagnosis. The results of this study suggest that there is a high rate of undiagnosed leprosy and subclinical infection amongst children in the Amazon Region. The advantages of school surveys in hyperendemic areas include identifying leprosy patients at an early stage when they show no physical disabilities, preventing the spread of the infection in the community and breaking the chain of transmission.

Serologic follow-up of IgG responses against recombinant mycobacterial proteins ML0405, ML2331 and LID-1 in a leprosy hyperendemic area in Venezuela

Leprosy is a slowly evolving disease that occurs mainly in adults. In this study, the Mamaría Village, state of Portuguesa was selected because it had one of the highest prevalence rates (13.25%) of leprosy cases in 1997. Between 1998-2004, 20.2% of the 89 cases registered in this village were less than 15 years old and 61.8% were males. Pau-cibacillary (PB) lesions were the predominant clinical forms identified, although also multibacillary (MB) forms were found. Additionally, 76% of the patients were bacteriologically negative. At the time of diagnosis, 75% of the patients presented with grade 0 disabilities, 23% with grade 1 and 2% with grade 2. Serum samples were collected from 18 PB and 15 MB patients, in addition to 14 family contacts, at the beginning and end of treatment. All the groups were re-evaluated during a three-year period (2008-2011). The proteins used for evaluation were ML0405, ML2331 and LID-1. These mycobacterial proteins were highly specific for Mycobacterium leprae and the IgG responses decreased in both MB and PB patients during multidrug treatment. Our results suggest that these antigens could be used as markers for successful treatment of non-reactional lepromatous patients.

Uso do teste ML-Flow como auxiliar na classificação e tratamento da hanseníase / Use of the ML-Flow test as a tool in classifying and treating leprosy

FUNDAMENTOS: O tratamento da hanseníase é definido pela classificação de pacientes em paucibacilares (PB) e multibacilares (MB). A OMS (Organização Mundial de Saúde) classifica os doentes de acordo com o número de lesões, mas Ridley-Jopling (R&J) utiliza também exames complementares, porém é de difícil utilização fora dos serviços de referência. Em 2003 foi desenvolvido um teste denominado ML-Flow, uma alternativa à sorologia por ELISA para auxiliar na classificação de pacientes em PB e MB e auxiliar na decisão terapêutica. OBJETIVOS: Observar a concordância entre o teste de ML-Flow e baciloscopia de linfa, exame já consagrado para detecção de MB. Analisar a utilidade do teste de ML-Flow em campo. MATERIAL E MÉTODOS: Estudo retrospectivo avaliando prontuário de 55 pacientes virgens de tratamento, diagnosticados como PB ou MB por R&J. Submetidos à baciloscopia e ao teste de ML-Flow. RESULTADOS: Nos MB, a baciloscopia foi positiva em 80 por cento dos casos, o ML-flow foi positivo em 82,5 por cento. Entre os PB, o ML-Flow foi positivo em 37,5 por cento e a baciloscopia do esfregaço foi negativa em 100 por cento dos casos. A concordância entre os resultados da baciloscopia do esfregaço e ML-Flow foi de 87,5 por cento, kappa=0,59, p<0,001. CONCLUSÃO: Nenhum teste laboratorial é 100 por cento sensível e específico para a correta classificação de todas as formas de hanseníase. O ML-Flow é um teste rápido, de fácil manuseio em campo, menos invasivo que a baciloscopia podendo ser útil para auxiliar na decisão terapêutica em locais de difícil acesso a serviços de referência.

BACKGROUND: The treatment of leprosy is defined by the classification of patients as paucibacillary (PB) or multibacillary (MB). The WHO (World Health Organization) classifies patients according to the number of lesions, but Ridley-Jopling (R & J) also uses complementary exams, which are difficult to use outside reference services. In 2003, a test called ML-Flow, an alternative to Elisa serology, was developed to help classify patients as PB or MB and decide about their treatment. OBJECTIVES: To assess the agreement between the ML-Flow test and slit skin smears, already largely used for MB detection, and to observe the efficacy of the ML-Flow test in the field. MATERIAL AND METHODS: A retrospective study evaluating the medical records of 55 patients who had not undergone previous treatment, diagnosed as PB or MB according to R & J and subjected to slit skin smears and the ML- Flow test. RESULTS: In MB patients, slit skin smears were positive in 80 percent of the cases, the ML-flow was positive in 82.5 percent. Among PB patients, the ML-Flow was positive in 37.5 percent and slit skin smears were negative in 100 percent of the cases. The agreement between skin smear and ML-Flow results was 87.5 percent, with a kappa value of 0.59, p <0.001. CONCLUSION: No laboratory test is 100 percent sensitive and specific for the correct classification of all forms of leprosy. The ML-Flow test is faster, easier to use, and less invasive than slit skin smears and therefore may be useful when making therapeutic decisions in areas of difficult access to reference services.

Características epidemiológicas e clínicas das reações hansênicas em indivíduos paucibacilares e multibacilares, atendidos em dois centros de referência para hanseníase, na Cidade de Recife, Estado de Pernambuco / Characteristics of leprosy reactions in paucibacillary and multibacillary individuals attended at two reference centers in Recife, Pernambuco

INTRODUÇÃO: As reações são frequentes e importantes no contexto da hanseníase, representando uma significativa parcela de pacientes com incapacidades e submetidos ao retratamento da hanseníase. A caracterização clínico-epidemiológica dos padrões reacionais é primordial para o manejo dos pacientes. O objetivo desse trabalho é descrever as características epidemiológicas e clínicas das reações hansênicas em indivíduos paucibacilares e multibacilares. MÉTODOS: Estudo transversal onde foram avaliados 201 pacientes com história de quadro reacional, atendidos em dois centros de referência para tratamento da hanseníase. Variáveis como baciloscopia inicial, sexo, idade, fototipo, procedência, forma clínica, tipo de tratamento e de reação, índice baciloscópico final e período de surgimento da reação em relação ao tratamento foram avaliados. A análise estatística foi realizada usando-se frequências simples. Para cálculo dos fatores de risco para as formas multibacilares, foram realizadas análises univariada e multivariada. RESULTADOS: Sexo masculino, idade entre 30-44 anos, fototipo V, a forma clínica borderline, tratamento regular, reação tipo I, neurite, presença de 10 a 20 nódulos e surgimento da reação hansênica durante o tratamento foram os achados mais frequentes. CONCLUSÕES: Predominaram os indivíduos do sexo masculino que se associaram a um maior risco de desenvolvimento da forma multibacilar. As reações hansênicas foram mais frequentes durante o tratamento, os pacientes multibacilares foram mais propensos ao retratamento da hanseníase e aqueles com reações tipo I e II, apresentaram maior frequência de neurite, linfadenopatia, artrite e irite do que aqueles com reação isolada.

INTRODUCTION: Significant reactions frequently occur among leprosy cases, and thus a significant proportion of leprosy patients present disabilities and undergo leprosy retreatment. Clinical-epidemiological characterization of reaction patterns is essential for managing such patients. Objective to describe the epidemiological and clinical characteristics of leprosy reactions among paucibacillary and multibacillary individuals. METHODS: In this cross-sectional study, 201 patients with histories of reactions who were attended at two reference centers for leprosy treatment were evaluated. Variables such as initial bacilloscopy, sex, age, skin phototype, origin, clinical presentation, type of treatment, type of reaction, final bacilloscopy index and time of reaction onset in relation to the treatment were evaluated. Statistical analysis was performed using simple frequencies. To calculate risk factors for multibacillary forms, univariate and multivariate analyses were performed. RESULTS: Male sex, age between 30 and 44 years, phototype V, borderline clinical form, regular treatment, type I reaction, neuritis, presence of 10 to 20 nodules and onset of the leprosy reaction during the treatment were the most frequent findings. CONCLUSIONS: Male patients predominated and were associated with greater risk of developing the multibacillary forms. Leprosy reactions occurred most frequently during the treatment. Multibacillary patients were more likely to need leprosy retreatment, and those with type I and type II reactions presented greater frequency of neuritis, lymphadenopathy, arthritis and iritis than did those with isolated reactions.