Hanseníase neural, aspectos diagnósticos da forma neural pura e mecanismos imunopatogênicos da lesão do nervo na doença. Participação de quimiocinas CCL2 e CXCL10 e metaloproteinases 2 e 9 / Neural leprosy, pure neural leprosy diagnosis and imunopatogenic mechanisms of nerve damage during the disease. Participation of chemokines CCL2 and CXCL10) and metalloproteinases 2 and 9

O diagnóstico da hanseníase neural pura baseia-se em dados clínicos e laboratoriais do paciente, incluindo a histopatologia de espécimes de biópsia de nervo e detecção de DNA de Mycobacterium leprae (M. leprae) pelo PCR. Como o exame histopatológico e a técnica PCR podem não ser suficientes para confirmar o diagnóstico, a imunomarcação de lipoarabinomanana (LAM) e/ou Glicolipídio fenólico 1 (PGL1) - componentes de parede celular de M. leprae foi utilizada na primeira etapa deste estudo, na tentativa de detectar qualquer presença vestigial do M. leprae em amostras de nervo sem bacilos. Além disso, sabe-se que a lesão do nervo na hanseníase pode diretamente ser induzida pelo M. leprae nos estágios iniciais da infecção, no entanto, os mecanismos imunomediados adicionam severidade ao comprometimento da função neural em períodos sintomáticos da doença. Este estudo investigou também a expressão imuno-histoquímica de marcadores envolvidos nos mecanismos de patogenicidade do dano ao nervo na hanseníase. Os imunomarcadores selecionados foram: quimiocinas CXCL10, CCL2, CD3, CD4, CD8, CD45RA, CD45RO, CD68, HLA-DR, e metaloproteinases 2 e 9. O estudo foi desenvolvido em espécimes de biópsias congeladas de nervo coletados de pacientes com HNP (n=23 / 6 BAAR+ e 17 BAAR - PCR +) e pacientes diagnosticados com outras neuropatias (n=5) utilizados como controle. Todas as amostras foram criosseccionadas e submetidas à imunoperoxidase. Os resultados iniciais demonstraram que as 6 amostras de nervos BAAR+ são LAM+/PGL1+. Já entre as 17 amostras de nervos BAAR-, 8 são LAM+ e/ou PGL1+. Nas 17 amostras de nervos BAAR-PCR+, apenas 7 tiveram resultados LAM+ e/ou PGL1+. A detecção de imunorreatividade para LAM e PGL1 nas amostras de nervo do grupo HNP contribuiu para a maior eficiência diagnóstica na ausência recursos a diagnósticos moleculares...

The diagnosis of pure neural leprosy (PNL) is based on clinical and laboratory data, including the histopathology of nerve biopsy specimens and detection of M. leprae DNA by polymerase chain reaction (PCR). Given that histopathological examination and PCR methods may not be sufficient to confirm diagnosis, immunolabeling of lipoarabinomanan (LAM) and/or phenolic glycolipid 1 (PGL1) M. leprae wall components were utilized in the first step of this investigation in an attempt to detect any vestigial presence of M. leprae in AFB- nerve samples. Furthermore, it´s well known that nerve damage in leprosy can be directly induced by Mycobacterium leprae in the early stages of infection; however, immunomediated mechanisms add gravity to the impairment of neural function in symptomatic periods of the disease. Therefore, this study also investigated the immunohistochemical expression of immunomarkers involved in the pathogenic mechanisms of leprosy nerve damage. These markers selected were CXCL10, CCL2 chemokines and CD3, CD4, CD8, CD45RA, CD45RO, CD68, HLA-DR, metalloproteinases 2 and 9 in nerve biopsy specimens collected from leprosy (23) and nonleprosy patients (5) suffering peripheral neuropathy. Twenty-three PNL nerve samples (6 AFB+ and 17 AFB-PCR+) were cryosectioned and submitted to LAM and PGL1 immunohistochemical staining by immunoperoxidase; 5 nonleprosy nerve samples were used as controls. The 6 AFB-positive samples showed LAM/PGL1 immunoreactivity. Among the 17 AFB- samples, only 8 revealed LAM and/or PGL1 immunoreactivity. In 17 AFB-PCR+ patients, just 7 had LAM and/or PGL1-positive nerve results. In the PNL cases, the detection of immunolabeled LAM and PGL1 in the nerve samples would have contributed to enhanced diagnostic efficiency in the absence of molecular diagnostic facilities...

Affection of immune zones in leprosy: a clinico-epidemiological study.

The study was undertaken to evaluate the prevalence of involvement of immune zones in leprosy and to assess the clinico-epidemiological characteristics of the disease in patients presenting with immune zone involvement. 200 leprosy cases were included in this study and detailed history, clinical examination, slit-skin smears and skin biopsies were carried out on all patients. Those cases presenting with immune zone involvement were further evaluated for clinical and epidemiological characteristics of disease process. Immune zone involvement was detected in 7% of cases with male preponderance in the study. Majority of patients (85.5%) had borderline tuberculoid leprosy and midline of back was the commonest site of involvement (50% of cases). Morphologically, macular lesions were the commonest presentation (85.68%) of immune zone involvement. The study heightens the clinical awareness of the possibility of occurrence of leprous lesions on uncommon and unusual sites, which should be termed as relatively immune, rather than absolutely immune zones of leprosy.

Primary involvement of penile skin in lepromatous leprosy.

Skin lesions in lepromatous leprosy (LL) are usually multiple and widespread. Though the lesion may occur anywhere on the skin, male genitalia is rarely involved. In all cases reported so far about penile lesions of LL, there were lesions on the other parts of the body also. In some of the cases scrotum was also involved. We report here a patient who presented himself with a single macular lesion of leprosy on the shaft of his penis diagnosed as a case of lepromatous leprosy on slit-skin smear and histopathological examinations.

A study on trend of relapse in leprosy and factors influencing relapse.

A retrospective analysis of data pertaining to the rural field operation area of the Central Leprosy Teaching and Research Institute, Chengalpattu, Tamil Nadu, was carried out to determine the magnitude of relapse after MDT and its significance with other variables. The study included 3248 leprosy patients who have successfully completed treatment during 1987-2003, of whom 2892 were PB and 356 MB cases. A total of 58 cases of relapse was reported which gives a crude cumulative relapse rate of 1.78% for the 16-year period of follow-up and the rates for PB and MB were 1.9% and 0.84% respectively. With respect to PB cases, 68% of relapses were reported in the first 3 years of RFT. The person-year relapse rate was highly significant with regard to the number of skin lesions (p<0.0002) and nerve involvement (p<0.0002). The person-year relapse rate did not differ significantly between PB and MB leprosy, male and female, and child and adult cases. RFT year cohort relapse rate reveals that the introduction of MB-MDT regimen for PB leprosy had resulted in the reduction of relapses among PB cases after 1998. The relapse rate with reference to the time gap after RFT reveals that relapse declines with passage of time after RFT. The risk of relapse was very low in both PB and MB leprosy which fact emphasizes that proper counselling about signs and symptoms of relapse during RFT is adequate to combat the problem. A majority of relapses occurred in the first three years after RFT. The number of skin lesions and involvement of nerves were the main risk factors for relapse.

Leprosy scenario in southern part of Dakshina Kannada district, Karnataka, after 16 years of control work.

This article examines the changes that occurred in epidemiological indices over a period of 16 years following the introduction of MDT in Ullal town, south of Mangalore city, having a population of 130,000. The analysis indicates that new case-detection rates and prevalence rates showed a declining trend due to shorter duration of treatment with MDT. There was a ten-fold reduction in the prevalence rate during the first 6 years, from 23 in 1987 (230 cases) to 2.76 per 10,000 (29 cases) at the end of 16 years. The number of nmultibacillary cases among the newly detected cases showed a downtrend (from 28 cases in 1987 to 5 in 2001). The number of newly detected cases presenting with single lesion also showed a declining trend.

Leprosy in HIV infection: a study of three cases.

The course of leprosy in patients with HIV infection has been a controversial issue for a long time. It is still a matter of debate whether the HIV status of an individual has any impact on the natural history of leprosy and response to anti-leprosy treatment. We report here three HIV-positive leprosy cases (two BT and one BB) along with their CD4 counts and HIV staging with anti-leprosy therapeutic response. Both BT cases responded well to conventional WHO MDT (PB) for 6 months, whereas the BB case relapsed 3 months after completion of MDT (MB) for one year. However, he became inactive again following a further one-year course of MDT (MB).

Impact of integration of NLEP into PHC system in Madurai district, Tamil Nadu, and status of integration of leprosy patients into the community.

Based on the encouraging results of the integration in Tamil Nadu, the Government of India introduced integration in the entire country. In this study on integration, Madurai district was taken as the study area. The impact of integration on essential indicators of leprosy elimination was analyzed and the results are discussed so that they will be useful to other states that are still considering integration.

Oxidative stress and anti-oxidant status in leprosy patients.

Severe oxidative stress has been reported in leprosy patients because of malnutrition and poor immunity. The purpose of this study was to investigate the serum lipid peroxidation products, serum LDH and important free radical scavenging enzymes, i.e. superoxide dismutase (SOD), and catalase and anti-oxidant glutathione levels and total anti-oxidant status, in different types of leprosy patients. The subjects for this study were normal human volunteers (NHVs, n=14), paucibacillary leprosy patients (PB, n=18), untreated MB patients (MB1, n=18), MB patients under treatment (MB2, n=19), and MB patients released from treatment (RFT) (MB3, n=28). The levels of lipid peroxidation product, malondialdehyde (MDA), and LDH increased significantly (p<0.001) in MB (MB1, MB2, MB3) patients, and both gradually decreased with clinical improvement following MDT. The levels of SOD, catalase and glutathione, and the total anti-oxidant status decreased significantly in MB (MB1, MB2, MB3) patients (p<0.001), in comparison with NHVs. They gradually increased with clinical improvement with MDT. There was no significant variation of these parameters in PB leprosy patients in comparison with healthy volunteers. High free radical activity and low anti-oxidant levels observed in MB (MB1, MB2, MB3) leprosy patients indicate that there is an oxidative stress in MB cases, irrespective of the treatment status and suggest a suitable anti-oxidant therapy to prevent possible tissue injury.

Leprosy situation in endemic states of India and prospects of elimination of the disease.

In India there is a dramatic fall in the prevalence rate (PR) of leprosy, but the new case-detection rate (NCDR) has not been reduced concomitantly. It is the operational efficiency of the National Leprosy Eradication Programme (NLEP) that has led to a significant reduction in the NCDR in Andhra Pradesh and Tamil Nadu. The ratio of PR to NCDR has been declining in these two states and it reveals that elimination could be reached even with the high NCDR level of 3 to 4 per 10000 population, particularly if single skin lesion (SSL) cases are discharged through single dose treatment of rifampicin, ofloxacin and minocycline (ROM). On the other hand, the significant number of cases detected in Bihar and Orissa during modified leprosy elimination campaigns (MLECs) reveals that there are lacunae in operational activities in new case-detection resulting in a large number of undetected cases in the community. Only one-third of the cases are reporting voluntarily. Awareness of leprosy is not adequate to motivate the patients to report voluntarily and complete their treatment, thus underscoring the need for relying on active case-detection so that transmission can be broken and elimination of leprosy achieved. In addition, the influence of socio-economic factors on continued occurrence of leprosy cannot be ruled out. The establishment of a sentinel surveillance system along with a computerized simplified information system to gain in-depth knowledge on the functioning of the NLEP will ensure operational efficiency. In view of this situation, the NLEP should adopt a more realistic approach towards reaching the elimination goal.

Localized lepromatous leprosy presenting as a painful nodule in a muscle.

Lepromatous leprosy is a generalized disease usually presenting with numerous macules, papules, nodules or plaques involving wide areas of the skin. It is generally believed that in India lepromatous leprosy often originates from the borderline spectrum (Jha et al, 1991). Localized lepromatous or borderline lepromatous disease is a rare variant of multibacillary leprosy (Yoder et al, 1985; Jha et al, 1991; Pfaltzgraff & Ramu, 1994; Vijaikumar et al, 2001). This variant usually presents as a single nodule or a localized area of nodules and papules, while most of the body surface appears normal (Pfaltzgraff & Ramu, 1994; Vijaikumar et al, 2001). Its occurrence in our case as a single painful nodule in the bicep muscle of left forearm was indeed intriguing, such presentation being rarely reported in the literature.

Incidence of leprosy in school-children and their family members in Berhampur.

A school survey, followed by a contact survey, was carried out in Berhampur, a city in southern Orissa. In a study of 8,870 school-children, leprosy was detected in 15, giving a prevalence rate of 16.91 per 10,000 with a male:female ratio of 8:7. Of these, 14 (93.99%) had paucibacillary leprosy. More cases [11 (73.33%)] were seen in the age-group of 10-15 years. Exposed parts, such as lower limbs, upper limbs and head and neck in that order, were the sites of predilection, accounting for 85.71% of total lesions. Nerve involvement was found in 2 (13.33%) girls with deformity (ulnar claw) in one of them (6.66%). BCG scar was present in 11 (73.33%) cases. Among the vaccinated cases, tuberculoid type was the most common, followed by indeterminate, pure neuritic and borderline, in that order. A contact survey detected 2 multibacillary cases in two families (13.33%). In each case, the father was the index source. The study revealed that a maximum number of students, 8 (53.3%), belonged to the middle socioeconomic class. Of the 15 affected, 60% were undernourished and the rest well nourished. No other systemic disease was found clinically associated with leprosy.

Reactions in borderline leprosy.

This is a retrospective study of 276 patients consisting of 157 active and 119 reactive patients of borderline leprosy. They were followed up for 10 years after sulphone monotherapy. The presenting symptoms were carefully examined from the records and systematically presented. Frequency of reactions was least in BT cases and most in BL cases. Risk factors of reaction appear to be the type of leprosy, multiplicity of lesions, high BI and, possibly, psychological stress. Biopsy of skin lesions was performed in all cases initially, and at the subsidence of the disease. Histological findings closely correlated with clinical classification. While all the cases showed clinical subsidence, histological subsidence was found in 200 (73%) cases, and the condition was static in 36 cases (13%). Immunological upgrading was seen in 110%, while 4% showed downgrading. Bacteriological status and lepromin reaction of active and reactive cases were compared. All these factors need to be taken into consideration for instituting prompt and proper treatment.

Co-infeccao pelo virus da imunodeficiencia humana (HIV) e o Mycobacterium leprae: aspectos imunologicos e caracterizacao anatomopatologica e imunofenotipica de lesoes de pele / ?

O aumento de susceptibilidade a infecções por micobactérias, notadamente Mycobacterium avium e Mycobacterium tuberculosis, é uma conseqüência bem conhecida da infecção pelo Vírus da Imnudeficiência Humana (HIV) refletindo em maior morbi/letalidade nos pacientes co-infectados. À medida que o HIV se dissemina em regiões tropicais e subtropicais endêmicas para a hanseníase, como é o caso do Brasil, os efeitos do HIV na hanseníase deveriam ser aparentes. No entanto, várias questões, como as listadas, ainda não estão totalmente esclarecidas. A infecção pelo HIV: constitui fa or de risco para a hanseníase? Agravaria a hanseníase pré-existente? Altera a progressão da resposta imune para o Mycobacterium leprae e as manifestações da doença levando a amior incidência de formas multibacilares? Altera a histoarquitetura e a compisição celular da pele? Favorece maior número de reações tipo 2? Representa fator de risco para incapacidades? Infuência o tratamento MDT-hansênico? Aumenta a letalidade? Relatos de casos isolados ou pequenas casuísticas de pacientes co-infectados descritos indicam que a interação HIV-M. leprae é incerta, pouco conhecida e representa um enigma do ponto de vista imunológico. A imunidade celular, gradativamente comprometida na infecção pelo HIV, representa o mecanismo protetor crucial para ambos patógenos. Embora pudéssemos prever um resultado desfavorável à medida que a imunossupressão se instala e a imunidade celular diminui, não está definido até que ponto a infecção por um patógeno influencia o curso da outra infecção. No contexto de uma região de alta endemicidade para a hanseníase e média endemicidade para o HIV, como é o Estado de Goiás, o presente estudo se propôs a avaliar a situação de co-infecção HIV-M. leprae entre os pacientes atendidos no centro de referência HAA/HDT. Dezoito pacientes co-infectados, atendidos no HAA/HDT, Goiânia, Goiás, no período de 1986 a 2001, que assinaram consentimento informado, tiveram biópsias de lesões de pele disponíveis para a análise histopatológica (HE e Fite-Faraco) e imunofenotípica (imuno-histoquímica). Utilizaram-se os critérios de classificação de Ridley-Jopling. A metade das biópsias analisadas era de pacientes virgens de tratamento e as demais, de pacientes em tratamento (n=3), em lesão residual pós tratamento (n=3) e nos casos de retratamento (n=3). Contagens de linfócitos T CD8+ periféricos (Citometria de Fluxo, FACSCount, BD) e valores de carga viral (NASBA, Organon), obtidos

Viability of M. leprae while undergoing laboratory procedures.

Studies were carried out to assess whether various methodological procedures adopted while conducting experiments, or, maintaining M. leprae under different conditions affected the number of organisms made available or their viability. Results of mouse foot-pad experiments showed that bacilli survived for one day at 37 degrees C, 7 days at 20 degrees to 30 degrees C and for 90 days in lyophilized conditions. Repeated daily exposure of the material preserved in refrigerator at +4 degrees C, to room temperatures showed that bacilli survived for only up to five days; whereas, with single exposure they survived up to 14 days. M. leprae were found to lose infectivity after 30 minutes of exposure to various disinfectants and ultra violet light. Centrifugation at high speed did not affect the viability of M. leprae.