Leprosy in Post-elimination Era: A Study Conducted in Rural Tertiary Settings in North India.

Background Leprosy is an age-old disease caused by Mycobacterium leprae. The disease was declared eradicated in India in 2005. Many new cases are still being identified in the outdoor patient department. This study was undertaken to understand the epidemiological, clinical, and social aspects of leprosy among new patients, and assess the current situation regarding caseload and presentation. Material and methods This study was designed as an observational study. It was carried out in people newly diagnosed with leprosy attending the outpatient department of Dermatology, Venereology, and Leprology in the tertiary care hospital in Uttar Pradesh University of Medical Sciences from July 2022 to January 2024. A total of 231 people afflicted with leprosy were included in the study. The data collected was statistically analyzed to identify demographic and social patterns, clinical presentations, and features associated with leprosy. Result Out of these 231 patients, 139 (60.17%) were male and 92 (39.83%) were female. Most cases belonged to the age group 40-59 years 87 (37.66%). History of close contact with an afflicted person was present in 34 (14.71%). Clinically, most patients belong to the borderline tuberculoid (BT) type. Only 24 (10.4%) patients were found positive for M. leprae by slit-skin smear examination. The ulnar nerve was the most common nerve involved in 63 (27.27%) cases. Trophic ulcers were the predominant deformity in 34 (14.7%), followed by foot drop in 13 (5.62 %). Conclusion The present study provides an overview of the prevailing trends of Leprosy within a specific region in the post-elimination era. The findings underscore the significance of the ongoing National Leprosy Eradication Program (NLEP) program and stress the importance of aligning them with the common goal of eliminating the burden and stigma of Leprosy from society.

Pressure Stockings for Edematous Feet in the Lepra Reaction: An Inexpensive Patronage.

Leprosy has been known for its wide range of peripheral nerve and tissue involvement and causing disabilities. Early diagnosis and treatment with multi-drug therapy can save lives and limbs and prevent disabilities. However, management and drug therapy are usually lengthy and full of ups and downs of side effects. Further, the lepra reaction is frequently noted during management, requiring immunosuppression and leading to associated side effects. Limb edema per se due to leprosy is unusual and mostly a symptom of a reactional state. There is no specific management for edema in such cases, and it subsides with improving reactionary states. Nevertheless, the edema may be persistent and bothersome. The present report highlights one such unusual case in a 40-year-old man, diagnosed with borderline-tuberculoid leprosy and experiencing a type-1 reaction. Owing to ocular complications, steroid therapy for the reaction was tapered abruptly, and his limb edema did not subside with the improving lepra reaction. Compression stockings helped to manage edema. This case also makes us ponder the possible use of compression stockings as an opioid-sparing aid in lepra reaction-related edema.

Dermlep Study Part 3: Post-RFT Events in Leprosy Patients Presenting to Dermatologists.

Introduction: Presently the leprosy program has no defined surveillance protocols for patients who complete the fixed duration multidrug therapy and are released from treatment (RFT). Hence, the information about the post-RFT events in these patients is sparse and qualitative and quantitative data regarding their health care requirements is missing. During the DermLep survey carried out by the Indian Association of Dermatologists,Venereologists and Leprologists (IADVL), a number of patients presented to dermatologists during the post RFT period for a variety of symptoms. This paper analyses the events in these patients during the post RFT period. Results: Out of a total of 3701 leprosy patients who presented to 201 dermatologists across India during the DermLep survey, 708 (26.2%) were in the post RFT period (488 males; 220 females). Of these, 21% were PB and 79% MB patients as per their treatment records. Majority were in the age group of 31-59 years (55.5%); however, a significant proportion of them (20.7%) were elderly (>60 years). Majority of the patients (45.5%) presented within the first year of RFT with variable symptoms; 28% were between 1-5 years, 5.5% between 5-10 years; and 11.0% presented more than 10 years after RFT. Most common presenting complaint being persistent skin lesions as perceived by patients in 21.2%, followed by neuritis in 14.5%; trophic ulcers in 13.8%; deformities in 67 (11.8%); lepra reactions in 66 (11.6%); and recurrence of original symptoms in 6.7%. Conclusion: The DermLep Survey highlights the importance of 'post RFT' patients as an important subset of leprosy patients who visit dermatologists for various health related issues. The most common complaints in this subset were active/persistent skin lesions, lepra reactions and neuritis. In these patients, who are a sub-group of 'persons affected with leprosy' the disease related issues can persist for many years post RFT. Hence, it is important to provide services in the programme to monitor and manage these complications for the prevention of impairments, disability and the related social issues.

Lepra reactions in new leprosy cases at diagnosis: A study of 50 Pakistani patients.

OBJECTIVE: To determine the occurrence and characteristics of the two types of lepra reactions in new leprosy cases at initial diagnosis. METHODS: The retrospective descriptive study was conducted at the Marie Adelaide Leprosy Centre, Karachi, and comprised all new leprosy cases registered from January 1, 2016, to June 30, 2018. Data was collected from the medical record database using a predesigned proforma. RESULTS: Of the 50 cases, 2(4%) were children and 48 (96%) were adults, with overall age ranging from 12 to 85 years. There were 41(82%) males and 9(18%) females.. Of the total, 30(60%) cases presented with type 1 reaction and 20(40%) with type 2. Further, 30(60%) cases were classified as borderline lepromatous. Among them, 17(57%) had type 2 reaction. Inflamed plaques were the main feature in 27(90%) cases of type 1. Crops of painful, erythematous nodules were seen in 19(95%) cases of type 2. CONCLUSION: Lepra reactions were found to be a presenting feature in a significant number of new leprosy cases at initial diagnosis.

Lepra reactions: A study of 130 cases from Pakistan.

OBJECTIVE: To determine the occurrence and characteristics of lepra reactions in leprosy patients. METHODS: The retrospective study was conducted at the Marie Adelaide Leprosy Centre, Karachi, and comprised data of patients admitted between January 1, 2013, and December 31, 2015, for the management of lepra reactions. Data was noted on a detailed proforma and was analysed using Microsoft Excel and applying chi-square test. RESULTS: Of the 130 cases, 95(73%) were males and 35(27%) were females. Mean age at onset of the first episode was 39±14 years. Borderline lepromatous was the most common classification 76(58%), with 40(53%) of them having type 1 reaction as the first episode and 36(47%) having a type 2 reaction Risk factors associated with recurrence were skin lesions, fever, lymphadenopathy and type of reaction (p<0.05). CONCLUSION: Healthcare providers need to be aware of the clinical manifestations of lepra reactions in order to diagnose them early.

Neuropathies of leprosy.

Neuropathies form an integral part of the symptomatology of leprosy. Neuropathies of leprosy take various forms and shapes. At one end is the cutaneous nerve involvement adjacent to the anaesthetic skin patch and the other is of symmetrical pansensory neuropathy and the devastating sensory ataxia of leprous ganglionits. Lepra reactions add to the spectrum. Hosts immunological status largely decides the clinical manifestations seen in nerves and skin. A wide array of diagnostic techniques like ultrasonography, magnetic resonance neurography, serological markers, molecular tests, skin biopsy and in selected cases, the nerve biopsy with special stains and electron microscopy are obtainable to help the clinical diagnosis. The unsuspecting clinician, lack of community awareness and limited availability of diagnostic tests are important adverse factors in the total outcome. Multi drug therapy is efficacious and corticosteroids reduce the impact of nerve damage in leprosy. The efficacy, dose and duration of corticosteroid therapy are presently inexact and other immune suppressants like azathioprine are being evaluated. Chronic disabilities and residual deficits require attention of multiple specialties. In the coming time, focus on prevention could lead to favourable results. This review will discuss the classification systems, common and uncommon clinical features, diagnostic armamentarium and therapeutic and preventive aspects of neuropathies of leprosy.

Cytokine gene polymorphisms in type I and type II reactions in Hansen's disease.

INTRODUCTION: Leprosy or Hansen's disease is a chronic debilitating disease caused by Mycobacterium leprae. Host genetics are believed to strongly influence the course of the disease. It is known that cytokines play an important role in leprosy and cytokine gene polymorphisms probably influence the course of the disease. METHODS: In the present study, we evaluated 70 patients with leprosy and 243 controls. DNA was extracted from the peripheral blood and genotyping was done for the following polymorphisms: IL-1 RA intron 2, IL-1ß-511 C/T and TNF-α A/G. RESULTS: A strong association of TNF-α-308 G/A polymorphism with Hansen's disease with both genotypes and alleles was found. However, no correlation was identified between the other two polymorphisms and Hansen's disease. A strong association between the IL-1ß gene polymorphisms and the type of reactions seen in leprosy was found. In contrast, the other two polymorphisms did not show any such association. LIMITATIONS: Genetic polymorphisms are association studies. They are not a direct reflection of the transcriptome or proteome and this is a major limitation of this study. CONCLUSION: In conclusion, cytokine gene polymorphisms appear to influence the susceptibility and course of Hansen's disease. An evaluation of the cytokine levels in the skin during lepra reactions would confirm this observation. Possibly, in future, this would be a guide to therapeutic decisions in cases of lepra reactions.

Hansen's disease: An unusual presentation.

Hansen's disease can present with varied and subtle symptoms which can be missed. A middle-aged gentleman presented with swelling of face and hands. Detailed examination and investigations confirmed borderline tuberculoid leprosy with lepra reaction. A high index of suspicion with vigilance can help to make an early diagnosis in this potentially treatable condition.

Safety and efficacy of oral fusidic acid as a steroid-sparing agent in the treatment of lepra reactions : A randomized controlled assessor-blinded clinical trial

BACKGROUND: Lepra reactions occur in 10-30% of patients with leprosy. The standard of treatment is prednisone. However , prolonged steroid use may cause side effects such as osteoporosis, hypertension, hyperlipidemia, atherosclerosis and infections. Fusidic acid targets cytokine systems responsible for the production of Type 1 lepra reaction (T1R) and erythema nodosum leprosum (ENL). It may be given as a steroid-sparing agent in treating lepra reactions. OBJECTIVE: To determine the safety and efficacy of fusidic acid as a steroid-sparing agent in the treatment of  Type 1 and Type 2  lepra reactions. METHODS: A randomized controlled trial was conducted on 67 subjects with lepra reactions, aged 18-60, each assigned to receive either prednisone or prednisone + fusidic acid for 12 weeks. Severity of lepra reactions were graded quantitatively using a modified scale by Walker et al and van Brakel et al, and qualitatively using modified National Leprosy Control Program (NLCP) Guidelines at baseline, weeks 2,4,6,8,10 and 12. Doses of prednisone needed to control lepra reactions were also noted at each follow up and statistical analyses were done . Adverse reactions were noted. RESULT: Sixty subjects (89.55%) completed the study. The prednisone + fusidic acid group had lower quantitative and qualitative scores compared to the prednisone group. There were significant differences between the two groups for the quantitative severity scores (p=1.44x10-11) and qualitative severity grading (p=9.36x10-14) at week 12. The mean dose of prednisone was 21.5 mg in the prednisone group and 2 mg in the prednisone + fusidic acid group at week 12 (p=1.01x10-12). No adverse reactions were reported. CONCLUSION: Fusidic acid tablet 250mg/tab two tablets three times a day is an effective and safe steroid-sparing agent for the treatment of lepra reactions.

Hansen's Disease in Penang: A 10-year Retrospective Analysis

Background Leprosy is a chronic granulomatous infection caused by Mycobacterium leprae. The principal manifestations are skin lesions and peripheral neuropathy. The aims of the study is to improve the understanding of leprosy cases managed in Penang General Hospital and to analyse the demographics, clinical patterns, treatment regimen and outcome of leprosy in Penang Hospital. Materials and Methods This retrospective study covered a 10-year period from 1997 to 2006. Demographic characteristics, clinical patterns, treatment regimen of leprosy and outcome were analysed. Results A total of 95 patients were diagnosed to have leprosy (prevalence rate of 0.68 per 100,000). The mean age at presentation was 40.4 years ± 17.9 (range from 3 to 91 years old). There were 35 Malays (36.8%), 34 Chinese (35.8%), 5 Indians (5.2%) and 21 others. Patients experienced symptoms for a mean of 21.4 months before being referred to our clinic. Only 29 patients (30.5%) had a family history of leprosy. 34 patients (35.8%) presented with lepromatous leprosy. 95 patients (100%) presented with skin lesions, 61 patients (61.2%) with nerve lesions, 17 patients (17.9%) with deformities and 12 (12.6%) with reactions. The skin lesions occurred predominantly over the lower limbs, face and trunk. 95.8% of skin lesions were hypo/anaesthetic. Common thickened nerves observed were ulnar nerve (40.0%), great auricular nerve (38.9%) and posterior tibialis nerve (25.3%). The lepra reaction rate was 51.6%. Type 1 reaction commonly involved those with borderline spectrum but type 2 reaction commonly involved those with lepromatous spectrum. Common side effects observed with MDT were dapsone induced hemolytic anaemia (10.5%), cutaneous adverse drug reaction (8.4%) and drug induced hepatitis (2.1%). None of them experienced severe drug toxicity. In terms of treatment for leprosy, 71.6% of patients had completed their treatment and 18.9% were still on treatment. 24.1% of patients had their regimen changed because of side effects and drug resistance. 6 patients died (due to unrelated cause) and another 3 patients defaulted treatment. Conclusions Our study showed similar epidemiological findings as other studies except for a higher reaction rate. There was a significant delay in diagnosis in our cohort. Identification of the reasons of delay in diagnosis, and the risk factors of lepra reaction are important in the management of leprosy. Anti-leprotic treatment is relatively safe and effective in treating leprosy.