Forgotten but not Gone yet... - Leprosy Newsletter (January 2023)

Intro to Intro to Leprosy Leprosy

It was in 600 B.C. when Sushruta, an Indian physician, wrote the ancient medical text "Sushruta Samhita," in which he described Kustha, a term that enclosed all skin diseases. This term meant "eating away, " and nowadays defines Leprosy.

For centuries, Leprosy was also known as "death before death" or a " curse from God." It has been stigmatized all around the world with prejudice emerging from a lack of knowledge about the disease.

Contrary to popular belief, this disease still affects hundreds nowadays. This is why we celebrate "World Leprosy Day" on January 29 every year. That day also coincides with the death of Mahatma Gandhi, whose campaign for Leprosy saved countless lives. On World Leprosy Day, we get informed, inform in return and stand in solidarity with those affected. This year ’ s theme is "Act Now, End Leprosy," and truly, it is only with our immediate actions to raise awareness about Leprosy that we can end it once and for all.

The Bacterium The Bacterium

Hansen's Disease, better known as Leprosy, is caused by a rod-shaped bacterium called Mycobacterium leprae. The bacterium progresses at a slow rate and it may take between 9 months and 20 years after infection for symptoms to appear.

The organs mainly affected are the skin, eyes, peripheral nerves, mucosa, and upper respiratory tract

Classification Classification

Leprosy is classified according to the severity of its symptoms:

If symptoms are mild, which indicates that the nerves, it is known as Tuberculoid Leprosy or If symptoms are extreme, which indicates tha known as Lepromatous Leprosy or Multibac If symptoms are mixed, this type of Leprosy and Lepromatous and is known as Borderline intermediate subtypes.

In terms o cases are 100,000 pe Globally h 129,389 ca worldwide, g p people. Consequently, the World Health Organization (WHO) developed the Global Leprosy Strategy 2021-2030: “Towards Zero Leprosy”.

Signs & Symptoms Signs & Symptoms

Symptoms of Leprosy mainly affect the skin, nerves, and mucous membranes.

Leprosy can cause skin symptoms such as:

Discolored patches of skin, usually flat, that may be numb and look faded

Growths or nodules on the skin

Thick, stiff or dry skin

Painless ulcers on the soles of feet

Painless swelling or lumps on the face or earlobes

Loss of eyebrows or eyelashes

Symptoms caused by damage to the nerves are:

Numbness of affected areas of the skin

Muscle weakness or paralysis, especially in the hands and feet

Enlarged nerves, especially those around the elbow and knee and in the sides of the neck

Eye problems that may lead to blindness when facial nerves are affected

Symptoms caused by the disease in the mucous membranes are:

A stuffy nose

Nosebleeds

Complications Complications

In Leprosy, the peripheral nerve trunks are invaded by bacilli and inflammatory cells. This causes tenderness, thickening, and irregularity of the nerve, as well as sensorimotor complications. Neuropathic pain may also occur.

Involvement of the facial nerve leads to failure of eyelid closure and lagophthalmos. Nasal mucosa also becomes dry and hypoesthetic, as do the cornea and conjunctiva.

Leprosy directly infects the eyes and interferes with the facial nerve branches that innervate the eyes. This results in:

Inability to close the eyelids (lagophthalmos)

Keratitis due to absence of tears and drying, which leads to corneal ulcers

Iridocyclitis

Cataract formation

All of the above typically lead to blindness in more than 3% of patients, and consist of a obstacle in communication after aesthesia of the hands and feet.

Renal damage may occur as a result of secondary amyloidosis affecting many organs. This is mostly observed when Leprosy takes a chronic course. Renal damage may manifest as glomerulonephritis and interstitial nephritis among others.

Orchitis or inflammation of testicles is very common and affects around 90% of patients. It has the potential to cause infertility and impotence.

Pulmonary tuberculosis is often detected and it affects the upper airway causing ischemic ulceration and autonomic dysfunction.

Lastly, generalized abnormalities of peripheral vessels and endothelial cell infection are common.

Risk Factors Risk Factors

Living in Living in High-risk High-risk Areas Areas

Gene Gene Susceptibility Susceptibility

You may be at a higher risk of contracting Leprosy if it is prevalent in your area or if you have prolonged contact with individuals who have not yet been treated for it.

In 2018, 71% of cases were reported in Southeast Asia. The Americas and Africa accounted for 15% and 10% of new cases respectively, with India, Indonesia, and Brazil having the highest number of cases.

It is believed that people who contract Leprosy have genes that make them more prone to infection once they are exposed to the bacterium.

The tendency to be susceptible to Leprosy appears to be inherited, but the specific pattern of inheritance is not fully understood yet.

Ethnicity Ethnicity & Age & Age

People of Asian and Pacific Islander descent are more likely to contract Leprosy

Also, children are more likely to contract Leprosy than adults.

IImmunity mmunity

Status Status

Individuals with weakened immune systems due to chronic conditions such as HIV, diabetes, or heart diseases may be more susceptible to the infection than healthy individuals.

Transmission Transmission

Mycobacterium leprae, the bacterium that causes Leprosy, has a long incubation period, which makes it hard to identify the exact source of infection. Nevertheless, it is known that Leprosy is contracted by inhaling cough or sneeze droplets as well as being in very close and prolonged contact with someone with untreated Leprosy.

Are patients being treated for Leprosy contagious?

Patients receiving treatment can no longer spread the bacterium even if they are not fully cured yet!

How prolonged should contact with an infected individual be to lead to transmission?

Random contact with an infected person does not lead to transmission of the infection. For instance, hugging infected patients, sitting next to them, or holding hands with them will not spread the disease Also, Leprosy is neither transmitted sexually nor from a mother to her fetus through the placenta. Is Leprosy only transmitted from one human to another?

Humans are not the only organisms that can transmit the disease. Armadillos naturally host this bacterium and can transmit it to humans via contact, but the the risk of contracting the bacterium from this animal is very low.

Diagnosis Diagnosis

Leprosy is an important global health concern. Contrary to popular folklore, it is NOT highly contagious, and very effective treatment is available However, early diagnosis and treatment are necessary to minimize the likelihood of disability involving the eyes, hands and feet due to neuropathy as these are often not reversible

Clinical Evaluation

(as the first step in the y)

WHO experts list 3 main diagnostic criteria: 1 2 3

Hypo-pigmented or erythematous skin lesions with loss of sensation

An enlarged peripheral nerve with loss of sensation and/or weakness of muscle supplied by the nerve

A positive acid-fast skin smear or bacilli observed in a smear/biopsy.

The preferred slits for sample collection are active lesions or lesions with altered sensitivity

A negative result does not rule out a clinical diagnosis of Leprosy.

Skin Biopsy and Histopathological Examination

Slit Skin Smear Test

A biopsy is obtained from the leading margin of an active lesion.

It is an intradermal injection of the lepromin antigen (inactivated M. leprae extracted from lepromas) into the flexor surface of the forearm.

The delayed-type hypersensitivity reaction is read at two-time points

It has poor accuracy in diagnosing Leprosy in children and lacks adequate sensitivity and specificity but is still useful for confirming classification and prognosis.

PCR Test

Lepromin Test

They are usually used to support the clinical diagnosis of Leprosy.

Phenolic glycolipid (PLG-1) is the most frequently studied antigen

This test is usually used to monitor the effectiveness of therapy.

Serology Test

Treatment Treatment

When it comes to deal rosy, time is the main criterion.

Although treatment hinders the progress of the disease, it cannot reverse disabilities, especially some that are too severe to be restored surgically. Thus, early diagnosis is a must to prevent any permanent damage.

As of 2018, the World Health Organization has shared the newest recommended treatment guidelines for Leprosy: Multidrug Therapy consisting of different dosages of They are available in blister packs, each containing specific dosages for four weeks’ worth of medication based on the patient’s age. Children who weigh less than 40 kilograms have to take single formulation medications since no combinations are available.

Rifampicin

The duration of treatment also varies based on the patient’s condition and whether he or she is suffering from a Paucibacillary Leprosy or a Multibacillary Leprosy, the first requiring 6 months of treatment while the latter 12 months of treatment.

The recommended dosages as per the 2018 WHO Guidelines for the Diagnosis, Treatment, and Prevention of Leprosy are listed as follows:

Adults

Rifampicin 600mg once a month

Clofazimine 300mg once a month and 50mg daily

Dapsone 100mg daily

Children (10-14 years old)

Rifampicin 450mg once a month

Clofazimine 150mg once a month and 50mg every other day

Dapsone 50mg daily

Children < 10 years old or <40kg

Rifampicin 10mg/kg once a month

Clofazimine 100mg once a month and 50mg twice per week

Dapsone 2mg/kg daily

Clofazimine Dapsone

Resistance Resistance

While MDT is effective, some patients resist rifampicin, or rifampicin and dapsone. These patients undergo a second-line treatment involving regardless of clinical outcomes with MDT.

Ofloxacin Minocycline Clofazimine Clarithromycin

The treatment options according to the 2018 WHO Guidelines for the Diagnosis, Treatment, and Prevention of Leprosy are:

Resistance Type

Ofloxacin 400mg* + Minocycline 100mg + Clofazimine 50mg

Ofloxacin 400mg* OR Minocycline 100mg + Clofazimine 50mg

Rifampicin Resistance

Rifampicin & Ofloxacin Resistance

Ofloxacin* 400mg +

Clarithromycin 500mg + Clofazimine 50mg

Clarithromycin 500mg + Minocycline 100mg + Clofazimine 50mg

Ofloxacin 400mg* + Clofazimine 50mg

Clarithromycin 500mg OR Minocycline 100mg + Clofazimine 50mg

*Ofloxacin 400mg can be replaced by Levofloxacin 500mg OR Moxifloxacin 400mg.

Drug Mechanism of Action

P h a r m a c o l o g i c a l

I n s i g h t

Dapsone

Is a competitive antagonist of paraaminobenzoic acid

Inhibits bacterial growth by preventing PABA utilization for the synthesis of folic acid.

Rifampin

Rifadin

Rimactane

Inhibits bacterial reproduction by binding to the beta subunit of DNA-dependent bacterial RNA polymerase, hindering it and inhibiting RNA transcription

Major Adverse Effects

Hemolysis

Methemoglobinemia

Abrupt changes in clinical activity

Elevated liver function tests

Epigastric pain

Anorexia

Pseudomembranous colitis

Pancreatitis

Skin discoloration

Clofazimine

Lamprene

Has a bactericidal effect and binds mycobacterial DNA. Also has antiinflammatory properties

Clarithromycin

Inhibits bacterial growth by separating peptidyl tRNA from ribosomes and thus blocking protein synthesis.

Ofloxacin

Levofloxacin

Moxifloxacin

Minocycline

Dynacin

Minocin

Cause bacterial cell death by hindering bacterial DNA gyrase, thus stopping DNA replication, transcription, repair, recombination, and transposition

Inhibit protein synthesis and bacterial growth by binding to ribosomal subunits of susceptible bacteria.

Gastrointestinal effects

Rash

Ocular irritation

Increased blood glucose

Gastrointestinal effects

Taste disturbances

Elevated BUN

Gastrointestinal effects

Tendonitis

Vaginitis

Sleep disturbances

Discoloration of teeth in children

Black tarry stools

Prevention Prevention

Leprosy can be prevented by awareness about early detection and about the early signs and symptoms of infection. The risk of contracting the disease is often very low, but it is recommended to avoid contact with infected patients.

Some studies have demonstrated that immunoprophylaxis and chemoprophylaxis such as with a single-dose rifampicin are effective preventive measures.

There is still no vaccine to prevent Leprosy, but the Bacillus Calmette–Guérin (BCG) vaccine which is effective against the spread of Tuberculosis could be effective as well against the spread of Leprosy. Truly, introducing a mycobacterium vaccine can help with effective prevention of infection and ensure excellent results when it comes to MDT while significantly reducing the risk of relapse.

The Psychological The Psychological Impact of Leprosy Impact of Leprosy

Simply put, Leprosy brings about burdens of physical and psychological impairment. The burdens stem from both the disabilities brought about by the disease itself but also from the societal stigma towards Leprosy and the hatred that its victims, often severely deformed, receive from society.

A systematic review of 65 studies discovered that the most prevalent mental disorder identified in Leprosy patients was depression followed by anxiety disorders such as generalized anxiety disorder, panic disorder, and obsessivecompulsive disorder (OCD). The study showed that Leprosy patients often displayed suicidal ideations and attempts. Another recorded problem was Schizophrenia, but the number of cases was small.

In terms of negative emotions, fear and shame were frequently found among infected individuals. Patients were afraid of dying or of spreading the disease and of being discriminated against or marginalized because of the physical manifestations of the disease.

Furthermore, not only does Leprosy impact the patient’s mental health, but also that of the patient’s family. Studies showed that depression and lack of self-esteem were common among children of such patients

Do's and Don'ts Do's and Don'ts of Leprosy of Leprosy

Do get the BCG Vaccine. It has been recognized to contribute to protection against Leprosy.

Do take Vitamin E to prevent oxidative stress that occurs during Leprosy. Do maintain good hygiene. Poor WASH (Water, Sanitation and Hygiene) conditions increase the risk of Leprosy.

Don't handle an armadillo, as some carry the bacterium causing Leprosy.

Don't stay in places where armadillos are found as the area may contain the bacterium.

Don't neglect changes to your skin. The earlier Leprosy, and any disease, is detected, the better its prognosis will be.

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