Module 1: LEPROSY: The Disease Module 1: LEPROSY: The Disease

WHAT IS LEPROSY? Leprosy is a chronic infectious disease caused by Mycobacterium leprae, WHAT IS LEPROSY? Leprosy is a chronic infectious disease caused by Mycobacterium leprae, an acid-fast, rod-shaped bacillus that mainly affects the skin, peripheral nerves, mucosa of the upper respiratory tract and eyes. an acid-fast, rod-shaped bacillus that mainly affects the skin, peripheral nerves, mucosa of the upper respiratory tract and eyes.

It has a very long incubation period or latency which ranges from 3 to 15 years.

Leprosy is an infectious disease directly transmitted from man to man. It is acquired through prolonged repeated exposure & chromo 6 Only a small proportion of the population is affected (5%);(95%) develop immunity. It is transmitted from one untreated person to another via the respiratory tract.

DIAGNOSIS OF LEPROSY: Diagnosis of leprosy is mainly based on clinical signs and symptoms. DIAGNOSIS OF LEPROSY: Diagnosis of leprosy is mainly based on clinical signs and symptoms. Only in rare instances is there a need to use laboratory and other investigations to confirm a diagnosis of leprosy.

An individual should be regarded as having leprosy if he exhibits the following cardinal signs:  Hypo-pigmented or reddish skin lesion(s) with definite sensory loss;  Peripheral nerve damage, as demonstrated by loss of sensation and muscle weakness in the hands, feet and/ or face;  Positive skin smear.

Other signs of leprosy are:  Skin lesion(s) with a decrease or loss of sweating and/or hair growth;

Other signs of leprosy are:  Skin lesion(s) with a decrease or loss of sweating and/or hair growth;  Constant redness in the eyes from irritation and dryness;

Other signs of leprosy are:  Skin lesion(s) with a decrease or loss of sweating and/or hair growth;  Constant redness in the eyes from irritation and dryness;  Loss of eyebrows and eyelashes (madarosis);

Other signs of leprosy are:  Skin lesion(s) with a decrease or loss of sweating and/or hair growth;  Constant redness in the eyes from irritation and dryness;  Loss of eyebrows and eyelashes (madarosis);

Other signs of leprosy are:  Collapse of nose bridge;  Nasal congestion / obstruction and frequent nosebleed

Other signs of leprosy are:  Enlargement of the breast in males (gynecomastia);

Other signs of leprosy are:  Mobile or stiff clawing of fingers and toes

Other signs of leprosy are:  Chronic ulcers, usually in the sole of the foot, palm of the hands and fingers.

Diagnosis of leprosy is mainly based on clinical signs and symptoms. Diagnosis of leprosy is mainly based on clinical signs and symptoms. i

The development of complications can be effectively prevented through early detection, correct diagnosis and effective treatment. The development of complications can be effectively prevented through early detection, correct diagnosis and effective treatment. i

PATIENT’S HISTORY: The leprosy case history should have the following information: PATIENT’S HISTORY: The leprosy case history should have the following information: 1.The nature of the first lesion or symptom and its progress. This is because the skin lesion usually develops slowly over several months and is not troublesome.

When did the patient first notice the lesion? Ask: ? What was its appearance? How did it feel? Was it painful? Itchy? What was its appearance? How did it feel? Was it painful? Itchy?

PATIENT’S HISTORY: 2.Past Treatment. What did the patient do when he first noticed the lesion? Ask: ? Did he apply any drug(s)? What was the effect of this/these drug(s)? Did he apply any drug(s)? What was the effect of this/these drug(s)?

PATIENT’S HISTORY: 3.Other Illnesses. Pay attention to contra-indications to MDT drugs; or any other illness requiring special attention and/or referral.

Does the patient have a history of liver disease? Ask: ? Allergy to drugs? If yes, what drugs? Allergy to drugs? If yes, what drugs?

PATIENT’S HISTORY: 4.Contact with Persons With Leprosy (PWLs) This information will help determine the patient’s susceptibility to the disease.

Does/did anyone in the family have leprosy? Ask: ? Does he have a friend or acquaintance who has/had leprosy?

CLASSIFICATION: Leprosy can be classified on the basis of clinical manifestations and skin smear results. The Ridley-Jopling classification has seven (7) types of leprosy:

CLASSIFICATION: (Ridley-Jopling) 1.Indeterminate (I). Solitary, ill-defined, faintly hypopigmented macule, with partial loss of sensation.

CLASSIFICATION: (Ridley-Jopling) 1.Indeterminate (I) Solitary, ill-defined hypopigmented macule on left cheek; only partially anesthetic.

CLASSIFICATION: (Ridley-Jopling) Solitary, ill-defined, faintly hypopigmented macule on the dorsum of the wrist; minimal surface changes; partially insensitive. 1.Indeterminate (I)

CLASSIFICATION: (Ridley-Jopling) Single, slightly hypochromic macule with ill-define borders on the dorsum of the lower right forearm; minimal surface changes; partially anesthetic. 1.Indeterminate (I)

CLASSIFICATION: (Ridley-Jopling) 2.Tuberculoid (TT) Small, solitary marginally hypopigmented oval lesion, with papulated well-defined margins with flat, slightly atrophic central area insensitive to pain.

CLASSIFICATION: (Ridley-Jopling) Faintly hypochromic, rounded macule with discontinuously papulate borders, fairly defined, anesthetic, above smallpox vaccination scar on the left arm. 2.Tuberculoid (TT)

CLASSIFICATION: (Ridley-Jopling) Solitary, well-defined early tuberculoid lesion with slightly papulate borders; completely anesthetic. 2.Tuberculoid (TT)

CLASSIFICATION: (Ridley-Jopling) Sharp-edged, hypopigmented, ringworm-like lesion with finely papulate borders; anesthetic. 2.Tuberculoid (TT)

CLASSIFICATION: (Ridley-Jopling) Superficial, circinate lesion with pinkish, elevated, finely granular margins; center is insensitive to touch and pain. 2.Tuberculoid (TT)

CLASSIFICATION: (Ridley-Jopling) Well-defined, hypopigmented lesion with dry surface and moderately raised granular margins; completely anesthetic. 2.Tuberculoid (TT)

CLASSIFICATION: (Ridley-Jopling) 3.Borderline Tuberculoid (BT) Rounded lesion with wide, slightly brownish and scaly elevated margins fairly well- defined, center flat, with noticeable hair loss; at posterior aspect of the leg; anesthetic.

CLASSIFICATION: (Ridley-Jopling) One of several sharp- edged, erythematous patches on the patient, with fairly thick granular margins and small satellite lesions; anesthetic. 3.Borderline Tuberculoid (BT)

CLASSIFICATION: (Ridley-Jopling) Well-defined, dry and rough surfaced plaque on cheek, insensitive to touch and pain; note papulo-nodular lesions near eye and upper lip 3.Borderline Tuberculoid (BT)

CLASSIFICATION: (Ridley-Jopling) Distinct, erythemato- hypochromic patch with a dry surface and raised, well defined margins showing satellite lesions; anesthetic. 3.Borderline Tuberculoid (BT)

CLASSIFICATION: (Ridley-Jopling) Large patch with wide, raised erythematous well-defined margins sloping toward center of lesion; central portion is anesthetic. 3.Borderline Tuberculoid (BT)

CLASSIFICATION: (Ridley-Jopling) Multiple, sharply- demarcated, scaly reddish-brown plaques; these subsiding lesions are only partially anesthetic. 3.Borderline Tuberculoid (BT)

CLASSIFICATION: (Ridley-Jopling) Large, thickly infiltrated, sharp-edged plaque with slightly scaling surface; anesthetic. 3.Borderline Tuberculoid (BT)

CLASSIFICATION: (Ridley-Jopling) Extensive, subsiding lesions showing large, clear center areas surrounded by well- defined, slightly raised, inner and outer margins; centers are anesthetic. 3.Borderline Tuberculoid (BT)

CLASSIFICATION: (Ridley-Jopling) 4.Borderline (BB) Fairly extensive succulent plaque with sharply demarcated clear central area; peripheral edges sloping into surrounding normal skin; central uninvolved area anesthetic.

CLASSIFICATION: (Ridley-Jopling) Several “punched-out” lesions very characteristic of borderline leprosy; central areas are anesthetic. 4.Borderline (BB)

CLASSIFICATION: (Ridley-Jopling) Irregular, erythematous, infiltrated bands around a large, anesthetic central “immune” area; inner margins of lesion tend to be better defined than the outer margins. 4.Borderline (BB)

CLASSIFICATION: (Ridley-Jopling) Classical “punched-out” lesions of borderline leprosy; central “immune” areas are anesthetic. 4.Borderline (BB)

CLASSIFICATION: (Ridley-Jopling) 5.Borderline Lepromatous (BL) Numerous and widespread borderline- type plaques, annular lesions, papules and macules; center of large lesions show some loss of sensation.

CLASSIFICATION: (Ridley-Jopling) Thick, erythematous plaques on face and ears. Lesions are not sharply defined and show no sensory impairment. 5.Borderline Lepromatous (BL)

CLASSIFICATION: (Ridley-Jopling) 5.Borderline Lepromatous (BL) Bilaterally distributed, irregularly shaped, erythematous, infiltrated patches; these are not anesthetic.

CLASSIFICATION: (Ridley-Jopling) 5.Borderline Lepromatous (BL) Fairly uniform symmetrically distributed, infiltrated, maculo-papular lesions, none of which show sensory impairment.

CLASSIFICATION: (Ridley-Jopling) 6.Sub-polar Lepromatous (LLs) Symmetrically distributed infiltration with prominent macular lesions. Note borderline-type, punched-out patches on the wrist.

CLASSIFICATION: (Ridley-Jopling) 6.Sub-polar Lepromatous (LLs) Symmetrical infiltration and erythematous macules, with an unusual borderline-type plaque on the left buttock.

CLASSIFICATION: (Ridley-Jopling) 6.Sub-polar Lepromatous (LLs) Extensive, symmetrically distributed infiltration with almost coalescent macules and plaques. These lesions are not anesthetic. Note small rounded borderline-type plaque on the left lumbar area.

CLASSIFICATION: (Ridley-Jopling) 7.Polar Lepromatous (LLp) Early lepromatous leprosy with recognizable diffuse infiltration all over face and ears.

CLASSIFICATION: (Ridley-Jopling) Fairly advanced lepromatous leprosy, with symmetrically distributed diffuse infiltration, nodules on face and ears, and madarosis. 7.Polar Lepromatous (LLp)

CLASSIFICATION: (Ridley-Jopling) Advanced lepromatous leprosy, with marked diffuse infiltration, madarosis and loss of eyelashes. 7.Polar Lepromatous (LLp)

CLASSIFICATION: (Ridley-Jopling) Advanced lepromatous leprosy with diffuse infiltration coupled with nodules over eyebrows, cheeks, ala nasae and chin, as well as earlobes. 7.Polar Lepromatous (LLp)

CLASSIFICATION: (Ridley-Jopling) Advanced lepromatous leprosy with diffuse infiltration and nodular lesions. 7.Polar Lepromatous (LLp)

The World Health Organization (WHO) classifies leprosy into only three (3) types: Single Lesion Paucibacillary (SLPB) Paucibacillary (PB) Multibacillary (MB) Single Lesion Paucibacillary (SLPB) Paucibacillary (PB) Multibacillary (MB)

CLASSIFICATION: CharacteristicSLPBPBMB Lesions: TypeMaculeInfiltrated patches Macules, plaques, papules & infiltration

CLASSIFICATION: CharacteristicSLPBPBMB Lesions: NumberOne (1)Two (2) to five (5) More than five (>5)

CLASSIFICATION: CharacteristicSLPBPBMB Lesions: SurfaceNormal, dry or scaly Normal, dry or scaly, absence of hair growth Smooth & shiny, some lesions may be dry

CLASSIFICATION: CharacteristicSLPBPBMB Lesions: Borderill-defined to well-defined Well-defined, clear-cut margins Vague, sloping outwards, merges imperceptibly with surrounding skin

CLASSIFICATION: CharacteristicSLPBPBMB Nerve Involvement: NoneZero (0) to one (1) More than one (1)

CLASSIFICATION: CharacteristicSLPBPBMB Slit Skin Smear: Negative Positive NOTE: Positive skin smear = Multibacillary (MB) regimen.