Download clinical features of leprosy

LEPROSY
HANSEN’S DISEASE
DISCOVERED THE ORGANISM IN
1874
CHRONIC INFECTIOUS DISEASE
AFFECTING THE COOLER PARTS OF
THE BODY
LEPROSY
EXAMPLE
SKIN ,MOUTH,RESPIRATORY
TRACT,EYES,
PERIPHERAL NERVES,SUPERFICIAL
LYMPH NODES & TESTIS.
LEPROSY
BACTERAEMIA FROM ENDOTHELIAL
COLONISATION OR
BY BACILLI FILTERED FROM BLOOD BY
RE SYSTEM, OTHER ORGANS SUCH AS
LIVER,SPLEEN ,BONE MARROW &
REGIONAL LYMPH NODES ARE ALSO
INVOLVED
LEPROSY
CAUSATIVE ORGANISM
MYCOBACTERIUM LEPRAE
LESS ACID-FAST THAN M.TUBERCULOSIS
1. ZIEHL-NEELSEN STAINING –DECOLOURISED
BY 5% SULPHURIC ACID
2. FITE – FARACO STAINING
3.GOMORI METHENAMINE SILVER
SLIT SKIN SMEAR TECHNIQUE
GIVES QUANTITATIVE MEASURE OF
M.LEPRAE STAINED WITH ZIEHL NEELSEN
METHOD
EXAMINED UNDER 100 x - OIL IMMERSION
OBJECTIVE TO DETERMINE THE DENSITY OF
ORGANISM IN THE LESION
SLIT SMEAR TECHNIQUE
BACTERIAL INDEX –SCORED FROM 1+ TO 6
RANGE
FROM 1 TO 10 BACILLI PER 100 FIELDS TO
MORE THAN 1000 PER FIELD AS
MULTIBACILLARY LEPROSY
BI – 0 IS TERMED - PAUSI -BACILLARY
INCIDENCE OF LEPROSY
ENDEMIC IN AREAS WITH HOT & MOIST
CLIMATES & IN POOR TROPICAL COUNTRIES
FIVE COUNTRIESINDIA,BRAZIL,INDONESIA,MYANMAR
& NIGERIA VAST MAJORITY OF CASES
INDIA –ONE THIRD OF ALL REGISTERED CASES
INCIDENCE OF LEPROSY
INCIDENCE OF LEPROSY
INCIDENCE OF LEPROSY
IN INDIA –
TAMILNADU,BIHAR,PONDICHERRY,AND
ANDHRA PRADESH,ORISSA ,WEST
BENGAL & ASSAM
MODE OF TRANSMISSION
SLOW COMMUNICABLE DISEASE
THE INCUBATION PERIOD BETWEEN FIRST
EXPOSURE & APPEARANCE OF SIGNS &
SYMPTOMS OF DISEASE VARIES FROM 2 –
20 YEARS
MODE OF TRANSMISSION
1.DIRECT CONTACT
2. MATERNOFETAL TRANSMISSION
3.MOTHER’S MILK
CLASSIFICATION OF
LEPROSY(RIDLEY JOPLING’S)
SEVEN GROUPS
TT –TUBERCULOID POLAR(HIGH RESISTANCE)
BT- BORDERLINE TUBERCULOID
TI – TUBERCULOID INDEFINITE
BB –MID BORDERLINE
LI- LEPROMATOUS INDEFINITE
CLASSIFICATION OF
LEPROSY(RIDLEY JOPLING’S)
BL - BORDERLINE LEPROMATOUS
LL- LEPROMATOUS POLAR
CLINICAL FEATURES OF LEPROSY
2 MAIN FORMS SHOW DISTINCTIVE FEATURES
1.LEPROMATOUS LEPROSY – SKIN LESIONS
ARE SYMMETRIC ,MULTIPLE ,SLIGHTLY
HYPOPIGMENTED,ERYTHEMATOUS
MACULES,PAPULES,NODULES
LEPROMATOUS LEPROSY
CLINICAL FEATURES OF LEPROSY
NODULAR LESIONS MAY COALESCE TO GIVE A
LEONINE FACIES APPEARANCE
LESIONS ARE HYPOAESTHETIC OR
ANAESTHETIC
BUT SENSORY DISTERBANCE IS NOT
DISTINCT AS IN TUBERCULOID LEPROSY
CLINICAL FEATURES OF LEPROSY
TUBERCULOID LEPROSY
SINGLE OR FEW ASYMMETRIC LESIONS
& ARE HYPOPIGMENTED &
ERYTHEMATOUS MACULES
THERE IS DISTINCT SENSORY
IMPAIRMENT
TUBERCULOID LEPROSY
HISTOPATHOLOGY OF LEPROSY
GUIDELINES
1. CELL TYPE GRANULOMA
2. NERVE INVOLVEMENT
3. BACTERIAL LOAD
HISTOPATHOLOGY OF LEPROSY
LEPROMATOUS LEPROSY
LEPROMATOUS LEPROSY
DERMIS – PROLIFERATION OF
MACROPHAGES WITH FOAMY
CYTOPLASM,SEEN AROUND THE BLOOD
VESSELS,NERVES &DERMAL APPENDAGES
HISTOPATHOLOGY OF LEPROSY
LEPROMATOUS LEPROSY
AFB STAIN – BACILLI IN GLOBULAR MASSES
OR IN PARALLEL FASHION LIKE CIGARETTES
IN PACK IN THE FOAMY MACROPHAGES
(LEPRA CELLS OR VIRCHOW CELLS)
AFB STAIN
HISTOPATHOLOGY OF LEPROSY
LEPROMATOUS LEPROSY
CLEAR ZONE BETWEEN THE
EPIDERMIS & THE INFILTRATE IN THE
DERMIS
EPIDERMIS OVERLYING THE
LESIONS IS THINNED OUT ,MAY
EVEN ULCERATE
TUBERCULOID LEPROSY
TUBERCULOID LEPROSY
HISTOPATHOLOGY OF LEPROSY
TUBERCULOID LEPROSY
POLAR TUBERCULOID FORM
TUBERCLES COMPOSED OF EPITHELOID
CELLS,LANGHANS TYPE OF GIANT CELLS
&PERIPHERAL MANTLE OF
LYMPHOCYTES
HISTOPATHOLOGY OF LEPROSY
TUBERCULOID LEPROSY
INFILTRATE HAS PREDILECTION FOR
DERMAL NERVES WITH GRANULOMAS &
DESTRUCTION OF NERVES
NO CLEAR ZONE
3. BORDERLINE LEPROSY
1.BORDERLINE TUBERCULOID(BT)
EPITHELOID CELLS, PLENTY OF LYMPHOCYTES
NARROW CLEAR ZONE
BACILLI ARE FEW & ARE FOUND IN NERVES
3. BORDERLINE LEPROSY
2. BORDERLINE LEPROMATOUS
PREDOMINANCE OF HISTIOCYTES,FEW
EPITHELOID CELLS.SOME IRREGULARLY
DISPERSED LYMPHOCYTES
NUMEROUS LEPRA BACILLI ARE SEEN
3. BORDERLINE LEPROSY
3. MID BORDERLINE(BB)
EPITHELOID CELLS
NO GIANT CELLS
SOME LYMPHOCYTES IN THE PERINEURIUM
LEPRA BACILLI IN THE NERVES
4.INDETERMINATE LEPROSY
NONSPECIFIC CHRONIC DERMATITIS LIKE
BUT FOLLOWING FEATURES HELP IN
DIAGNOSIS
a. LYMPHOCTIC OR MONONUCLEAR CELL
INFILTRATE AROUND SKIN ADNEXAL
STRUCTURES LIKE HAIR FOLLICLES
4.INDETERMINATE LEPROSY
b.NERVE INVOLVEMENT
c. AFB STAIN
REACTIONS IN LEPROSY
2 TYPES
1.TYPE 1 – BORDERLINE REACTIONS
2.TYPE II – ERYTHEMA NODOSUM
LEPROSUM
TYPE I REACTION
POLAR FORMS OF LEPROSY DO NOT
UNDERGO CHANGE IN CLINICAL OR
HISTOPATHOLOGICAL PICTURE
TYPE I REACTION
OCCURS IN PATIENT’S WITH
BORDERLINE
LEPROMATOUS LEPROSY(BL) ON
TREATMENT.
UPGRADE OR SHIFT TOWARDS
TUBERCULOID TYPE
TYPE I REACTION
THE BORDERLINE GROUPS ARE UNSTABLE
& MAY MOVE ACROSS THE SPECTRUM IN
EITHER DIRECTIONS WITH UPGRADING &
DOWNGRADING OF PATIENT’S IMMUNE
STATUS
TYPE I REACTION
UPGRADING REACTION
ACCORDINGLY THERE MAY BE 2 TYPES OF
BORDERLINE REACTIONS
1. UPGRADING REACTION – CHARACTERISED
BY INCREASED CELL MEDIATED
IMMUNITY
TYPE I REACTION
UPGRADING REACTION
HISTOLOGY - INCREASE OF LYMPHOCYTES
OEDEMA
REDUCED BACTERIAL INDEX
TYPE I REACTION
DOWNGRADING TYPE
2 .DOWNGRADING REACTION
CHARACTERISED BY LOWERING
OF CELLULAR IMMUNITY
TYPE I REACTION
DOWNGRADING TYPE
SEEN IN BORDERLINE TUBERCULOID TYPE
DOWNGRADE OR SHIFT TOWARDS
LEPROMATOUS TYPE
HISTOLOGY –DISPERSAL OF GRANULOMAS
INCREASED NUMBER OF LEPRA CELLS
TYPE II REACTION –ERYTHEMA
NODOSUM LEPROSUM
OCCURS IN LEPROMATOUS PATIENTS AFTER
TREATMENT
CHARACTERISED BY TENDER CUTANEOUS
NODULES ,FEVER,IRIDOCYCLITIS,SYNOVITIS &
LYMPH NODE INVOLVEMENT
TYPE II REACTION –ERYTHEMA
NODOSUM LEPROSUM
HISTOLOGY - INFILTRATION BY
NEUTROPHILS & PROMINENCE OF
VASCULITIS
SECONDARY AMYLOIDOSIS MAY FOLLOW
REPEATED ATTACKS
IMMUNOLOGY OF LEPROSY
LEPROMIN TEST –INTRADERMAL
INJECTION OF LEPROMIN , AN
ANTIGENIC EXTRACT OF M.LEPRAE.
NOT A DIAGNOSTIC TEST
BUT USED FOR CLASSIFYING LEPROSY
ON THE BASIS OF IMMUNE RESPONSE
IMMUNOLOGY OF LEPROSY
M.LEPRAE REVEALS DELAYED
HYPERSENSITIVITY REACTION (BY
T HELPER CELLS) IN PATIENT’S WITH
TUBERCULOID LEPROSY
IMMUNOLOGY OF LEPROSY
1.FERNANDEZ REACTION –EARLY
POSITIVE REACTIONAS AN INDURATED AREA IN 24- 48
HOURS
IMMUNOLOGY OF LEPROSY
2.MITSUDA REACTION - A DELAYED
GRANULOMATOUS LESION AFTER 3 – 4
WEEKS
PATIENTS OF LEPROMATOUS LEPROSY ARE
NEGATIVE BY THE LEPROMIN TEST
IMMUNOLOGY OF LEPROSY
LL LACK T HELPER CELLS
BUT LL HAVE HIGH LEVELS OF
IMMUNOGLOBULINS LIKE IgG,IgA,IgM
&
ANTIBODIES TO MYCOBACTERIAL
ANTIGENS