26th Kellersberger Memorial Lecture. Lessons from leprosy rehabilitation for general rehabilitation

Leprosy is primarily a disease of skin and peripheral nerves. Because of nerve function impairment, leprosy patients may develop primary nerve related impairments such as, loss of sensation and weakness or paralysis. These primary impairments may lead to secondary impairments such as ulceration and contractures. Many other diseases and disorders present with similar impairments as seen in leprosy e.g. diabetes and peripheral nerve injuries. Nerve function assessment and ulcer prevention and treatment are areas that have been researched in leprosy but these research findings are not yet commonly known and adopted in diseases and disorders that 'relate' to leprosy. Rehabilitation is a relatively new field in medicine and not (well) developed in many developing countries. Rehabilitation requires an integrated approach from different disciplines and professionals. As for other medical specialty fields, rehabilitation demands evidence based practice.

[Survey of newly diagnosed leprosy patients in Japan (1993-2000)]

We analyzed the medical and social problems of newly registered leprosy patients in the past 8 years from 1993 to 2000 in a low endemic country, Japan. There were 56 registered Japanese patients (males, 32; females, 24), and 76 registered foreign patients (males, 56; females, 20). The number of Japanese patients in each year was between 5 and 9, and 2/3 of them were from Okinawa Prefecture, located in subtropical zone. But the number of foreign patients in each year was between 5 and 18, and 2/5 of them were from Brazil. The number of foreign patients was greater than that of Japanese patients. Male/female ratio has decreased among the Japanese.

[Immunopathology of leprosy: the complexity of the mechanisms of host immune response to Mycobacterium leprae]

Leprosy, whose etiologic agent Mycobacterium leprae, is an illness of ample clinical and immunopathological spectrum. Its clinical manifestations are correlated with distinct immunologic forms, varying from a vigorous immune response mediated by cells to M. leprae, with Th1 standard in the tuberculoid polar region, to an absence of specific cellular response to antigens of M. leprae in the lepromatous polar region, with predominance of Th2 response and exacerbation of humoral response. It is probable that different polymorphic genes determine susceptibility to M. leprae. Additional studies are necessary to clarify the complex interactions between cytokines and the role of the phenotypic diversity of cells network that contribute to the host defense. The comprehension of such mechanisms will provide new insights for the identification of agonists and/or antagonists for pro- or anti-inflammatory effects, and also will indicate possible situations for its appropriate use in immunologic and/or immunotherapeutic interventions.

Healthy imaginations: a social history of the epidemiology of Aboriginal and Torres Strait Islander health

It is difficult to imagine Aboriginal and Torres Strait Islander health without the powerful descriptors of epidemiology. The statistical imagery of numerical tables, pie charts, and bar graphs have become a key element in the public presentation of Indigenous public health issues. Such quantitative measurements of health draw on the authority of neutral, objective science and are thus rarely questioned in terms of their social meaning. This paper traces the history of this imagery through the 20th century, providing a social account of epidemiological description. Historical notions such as social Darwinism, assimilation, and dangerous other are all seen to be woven into the epidemiological text. The enormous rise in the epidemiological description of Indigenous health problems in recent years needs to be analyzed as a social phenomenon and, in particular, as an aspect of emerging forms of governmentality. Finally, it is argued that such analyses are needed in order to promote an anthropology of epidemiology and to avoid limiting medical anthropology to applications within epidemiology.

Leprosy. Recognition and treatment

Leprosy is a slowly progressive, chronic infectious disease caused by the bacillus Mycobacterium leprae. It is a very serious, multilating and stigmatizing disease in many parts of the world and early diagnosis and therapy is the most important strategy for its control. The skin and peripheral nerves are the most affected organs. It is highly infective, but has low pathogenicity and low virulence with a long incubation period. The geographical distribution of leprosy has varied greatly with time and it is now endemic only in tropical and subtropical regions such as India and Brazil. The diagnosis of leprosy is made from the clinical picture, but must be complimented by skin bacilloscopy and histopathology. Leprosy has a number of distinct clinical presentations. Indeterminate leprosy is frequently the initial form consisting of a few lesions that either evolves into the other forms or resolves spontaneously. Lepromatous leprosy is the more contagious form and affects mainly the skin. In addition, some peripheral nerves may be thickened and other symptoms maybe present. The tuberculid form affects the skin and nerves, although usually there are few lesions. There is also a form borderline between the lepromatous and tuberculoid forms. Current treatment of leprosy involves use of 3 drugs: rifampicin (rifampin); clofazimine; and dapsone. Multidrug therapy aims to effectively eliminate M. leprae in the shortest possible time to prevent resistance from occurring. The duration of therapy was recently reduced from 24 to 12 months. Other treatment options are under evaluation in both preclinical and clinical trials and a number show promise. The combination of rifampicin, ofloxacin and minocycline given as a single dose has been recommended for the treatment of paucibacillar leprosy. Only when physicians, other health workers, and the population in endemic countries become fully aware of, and able to recognize, the disease in its initial phase, will it be possible for therapy to be instituted at the very beginning with either the standard scheme or the newer ones. Intervention at such an early stage will avoid the onset of the more serious signs and symptoms, meaning that leprosy will eventually become a less important public health problem. Therefore, efforts must be made to alert populations at risk and all health workers of the importance of an early diagnosis and treatment in leprosy infection.

Upward trend in the rate of detection of new cases of leprosy in the State of Bahia, Brazil

BACKGROUND

The worldwide fall in the rate of detection of new cases of leprosy has been partly attributed to the introduction of multidrug therapy and other improvements in control programs. However, the rate of detection of new cases has not decreased in Brazil.

METHODS

An analysis was made of the temporal distribution of 18,872 newly reported leprosy cases in Bahia, Brazil, from 1974 to 1997. Population denominators for the annual detection rate were obtained from population estimates based on the national census. Trends were presented by sex, date of birth, date of diagnosis, date of release, clinical form and by residence in areas which had notified cases in the 5 years prior to the rise in detection rate.

RESULTS

There was a marked increase in the new case detection rate (NCDR) in the State of Bahia, from 0.19 to 1.43 cases per 10,000 inhabitants during the study period, an increment of nearly 7% to 8% per year. This increase was also observed in people aged 14 years and younger. During this period tuberculoid and indeterminate forms have become predominant among women and younger people. The average age of male cases has shifted toward younger ages.

CONCLUSIONS

We interpret this pattern to mean that the increase in NCDR reflects a real increase in incidence of leprosy, whether or not accompanied by improved detection.

Association of NRAMP1 polymorphism with leprosy type but not susceptibility to leprosy per se in west Africans

Twin and family studies indicate that host genetic factors influence susceptibility to leprosy and, possibly, leprosy type. Murine studies have suggested a role for the natural resistance-associated macrophage protein 1 (Nramp1) gene, which can influence cellular immune responses to intracellular pathogens. We evaluated a variation in the human homolog, NRAMP1, recently associated with tuberculosis susceptibility in West Africa. A total of 273 patients with leprosy and 201 controls from Mali were genotyped for NRAMP1 polymorphisms previously associated with tuberculosis. No association was found with leprosy per se (P = 0.83), but the NRAMP1 3'-untranslated region 4-bp insertion/deletion polymorphism was associated with leprosy type (P = 0.007). Heterozygotes were more frequent among multibacillary than paucibacillary leprosy cases. Thus, variation in or near the NRAMP1 gene may exert an influence on the clinical presentation of leprosy, possibly by influencing cellular immune response type.

Correlation of clinical, histological and immunological features across the leprosy spectrum

The Ridley-Jopling system of classification of the variegated clinical pattern of leprosy is based on the specific cell-mediated immunity observed in the histopathology of skin lesions conforming to a spectrum from TT at one end to LL at the other. In this study a fairly large sample of 90 patients was classified on clinical grounds; the histopathology of the skin lesions was studied blind. There was an overall concordance of 90% between the clinical and histological classifications. In addition, the systemic cell-mediated and humoral immune responses were studied. The in vivo cell-mediated immune response, namely the Mitsuda skin response, mostly conformed to the clinical classification. While the in vitro lymphoproliferative responses to BCG and its sonicate were high, the lymphoproliferative responses to Dharmendra lepromin were surprisingly poor. Humoral responses to 35 kDA protein of M. leprae and PGL-1 were good in most LL, BL patients and tapered off towards TT. IgG antibodies to recombinant ML 65 kDa proteins denoted mycobacterial presence.

[Clinical leprosy in Japan]

The Leprosy Prevention Law was abolished at the end of March, 1996. Since medical insurance for leprosy started in April, 1996, dermatologists in clinics have to take care of leprosy patients. However, dermatologists have not learned enough about leprosy, and only a few of them are familiar with it. Japanese patients newly diagnosed with leprosy in Japan have decreasing, and patients who come from foreign countries to work in Japan have more important in leprosy control. Therefore, it is important to educate dermatologists about leprosy. Recently, diagnostic guides including information about network systems have become available in book stores. It is possible to obtain all kinds of information about leprosy from the network systems.

Evaluation of leprosy lesions by skin smear cytology in comparison to histopathology

Cytological evaluation of leprosy skin lesion was done to evaluate cytohistological correlation. Twenty five clinically suspected patients of leprosy were evaluated by performing fine needle aspiration (FNA) in nodular lesions and slit skin smear technique in flat lesions to classify across R-J scale. May-Grunwald-Giemsa (MGG) and Ziehl-Neelsen stain were employed on slit skin smears and fine needle aspiration material. Histopathological assessment of slides from same lesion was done. The overall diagnostic accuracy of fine needle aspiration was 76.1% and that of slit skin smear 50%. However, on adequate material diagnostic accuracy of slit skin smear was high, 100% as compared to 81.8% of fine needle aspiration smears. In cases of polar leprosy cytological findings paralleled histopathological diagnosis. Within the constraints of cytological interpretation the cases in borderline unstable spectrum of leprosy can be classified broadly.

Comparative study of anti-PGL-1, anti-35 kDa and anti-lipoarabinomannan assays for serodiagnosis of leprosy

Three antibody assays (anti-PGL-1, anti-35 kDa and anti-LAM) were used to determine the levels of antibodies in the sera of untreated leprosy patients. All the three assays showed higher levels of antibodies in BL/LL patients as compared to I and TT/BT patients, as well as healthy controls. BL/LL patients showed positivity of 100%, 84.2% and 78.9% by anti-PGL-1, anti-35 kDa and anti-LAM assays respectively. All the three assays were negative for leprosy in healthy controls. Anti-PGL-1 assay was positive in 20% of TT/BT patients and 17.9% of I patients. Anti-35 kDa assay was negative in all the TT/BT patients and positive in 7.14% of I patients. Anti-LAM assay was positive in 13.3% of TT/BT patients and in 10.7% of I patients. Hence, while these assays are valuable in diagnosing BL/LL patients, their usefulness in diagnosing I, BT or TT leprosy is limited.

Protein profile in leprosy

Serum proteins and plasma fibrinogen were estimated in 103 patients in various groups of leprosy and 52 patients of reactional leprosy. Total proteins, serum globulin and fibrinogen showed significant rise while serum albumin showed fall over the immunological spectrum from TT to LL. Type II reactional leprosy similarly revealed significant rise in globulin and fibrinogen. The comparison of these parameters between most of the comparable groups of leprosy was statistically significant. ENL patients after complete subsidence of reaction and after steroid treatment showed significant decrease in these protein fractions, thus conferring some prognostic implication on these tests.

Fine needle aspiration cytology (FNAC) of nerves in leprosy

Leprosy is primarily a disease of the peripheral nerves and a technique that is simpler than nerve biopsy is required to evaluate nerve involvement, especially in pure neuritic (PN) leprosy. This study was designed to evaluate the role of FNAC of the nerve in the diagnosis and classification of leprosy. A prospective study was carried out on 25 patients with clinically active leprosy and at least one thickened peripheral sensory nerve. Nerve aspirates were evaluated by May-Grunwald-Giemsa and Fite's staining. Lepromin test, slit skin smears (SSS), skin biopsies (except PN cases) and nerve biopsies were performed and compared with FNAC. FNAC of nerve from 23 cases (92%) yielded diagnostic aspirates. Acid fast bacilli were observed in six cases by FNAC. FNAC and nerve pathology were equally comparable with the other parameters evaluated. Based on the results, cytological criteria were developed for interpreting nerve aspirates and the cases were classified as paucibacillary (18), BB (2), BL (2), LL (1) and non-diagnostic (2). All PN cases showed diagnostic paucibacillary type cytology. FNAC of the nerve yields diagnostic aspirates in leprosy comparable with nerve pathology and the proposed cytological criteria may be useful in classification of nerve aspirates.

Effect of HIV infection on the clinical spectrum of leprosy in Maiduguri

The clinical features associated with different classes of leprosy patients co-infected with HIV in Maiduguri was studied and the classification of leprosy was done clinically and bacteriologically using Ridley-Jopling classification and bacteriological index respectively. The cases were classified as paucibacillary (Tuberculoid--TT and Borderline Tuberculoid--BTT) and multibacillary (Borderline Borderline--BB, Borderline Lepromatous BL and Lepromatous Leprosy--LL) leprosy. Eleven (10.5%) of 105 leprosy cases were HIV-seropositive comprising of 7 males and 4 females. Age range was 15 and 62 years. Among the HIV seropositive patients, those with paucibacillary (PB) leprosy were 6 (TT-1, BT-5) while multibacillary (MB) leprosy 5 (BB-1, BL-2, LL-2). The predominant clinical features were clawing of fingers (64%), ulcerations (64%), hand muscle atrophy (55%) and clawing of toes (45%). Some clinical features of paucibacillary leprosy such as sensory and hair losses (as is also seen in HIV negative patients) occurred in increased frequency in HIV positive patients belonging to the multibacillary class. The HIV infected leprosy patients are more likely to manifest advanced stages of the disease than the HIV seronegative patients.

Utility of fine-needle aspiration cytology in the classification of leprosy

The role of fine-needle aspiration cytology (FNAC) in the diagnosis of benign skin lesions has been restricted primarily to the evaluation of bacteriologic and morphologic indices in leprosy. This study was undertaken to evaluate the efficacy of FNAC in the diagnosis and classification of lepromatous lesions. Aspirates of 94 newly diagnosed cases of leprosy were studied, and the bacterial load was determined by modified Ziehl-Neelsen (ZN) stain. A skin biopsy was taken from the same site at the same sitting. Frozen and paraffin sections stained with hematoxylin-eosin (H&E) and ZN stains were examined from the biopsy specimen. In 61 of 94 cases (64.9%), the aspirates were satisfactory. Both diagnosis and classification of leprosy were possible in 40 of these 61 cases; the rest of the aspirates showed nonspecific chronic inflammation. The 39 cases of leprosy where a biopsy was available from the same site were classified on FNAC into tuberculoid (TT and BT), lepromatous (LL and BL), and midborderline (BB) subtypes. Taking the histologic diagnosis and Ridley-Jopling classification to be the gold standard, a strong concordance in tuberculoid leprosy cases (18 of 20 cases, 90%) and in lepromatous cases (15 of 16 cases, 93.7%) was observed. Midborderline cases of leprosy posed a problem, and a correct cytohistological correlation was observed in only one of the three cases.

Dipstick assay to identify leprosy patients who have an increased risk of relapse

Classification of leprosy patients into paucibacillary (PB) and multibacillary (MB) determines the duration of treatment; misclassification increases the risk of relapse because of insufficient treatment if an MB patient is classified as PB. We explored the possibility of using a simple dipstick assay based on the detection of antibodies to the Mycobacterium leprae-specific phenolic glycolipid-I (PGL-I) as a tool for classification of patients into PB and MB for treatment purposes. The sensitivity of the dipstick test for detection of MB patients was 85.1%, the specificity 77.7%. We found that of the 71 dipstick negative PB patients 25 (35.2%) were clinically cured at the end of treatment, compared with only two (9.5%) of the 21 dipstick positive PB patients. Of 170 patients in the study population, nine (5.3%) relapsed within the 5-year follow-up period. Seven were MB patients, all dipstick positive. Two PB patients relapsed, one was dipstick negative and one was dipstick positive. Dipstick positivity is a risk factor for the future development of relapses, especially in those groups of patients who had received a shorter-than-usual course of treatment and the dipstick can be used as an additional, simple tool for classification of patients and for identification of those patients who have an increased risk of relapse.

Clinico-histopathological concordance in leprosy

Histopathological examination of biopsies from 111 patients with clinically diagnosed leprosy was carried out in order to observe the clinico-histopathological correlation. Clinical diagnosis was based on Ridley and Jopling (R-J) classification and World Health Organization (WHO) classification. The concordance rate between the two clinical classifications was 73.8%. Sections were stained with haematoxylin and eosin (H&E) and Ziehl-Neelsen's (Z-N) stains. The histological classification was as per the R-J criteria. Skin biopsy showed evidence of leprosy in 104 cases (93.69%). Overall concordance was observed in 58.6% (R-J) and 85.6% (WHO classification). The kappa test, when applied, showed significant agreement between clinical and histopathological diagnosis (z=11.775; P<0.001). Individual subtypes showed variable concordance rates which were again higher using WHO classification. When some of the subtypes were combined, the concordance rate was 83.02% for TT+BT; 72.58% for BT+BB+BL; 73.91% for BL+LL; 80.77% for BL+HL and 100% for LL+HL. (See Introduction for definitions of abbreviations.) The present study highlights the importance of histopathological examination for exact subtyping of leprosy, so as to facilitate the institution of accurate mode of therapy and regular follow-up of patients to prevent undesirable complications.

The ALERT MDT Field Evaluation Study (AMFES): a descriptive study of leprosy in Ethiopia. Patients, methods and baseline characteristics

The ALERT MDT Field Evaluation Study (AMFES) is a long-term prospective study of 650 patients (594 new cases and 56 relapses after dapsone monotherapy), treated with fixed-duration multiple-drug therapy (MDT), as recommended by WHO. Follow-up has continued for up to 11 years from the start of treatment. This paper presents the methodology of the study and the baseline characteristics of the cohort, while accompanying papers examine the incidence of, and possible risk factors for, the various complications of leprosy, including relapse, reactions and nerve function impairment. The methods of diagnosis, classification and treatment with MDT are described; nerve function was assessed at every visit to the clinic using a standardized methodology, so that reactions and new impairment could be detected early and treated. Eighty-four per cent of new case had at least one thickened nerve, with the ulnar nerve most commonly involved. Seventy-seven per cent of cases completed treatment and only one adverse reaction to the MDT drugs was noted. Twenty-eight per cent of all patients were given steroids at one time or another, almost always for new nerve function impairment, and 3% of these developed significant complications of steroid treatment. Twenty-nine patients (5%) received hospital care, including 14 patients who underwent major surgery. Sixty-one per cent of the women over 19 years of age had at least one pregnancy, but pregnancies were much less common after leprosy was diagnosed.