The allocation of leprosy patients into paucibacillary and multibacillary groups for multidrug therapy, taking into account the number of body areas affected by skin, or skin and nerve lesions

In Nepal, the setting up and maintaining of reliable services for slit-skin smears has proven difficult. A clinical classification system for leprosy has therefore been developed to assist in the allocation of patients to either paucibacillary or multibacillary groups for the purpose of multiple drug therapy (MDT), using 9 body areas: head (1), arms (2), legs (2), trunk (4). Patients with more than two areas of the body affected are grouped as multibacillary (MB) and those with only one or two areas affected are paucibacillary (PB). Using a computer simulation model and the data of 53 patients registered at Green Pastures Hospital (GPH) in Pokhara and 703 field patients from the Western Region, different clinical classification systems were evaluated with regard to their sensitivity, specificity, and predictive value for MB or PB classification, as compared with the histological classification for the GPH cases and the bacteriological classification for the field patients. The sensitivity and specificity of the body area system in present use were 93% and 39%, respectively. The low specificity is due to MB overclassification. The sensitivity of the WHO classification system without skin smear facilities is 73% (the difference with the body area system is significant: p < 0.05, McNemar's test). Our histology findings confirm previous publications indicating that, while some borderline-tuberculoid (BT) patients may outwardly have a 'PB appearance' and be skin-smear negative, their nerve biopsy and sometimes skin biopsy may show a 'MB' picture. This is the first publication discussing a 'body area system' for the purpose described, including diagrams of the areas used. In Nepal it has proved easy to use and teach and its use may be justified in other control programmes which implement MDT, particularly if slit-skin smear services are unreliable or nonexistent.

Study of the characteristics and causes of relapse amongst leprosy cases in an urban area (Calcutta)

In this retrospective study of the 3737 cases of leprosy released from treatment and followed-up during 1975 to 1990, 63 had relapsed giving an overall relapse rate of 1.69%. The relapse rate was significantly higher in the immunologically unstable N?L (Borderline) cases (2.9%). It was also higher in those who had dapsone monotherapy (1.92%) compared to those who had multidrug therapy (1.01%). The relapse rate was higher in the 10 to 29 years age group and among those who became pregnant suggesting puberty and pregnancy could be risk factors. Males had a significantly higher relapse rate (2.1%) than females (1.1%). 45.2% of relapses in N (Non-lepromatous) cases occurred within 24 months and 71.4% within 36 months of stopping treatment. In those having monotherapy, 57.1% of relapses occurred within 24 months and 76.8% within 36 months. Regularity in treatment did not seem to have much influence on relapse rates.

[Leprosy. Developmental modalities]

The very broad clinical spectrum of the Mycobacterium leprae infection is due to the diversity of the underlying immunological and genetic factors. The evolutive modalities of leprosy are mainly determined by a dual pathogenesis: An infectious disease due to a bacillus of low virulence which, even when dead, persists in the body for several years, independently of the antibiotic therapy prescribed. A dysimmune disease maintained by a chronic discharge of antigens. Neuropathies and leprous reactions are still the most troublesome episodes in the course of the disease. They constitute the principal prognostic factor in both pauci- and multibacillary forms of leprosy.

Leprosy among university and high school students in Benin City, Nigeria. A eight years review

36 cases of leprosy were seen among University and High School students in the Skin Clinic of the University of Benin Teaching Hospital during an 8 years period (1982-1989). The male to female ratio was 2 to 1. Borderline tuberculoid and tuberculoid leprosy were the commonest form of presentation, seen in 66.6% of all cases. Borderline lepromatous and lepromatous leprosy were seen in 22% while indeterminate in 11% of cases. There has been a gradual reduction of new cases from a peak of about 8 cases in 1983 to one in 1989. Most patients complied with treatment and were able to continue their education with little or no hinderance.

Comparison of the old and new W.H.O. leprosy disability grading scheme for ocular disabilities

We compared the old (1970) and new (1988) World Health Organization schemes for classifying the ocular disabilities in leprosy patients. 509 leprosy patients from eight resettlement villages in central South Korea were examined and graded by eye according to both of the schemes. A more liberal definition of severely disabled in 1988 resulted in a 119% increase in eyes graded as severely disabled in this population. 59 eyes were graded as severely disabled by the old scheme and 129 eyes were so graded according to the new scheme. Keratitis, one of three measures of moderate disability in the old scheme, was replaced by corneal anaesthesia in the new scheme, but this change did not make a substantial difference in the number of patients in the moderately impaired category. In the absence of longitudinal studies documenting the significance of keratitis, it is unclear whether the change in an improvement. The new disability scheme improved upon the old by removing the criteria for mild impairment.

Leprosy in Bangladesh, 1984-88

A total of 2517 patients with leprosy were studied in Leprosy Control Institute and Hospital, Mohakhali, Dhaka, during the period 1984-1988. Among the total cases, 1891 (75.1%) were male and 626 (24.9%) were female. The male to female ratio was 3:1. The age groups comprised 185 (7.4%), below 15 years and 2332 (92.6%), 15 years and over. Most of the cases were diagnosed by clinical examination and classified as Indeterminate form (I), 52 (2.1%); tuberculoid form (T), 1326 (52.7%); borderline tuberculoid form (BT), 439 (17.4%); borderline lepromatous form (BL), 110 (4.4%); and lepromatous form (L), 590 (23.4%).

Allocation of patients to paucibacillary or multibacillary drug regimens for the treatment of leprosy--a comparison of methods based mainly on skin smears as opposed to clinical methods--alternative clinical methods for classification of patients

This paper reports on the experience with classification of patients at the All-Africa Leprosy and Rehabilitation Training Centre (ALERT) in the Shoa Province in Ethiopia. Classification on clinical grounds is compared with classification which is primarily based on the result of skin-smear examinations. In addition, possible alternative clinical methods for the allocation of patients to the multidrug therapy (MDT) regimens are discussed. The analysis includes 1525 new patients. In 730 patients classified clinically as paucibacillary (PB), this classification was not confirmed by skin-smear results in only 1.5%; whereas in 795 patients classified clinically as multibacillary (MB), the classification was not confirmed in 21.1%. Possible reasons, notably for the latter discrepancy, are discussed. Based on an assessment of the correctness of the diagnosis and the most probable classification, it was found that if classification had been based on the skin-smear results, 9.3% of the 795 patients classified as MB would have been classified incorrectly as PB. Classification based on clinical signs resulted in incorrect classification, MB instead of PB, of 8.7% of the 795 patients. Over-classification of MB patients, which was found to be supervisor related, is open to improvement by a strict application of clinical criteria for classification. The experience in the ALERT leprosy control program shows that classification which is based on clinical signs may, in particular, result in some PB patients being classified as MB, while classification based on the results of skin-smear examinations is more likely to result in some MB patients being classified as PB. It was concluded that, provided a number of requirements aimed at limiting the number of misclassified patients are introduced, patients can be classified based on clinical signs and, hence, in the absence of skin-smear services for routine classification purposes.

Disability index of hands and feet in patients attending an urban leprosy clinic

189 leprosy patients including 20 from a leprosy colony having disabilities and deformities were graded by the WHO (1960) classification and their disability indices were calculated. Disabilities occurred more frequently in males and the disability index was significantly higher in those with longer duration of the disease and in multibacillary patients. Majority of the disabled patients (82.5%) were manual workers, but the highest disability index was observed in beggars. Irregularly treated and untreated patients had significantly higher disability indices (DI 2.40 and DI 1.40) than those taking regular treatment (DI 1.09). No correlation was found between severity of disability and occurrence of type I and type II reactions. Disabilities of hands and feet occurred with equal frequency.

[Leprosy. Pathogenesis--classification--diagnosis--treatment]

Leprosy (hanseniasis) is caused by chronic infection with Mycobacterium leprae (M. leprae). The disease involves primarily the superficial peripheral nerves and the skin, but almost any organ can be affected. The clinical features vary and are determined by the host's immune response to the infection. A distinction is made between multibacillary and paucibacillary forms of leprosy. The multibacillary forms are lepromatous, borderline-lepromatous and borderline-borderline leprosy; the paucibacillary forms are tuberculoid and borderline-tuberculoid leprosy. The clinical features and the histological picture depend on the patient's immune response. Because effective chemotherapy has become available, leprosy can now be cured, and frightening disabilities are therefore preventable.

The response of human B cells to Mycobacterium leprae. Identification of target antigens following polyclonal activation in vitro

We have investigated the B cell response to Mycobacterium leprae in leprosy patients and healthy controls. A comparison of Western-blotted proteins separated by two-dimensional gel electrophoresis and probed with pooled sera from LL and BT patients revealed distinct antigen recognition patterns for the two classifications of the disease. To characterize the circulating B cells capable of producing anti-M. leprae antibodies in vitro, peripheral blood lymphocyte cultures were activated polyclonally with an anti-CD3 mAb. The resulting culture supernatants were used to probe Western-blotted M.leprae proteins and contained antibody reactive with a 10 kd M.leprae antigen. This antibody was absent in stimulated culture supernatants from healthy occupational contacts or unexposed controls, suggesting the specificity of the response. Distinct repertoires of serum and culture supernatant anti-M.leprae antibodies were observed when Western-blotted antigens were probed after two-dimensional gel electrophoresis. This method for assay of specific antibody production against individual components present in a complex mixture of antigens after polyclonal activation in vitro may be used to study the regulation of B cell activation in leprosy and other diseases.

Determination of different populations of blood lymphocytes in Brazilian patients with hanseniasis

The number of B and T lymphocytes were determined in the blood of 35 Brazilian patients with leprosy: 19 lepromatous (L), 9 borderline (B), 4 tuberculoid (T), and 3 indeterminate (I) and also in a control group of 30 normal individuals. The results, were as follows. B lymphocytes, no differences between the patients with hanseniasis and the control group; T lymphocytes, there was an evident depletion in the patients with L compared to the control group and patients with T; and the average of T lymphocytes in B and I was lower than that seen in the control group and in patients with T. Despite this alteration they approach to what is found in the patients with T and the control group.

[Difficulties in the use of the Ridley and Jopling classification--a morphological analysis]

There are many difficulties in the use of the Ridley & Jopling classification in daily practice. The author identified the morphologic parameters whose variations permit to distinguish the polar types and borderline groups according to Ridley. If we avoid the inconstant histologic alterations we believe that this distinction depends basically on the following parameters: epithelioid cell, granuloma of epithelioid cells, numbers of lymphocytes and number of bacilli. A critical analysis is performed of each of these parameters and the author concludes that they are scarce, and that there are great difficulties for the identification and interpretation of their variations for classification purposes. These difficulties are even more important during the reactional episodes.

Low intraocular pressure and postural changes in intraocular pressure in patients with Hansen's disease

We found intraocular pressures of less than 7 mm Hg in 11 of 72 patients (15%) with early Hansen's disease. Furthermore, significant postural changes in intraocular pressure (greater than 30%) occurred in 43 of 72 patients (60%). This loss of intraocular pressure homeostasis, which results from reduced aqueous humor production or increased uveoscleral outflow with reduced local adrenergic control in the ciliary body-iris-trabecular meshwork region, suggests that early autonomic neuropathy of the eye may occur in Hansen's disease. The only predictive value for significant postural change in intraocular pressure was the presence of immunologically unstable disease.

Testicular dysfunction in leprosy: relationships of FSH, LH and testosterone to disease classification, activity and duration

Luteinizing hormone (LH), follicle-stimulating hormone (FSH) and testosterone levels were determined by radioimmunoassay (RIA) in leprosy patients and analysed for effect of disease classification, disease activity and duration of disease. LH and FSH levels were found to be significantly elevated in lepromatous patients compared to borderline-lepromatous, midborderline and borderline-tuberculoid patients. A positive correlation was seen between LH and FSH and a negative correlation was seen between testosterone and both LH and FSH. No correlation was seen between hormone levels and measures of disease activity: bacillary index and IgM to phenolic glycolipid I, a Mycobacterium leprae antigen. A significant correlation was seen between duration of disease and FSH when age was taken into account, indicating that testicular dysfunction is probably cumulative and irreversible. It is recommended that LL patients be routinely screened for hypogonadism using FSH, LH and testosterone levels.

A study of palmo-plantar lesions in leprosy: a preliminary report

Out of 500 leprosy patients screened for palmar and/or plantar lesions, eighteen cases were detected. They were classified according to Ridley-Jopling classification. In majority of cases it was macular lesion. Cases were from TT, BT and BB group. In 50% cases, palmo-plantar involvement was associated with type I reaction. In 66.7% cases, it was extension of patch from surrounding area, 11.1% cases isolated lesions were seen and in 22.2% cases both extension as well as isolated lesions were present.