The clinical and immunological features of leprosy

The PEP++ study protocol: a cluster-randomised controlled trial on the effectiveness of an enhanced regimen of post-exposure prophylaxis for close contacts of persons affected by leprosy to prevent disease transmission

BACKGROUND

Leprosy is an infectious disease with a slow decline in global annual caseload in the past two decades. Active case finding and post-exposure prophylaxis (PEP) with a single dose of rifampicin (SDR) are recommended by the World Health Organization as measures for leprosy elimination. However, more potent PEP regimens are needed to increase the effect in groups highest at risk (i.e., household members and blood relatives, especially of multibacillary patients). The PEP++ trial will assess the effectiveness of an enhanced preventive regimen against leprosy in high-endemic districts in India, Brazil, Bangladesh, and Nepal compared with SDR-PEP.

METHODS

The PEP++ study is a cluster-randomised controlled trial in selected districts of India, Brazil, Bangladesh, and Nepal. Sub-districts will be allocated randomly to the intervention and control arms. Leprosy patients detected from 2015 - 22 living in the districts will be approached to list their close contacts for enrolment in the study. All consenting participants will be screened for signs and symptoms of leprosy and tuberculosis (TB). In the intervention arm, eligible contacts receive the enhanced PEP++ regimen with three doses of rifampicin (150 - 600 mg) and clarithromycin (150 - 500 mg) administered at four-weekly intervals, whereas those in the control arm receive SDR-PEP. Follow-up screening for leprosy will be done for each individual two years after the final dose is administered. Cox' proportion hazards analysis and Poisson regression will be used to compare the incidence rate ratios between the intervention and control areas as the primary study outcome.

DISCUSSION

Past studies have shown that the level of SDR-PEP effectiveness is not uniform across contexts or in relation to leprosy patients. To address this, a number of recent trials are seeking to strengthen PEP regimens either through the use of new medications or by increasing the dosage of the existing ones. However, few studies focus on the impact of multiple doses of chemoprophylaxis using a combination of antibiotics. The PEP++ trial will investigate effectiveness of both an enhanced regimen and use geospatial analysis for PEP administration in the study communities.

TRIAL REGISTRATION

NL7022 on the Dutch Trial Register on April 12, 2018. Protocol version 9.0 updated on 18 August 2022 https://www.onderzoekmetmensen.nl/en/trial/23060.

Critical observation of WHO recommended multidrug therapy on the disease leprosy through mathematical study

Leprosy is a skin disease and it is characterized by a disorder of the peripheral nervous system which occurs due to the infection of Schwann cells. In this research article, we have formulated a four-dimensional ODE-based mathematical model which consists of the densities of healthy Schwann cells, infected Schwann cells, M. leprae bacteria, and the concentration of multidrug therapy (MDT). This work primarily aims on exploring the dynamical changes and interrelations of the system cell populations during the disease progression. Also, evaluating a critical value of the drug efficacy rate of MDT remains our key focus in this article so that a safe drug dose regimen for leprosy can be framed more effectively and realistically. We have examined the stability scenario of different equilibria and the occurrence of Hopf-bifurcation for the densities of our system cell populations with respect to the drug efficacy rate of MDT to gain insight on the precise impact of the efficiency rate on both the infected Schwann cell and the bacterial populations. Also, a necessary transversality condition for the occurrence of the bifurcation has been established. Our analytical and numerical investigations in this research work precisely explores that the process of demyelination, nerve regeneration, and infection of the healthy Schwann cells are the three most crucial factors in the leprosy pathogenesis and to control the M. leprae-induced infection of Schwann cells successfully, a more flexible version of MDT regime with efficacy rate varying in the range η∈(0.025,0.059) for 100-120 days in PB cases and 300 days in MB cases obtained in this research article should be applied. All of our analytical outcomes have been verified through numerical simulations and compared with some existing clinical findings.

A Case of Borderline Tuberculoid Leprosy With Type One Lepra Reaction

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, which primarily affects the skin and peripheral nerves. The variants that can be identified include tuberculoid (TT), borderline tuberculoid (BT), mid-borderline (BB), borderline lepromatous (BL), and lepromatous forms (LL). Type one lepra reactions are delayed hypersensitivity reactions that are often observed in borderline variants due to an unstable immunological response. They can exacerbate skin lesions and neuritis, leading to a higher risk of disabilities and deformities. Early detection and management would play a major role in limiting morbidity. Here, we present a case of a 46-year-old male diagnosed with borderline tuberculoid leprosy on multidrug therapy who developed features suggestive of type one lepra reaction. Early recognition of this entity helps in mitigating the risk of permanent nerve damage, disability, deformity, and morbidity.

Leprosy rash precipitated by immunotherapy for suspected inflammatory neuropathy

Leprosy is a chronic granulomatous infection caused by Mycobacterium leprae complex, causing skin and nerve lesions with potential for permanent disability. Leprosy can be overlooked in Western settings, as it is more prevalent in low-income and middle-income countries. We describe a 38-year-old woman with a 4-year history of progressive numbness of the left hand incorrectly diagnosed as multifocal acquired demyelinating sensory and motor neuropathy on the basis of clinical and neurophysiological findings. Treatment with empirical weekly corticosteroid followed by intravenous immunoglobulin resulted in the sudden development of a widespread rash; we then diagnosed borderline lepromatous leprosy on skin biopsy. We postulate that the immune treatments induced a temporary state of immune tolerance followed by a rebound of a T cell-mediated immune response resulting in a type 1 immunological response.

Identifying clusters of leprosy patients in India: A comparison of methods

BACKGROUND

Preventive interventions with post-exposure prophylaxis (PEP) are needed in leprosy high-endemic areas to interrupt the transmission of Mycobacterium leprae. Program managers intend to use Geographic Information Systems (GIS) to target preventive interventions considering efficient use of public health resources. Statistical GIS analyses are commonly used to identify clusters of disease without accounting for the local context. Therefore, we propose a contextualized spatial approach that includes expert consultation to identify clusters and compare it with a standard statistical approach.

METHODOLOGY/PRINCIPAL FINDINGS

We included all leprosy patients registered from 2014 to 2020 at the Health Centers in Fatehpur and Chandauli districts, Uttar Pradesh State, India (n = 3,855). Our contextualized spatial approach included expert consultation determining criteria and definition for the identification of clusters using Density Based Spatial Clustering Algorithm with Noise, followed by creating cluster maps considering natural boundaries and the local context. We compared this approach with the commonly used Anselin Local Moran's I statistic to identify high-risk villages. In the contextualized approach, 374 clusters were identified in Chandauli and 512 in Fatehpur. In total, 75% and 57% of all cases were captured by the identified clusters in Chandauli and Fatehpur, respectively. If 100 individuals per case were targeted for PEP, 33% and 11% of the total cluster population would receive PEP, respectively. In the statistical approach, more clusters in Chandauli and fewer clusters in Fatehpur (508 and 193) and lower proportions of cases in clusters (66% and 43%) were identified, and lower proportions of population targeted for PEP was calculated compared to the contextualized approach (11% and 11%).

CONCLUSION

A contextualized spatial approach could identify clusters in high-endemic districts more precisely than a standard statistical approach. Therefore, it can be a useful alternative to detect preventive intervention targets in high-endemic areas.

Pathogenicity and virulence of Mycobacterium leprae

Leprosy is caused by Mycobacterium leprae (M. leprae) and M. lepromatosis, an obligate intracellular organism, and over 200,000 new cases occur every year. M. leprae parasitizes histiocytes (skin macrophages) and Schwann cells in the peripheral nerves. Although leprosy can be treated by multidrug therapy, some patients relapse or have a prolonged clinical course and/or experience leprosy reaction. These varying outcomes depend on host factors such as immune responses against bacterial components that determine a range of symptoms. To understand these host responses, knowledge of the mechanisms by which M. leprae parasitizes host cells is important. This article describes the characteristics of leprosy through bacteriology, genetics, epidemiology, immunology, animal models, routes of infection, and clinical findings. It also discusses recent diagnostic methods, treatment, and measures according to the World Health Organization (WHO), including prevention. Recently, the antibacterial activities of anti-hyperlipidaemia agents against other pathogens, such as M. tuberculosis and Staphylococcus aureus have been investigated. Our laboratory has been focused on the metabolism of lipids which constitute the cell wall of M. leprae. Our findings may be useful for the development of future treatments.

Creating communities of care: Sex estimation and mobility histories of adolescents buried in the cemetery of St. Mary Magdalen leprosarium (Winchester, England)

Objectives

This study examines the biological sex and geographical origins of adolescents buried at the St Mary Magdalen leprosarium (Winchester, UK). The data are combined with archaeological and palaeopathological evidence to broaden the understanding of mobility and its relationship to leprosy and leprosaria in Medieval England.

Materials and Methods

Nineteen individuals (~10–25 at death) with skeletal lesions diagnostic of leprosy were analyzed using standard osteological methods. Amelogenin peptides were extracted from five individuals whose biological sex could not be assessed from macroscopic methods. Enamel samples were analyzed to produce ⁸⁷Sr/⁸⁶Sr and δ¹⁸O values to explore mobility histories.

Results

Amelogenin peptides revealed three males and two females. Tooth enamel samples provided an ⁸⁷Sr/⁸⁶Sr ratio range from 0.7084 to 0.7103 (mean 0.7090, ±0.0012, 2σ). δ¹⁸O_P values show a wide range of 15.6‰–19.3‰ (mean 17.8 ± 1.6‰ 2σ), with corresponding δ¹⁸O_DW values ranging from −9.7‰ to −4.1‰ (mean −6.3 ± 2.4‰ 2σ).

Discussion

Amelogenin peptide data reveal the presence of adolescent females with bone changes of leprosy, making them the youngest confirmed females with leprosy in the archaeological record. Results also show at least 12 adolescents were local, and seven were from further afield, including outside Britain. Since St. Mary Magdalen was a leprosarium, it is possible that these people traveled there specifically for care. Archaeological and palaeopathological data support the notion that care was provided at this facility and that leprosy stigma, as we understand it today, may not have existed in this time and place.

Immunoassay standardization for the detection of immunoglobulin A (IgA) against Porphyromonas gingivalis antigens in saliva of individuals with and without leprosy

Leprosy reactions are immune processes that cause neural damage in individuals with leprosy. As periodontitis is an infectious disease related to its development, specific antibodies to periodontal pathogens must be evaluated to better understand the humoral mechanisms underlying this relationship. Therefore, the objective of this study was to standardize an immunoassay to measure IgA specific to P. gingivalis antigens in the saliva of individuals with leprosy. An ELISA checkerboard titration was performed. A validation test involving 53 individuals with leprosy, 24 with and 19 without periodontitis, was conducted and a ROC curve constructed to calculate sensitivity and specificity. The coefficient of the optical densities was 2.21 and 2.66 for P. gingivalis crude extract and the recombinant protein HmuY, respectively. Sensitivity and specificity for the P. gingivalis crude extract were 66.7% and 73.7%, respectively, and for HmuY, were 62.5% and 52.6%, respectively. Specific recognition of P. gingivalis occurred predominantly in individuals with periodontitis, which validates the use of this test for studying periodontitis in individuals with leprosy.

Trial registration CAEE 64476117.3.0000.0049, 21/07/2017, retrospectively registered

Mycobacterium leprae Infection in Ticks and Tick-Derived Cells

Leprosy is a zoonosis in the southern United States involving humans and wild armadillos. The majority of patients presenting with zoonotic strains of Mycobacterium leprae note extensive outdoor activity but only rarely report any history of direct contact with wild armadillos. Whether M. leprae is transmitted to new vertebrate hosts through the environment independently or with the aid of other organisms, e.g., arthropod vectors, is a fundamental question in leprosy transmission. The objectives of this study were to assess the potential for ticks to transmit M. leprae and to test if viable M. leprae can be maintained in tick-derived cells. To evaluate tick transmission, nymphal Amblyomma maculatum ticks were injected with isolated M. leprae. Infection and transmission were assessed by qPCR. Ticks infected as nymphs harbored M. leprae through vertical transmission events (nymph to adult and adult to progeny); and, horizontal transmission of M. leprae to a vertebrate host was observed. Mycobacterium leprae DNA was detected in multiple tick life cycle stages. Likewise, freshly isolated M. leprae (Thai-53) was used to infect a tick-derived cell line, and enumeration and bacterial viability were assessed at individual time points for up to 49 days. Evaluations of the viability of long-term cultured M. leprae (Thai-53 and Br4923) were also assessed in a mouse model. Tick-derived cells were able to maintain viable M. leprae over the 49-day course of infection and M. leprae remained infectious within tick cells for at least 300 days. The results of this study suggest that ticks themselves might serve as a vector for the transmission of M. leprae and that tick cells are suitable for maintenance of viable M. leprae for an extended period of time.

The state of the leprosy epidemic in Yunnan, China 2011-2020: A spatial and spatiotemporal analysis, highlighting areas for intervention

BACKGROUND

Despite public health efforts to reduce the leprosy burden in Yunnan, China, leprosy remains an important public health problem in some specific areas. We analyzed the epidemiological characteristics and spatial distribution of leprosy in Yunnan, China, and provide data to guide disease prevention and control efforts.

METHODOLOGY/PRINCIPAL FINDINGS

The surveillance data of newly detected leprosy cases in Yunnan, China, during 2011-2020 were extracted from the LEPROSY MANAGEMANT INFORMATION SYSTEM IN CHINA (LEPMIS), and spatial distribution analysis, spatial autocorrelation analysis, and spatiotemporal scanning were performed with ArcGIS 10.6.1, GeoDa 1.8.8, and SaTScan 9.4.3 software, respectively. A total of 1907 newly detected leprosy cases were reported in Yunnan, China, during 2011-2020. The new case detection rate (NCDR) decreased from 0.62 in 2011 to 0.25 in 2020, with an annual incidence of 0.41/100,000 population. The proportions of multibacillary (MB) cases, cases in female patients, cases causing grade 2 physical disability (G2D), and cases in pediatric patients were 67.07%, 33.93%, 17.99%, and 2.83%, respectively. The number of counties with an incidence above 1/100,000 population decreased from 30 in 2011 to 8 in 2020. The Moran's I of leprosy in Yunnan, China, during 2011-2020 ranged from 0.076 to 0.260, indicating the presence of spatial clusters. Local spatial autocorrelation (LSA) analysis showed that high-high cluster areas (hot spots) were mainly distributed in the southeastern, northern, and northwestern regions. Spatiotemporal scanning showed three clusters with high NCDRs. The probably primary clusters, occurring during January 1, 2011-December 31, 2015, covered 11 counties in the southeastern region (RR = 5.046515, LRR = 271.749664, P = 0.000).

CONCLUSION

The number of leprosy cases in Yunnan decreased overall, although some high-NCDR regions remained. Geographic information system (GIS) analysis coupled with spatial analysis indicated regions with leprosy clusters. Continuous leprosy prevention and control strategies in Yunnan Province should be established, and interventions in high-risk regions should be prioritized and further strengthened.

Epitope mapping from Mycobacterium leprae proteins: Convergent data from in silico and in vitro approaches for serodiagnosis of leprosy

Knowledge of immunodominant B-cell epitopes is essential to design powerful diagnostic strategies aiming for antibody detection. Outstanding progress in computational prediction has achieved a significant contribution to the biomedical fields, including immunodiagnosis. In silico analysis may have an even more important role when information concerning antigens from etiologic agents of neglected diseases, such as leprosy, is scarce. The aim of this study was to provide mapping of B-cell epitopes from two Mycobacterium leprae-derived antigens (Ag85B and ML2055), confirm their antigenicity, and to assess the ability of in silico immunoinformatics tools to accurately predict them. Linear B-cell epitopes predicted by ABCpred and SVMTrip servers were compared to antigenic regions of synthetic overlapping peptides that exhibited reactivity to antibodies from patients with leprosy. Our in vitro results identified several immunodominant regions that had also been indicated by in silico prediction, providing agreement between experimental and simulated data. After chemical synthesis, we used enzyme-linked immunosorbent assays to determine the effectiveness of the first identified sequence (GTNVPAEFLENFVHG) which had 72 % sensitivity and 78 % specificity (AUC = 0.79) while the second one (PVSSEAQPGDPNAPS) had 72 % sensitivity and 93.8 % specificity (AUC = 0.85). Using dot blotting, an easy-to-read visual test, both peptides could distinguish sera from patients with leprosy from those with tuberculosis and from sera of healthy volunteers. Our findings suggest that these synthetic peptides, with some refinement, may be useful as serological diagnostic antigens for leprosy. In addition, it was displayed that immunoinformatics provides reliable information for mapping potential B-cell epitopes for development of peptide-based diagnostic assays for neglected diseases.

Bacille calmette-guérin: An ophthalmic perspective

Vaccines such as bacille Calmette-Guérin (BCG) are known for their heterologous effects mediated through a number of mechanisms, including trained immunity constituted by monocyte-macrophage based innate immunity. Other events such as direct hematogenous spread and induction of autoimmunity are also described. There has been a resurgent interest in harnessing some of the benefits of trained immunity in the management of COVID-19, even as several specific vaccines have been approved. We summarize the current knowledge of ocular effects of BCG. Potential effect of granulomatous inflammation on angiotensin converting enzyme activity and accentuation of cytokine storm that may result in undesirable ocular and systemic effects are also discussed.

Persistent Infection Versus Type 2 Immunological Reaction in Lepromatous Leprosy

The distinction between persistent infection and immunologic reactions in leprosy is often difficult but critically important since their management is different. We present the case of a 51-year-old Vietnamese female who presented in 2015 with areas of erythema and skin infiltration on face and chest, as well as edema on her hands and feet. Skin biopsy was consistent with lepromatous leprosy. She was treated with rifampin, clarithromycin, and levofloxacin for 2 years. Her lower extremity edema was attributed to type 2 immunological reaction for which she was started on prednisone and methotrexate, but she was lost to follow-up for 19 months. She presented with new skin lesions and pain on her extremities. New biopsies revealed an intense neutrophilic infiltrate in the dermis and acid-fast bacilli focally within cutaneous nerve twigs. As compared with the initial biopsy, the inflammatory infiltrates were diminished and the bacilli had a degenerating appearance. These findings were consistent with type 2 immunological reaction. The patient was treated with thalidomide with improvement in the appearance of the skin lesions. A follow-up biopsy showed lack of neutrophilic infiltrates and decreased number of bacilli. This case illustrates the importance of differentiating between persistent infection and immunologic reactions in leprosy. Clinicians should be aware of these complications. A high index of suspicion and accurate interpretation of skin biopsy results are essential for appropriate diagnosis.

Role of shear wave elastography in treatment follow-up of leprosy neuropathy

PURPOSE

Grayscale ultrasonography when complemented with shear wave elastography helps in better evaluation of treatment response of leprosy neuropathy and in guiding appropriate management of the patient. There is limited literature regarding the use of shear wave elastography in ulnar nerve neuropathy. Our purpose was to evaluate the role of shear wave elastography in assessing stiffness changes within the ulnar nerve during treatment of leprosy.

METHODS

This was a prospective study which included 30 patients diagnosed with leprosy neuropathy. Recruited patients were followed up, during the course of treatment, i.e. for 1 year. Serial ultrasonography of these patients was done at 0, 3, 6 and 12 months interval.

RESULTS

Significant (P < 0.05) decrease in elastography parameters was seen in transverse imaging plane between first and third, as well as first and fourth visits (mean stiffness and velocity pretreatment ~ 25.78 ± 18 kPa and 2.74 ± 0.98 m/s, mean stiffness and velocity post-treatment 15.67 ± 5.89 kPa and 2.24 ± 0.428 m/s). Although elastography parameters decreased during these visits in the long-axis imaging plane, they were not found to be statistically significant. However, gross morphology and cross-sectional area of the nerve did not change significantly across visits. Interestingly, elastography values were higher in patients with neuritis, though not statistically significant.

CONCLUSION

Shear wave elastography is a novel, upcoming modality in musculoskeletal imaging especially in the evaluation of peripheral neuropathy. It can act as an adjunct to grey-scale imaging, which can help in early diagnosis and in guiding treatment of leprosy neuropathy.

Structural aspects of lesional and non-lesional skin microbiota reveal key community changes in leprosy patients from India

Although skin is the primary affected organ in Leprosy, the role of the skin microbiome in its pathogenesis is not well understood. Recent reports have shown that skin of leprosy patients (LP) harbours perturbed microbiota which grants inflammation and disease progression. Herein, we present the results of nested Polymerase Chain Reaction-Denaturing Gradient Gel Electrophoresis (PCR-DGGE) which was initially performed for investigating the diversity of bacterial communities from lesional skin (LS) and non-lesional skin (NLS) sites of LP (n = 11). Further, we performed comprehensive analysis of 16S rRNA profiles corresponding to skin samples from participants (n = 90) located in two geographical locations i.e. Hyderabad and Miraj in India. The genus Staphylococcus was observed to be one of the representative bacteria characterizing healthy controls (HC; n = 30), which in contrast was underrepresented in skin microbiota of LP. Taxa affiliated to phyla Firmicutes and Proteobacteria were found to be signatures of HC and LS, respectively. Observed diversity level changes, shifts in core microbiota, and community network structure support the evident dysbiosis in normal skin microbiota due to leprosy. Insights obtained indicate the need for exploring skin microbiota modulation as a potential therapeutic option for leprosy.

Profiles of Pediatric Leprosy: A Report from a University Hospital of Nepal in the Post-Elimination Era

Because pediatric leprosy strongly indicates continuous disease transmission in the community, knowing the profiles of pediatric leprosy is of great value for a leprosy-free world. We conducted this study to assess the clinical profiles of pediatric leprosy in Nepal. This retrospective study analyzed the 7-year record from 2011 to 2017. There were a total of 68 pediatric leprosy cases. Male (63.2%) cases outnumbered female cases. The minimum age of the leprosy-affected children was 6 years, with the mean age 12.17 (±1.95) years. Contact history was present in 26 (38.2%) children. Most of them (83.8%) had positive slit-skin smear. Lepra reaction was present in 14.7%. Nine had disability, with 4/9 (44.4%) of them having grade 2 disability. More than two-thirds (70.6%) were multi-bacillary cases. Some (2.9%) even had lepromatous leprosy. Leprosy continues to be a disease of concern in the post-elimination era even in the pediatric population.

A Study on the Impact of Genetic Polymorphisms of Cytokines TNFα, IFNγ and IL10 in South Indian Leprosy Patients

Background:

Leprosy (Hansen's disease) is a chronic, debilitating disease predominantly of the peripheral nervous system characterized by the impairment of peripheral nerves and subsequent sensory loss caused by Mycobacterium leprae. The pro- and antiinflammatory cytokine genes play a major role in nerve damage in leprosy.

Aims and Objectives:

The objective of the present study is to ascertain the association of cytokine gene polymorphisms TNFα - 308G/A (rs 1800629), IFNγ +874A/T (rs 2430561), and IL10 - 1082G/A rs 1800896 in causation with leprosy.

Materials and Methods:

The present study comprised 365 leprosy patients and 185 control subjects. The polymorphisms in TNFα-308, IFNγ+874, and IL10-1082 genes were typed using the amplification refractory mutation system polymerase chain reaction method (ARMS PCR).

Results:

The present study found significant association between IL10-1082 GA heterozygote (P < 0.02) and IFNγ+874 AA (P < 0.001) genotype and leprosy. TNFα-308GA could not establish any association with the disease.

Conclusion:

The identification of genetic variations in pro- and antiinflammatory cytokines that are susceptible to leprosy would assist in better understanding of the pathogenesis of leprosy and perhaps lead to new approaches for diagnosis and treatment.

Immunology of leprosy

Leprosy is a disease caused by Mycobacterium leprae (ML) with diverse clinical manifestations, which are strongly correlated with the host's immune response. Skin lesions may be accompanied by peripheral neural damage, leading to sensory and motor losses, as well as deformities of the hands and feet. Both innate and acquired immune responses are involved, but the disease has been classically described along a Th1/Th2 spectrum, where the Th1 pole corresponds to the most limited presentations and the Th2 to the most disseminated ones. We discuss this dichotomy in the light of current knowledge of cytokines, Th subpopulations and regulatory T cells taking part in each leprosy presentation. Leprosy reactions are associated with an increase in inflammatory activity both in limited and disseminated presentations, leading to a worsening of previous symptoms or the development of new symptoms. Despite the efforts of many research groups around the world, there is still no adequate serological test for diagnosis in endemic areas, hindering the eradication of leprosy in these regions.

Case Report: Leprosy Osteoarticular Alterations Mimicking Rheumatoid Arthritis

Deformities of bones of the face and extremities are markers of leprosy (Hansen's disease) which contribute to stigma associated with this disease. Among these deformities are articular alterations that can mimic rheumatoid arthritis (RA). In this case, a 64-year-old man presented with a history of having been treated for lepromatous leprosy and erythema nodosum leprosum episodes, which evolved with joint alterations similar to those of RA. Most cases of leprosy-related arthritis are associated with reactional episodes, of which a large number do not respond to conventional therapy for leprosy reactions. In cases of chronic arthritis not associated with leprosy reactions, although patients show considerable relief with anti-leprosy therapy, arthritis is not completely resolved. This emphasizes the need for early diagnosis and treatment of leprosy to prevent the development of osteoarticular alterations.

Is Cutibacterium (previously Propionibacterium) acnes a potential pathogenic factor in the aetiology of the skin disease progressive macular hypomelanosis?

Progressive macular hypomelanosis (PMH) is a skin condition that normally causes symmetrically distributed hypopigmented macules on the front and back of the trunk, but rarely the face. To date, the pathophysiology of the condition is not well understood, but a role for the anaerobic skin bacterium Cutibacterium (previously Propionibacterium) acnes in the development of the disease has been proposed due to its sole presence within lesional, but not normal peri-lesional, skin. The success of antimicrobials in the treatment of PMH also provides circumstantial evidence that this association may be causal, although this is still to be proven. More recent culture and metagenomic typing studies indicate that strains of C. acnes subsp. elongatum (type III) may be important in the aetiology of the condition, which would help to explain why PMH does not normally affect the face since such strains are rarely present there, and why no association between this condition and acne vulgaris is found; acne appears to primarily involve type IA₁ strains from C. acnes subsp. acnes (type I). In this review, we summarize current knowledge on the relationship between C. acnes and PMH, and re-examine previous challenges to the view that the bacterium plays a role in the condition against the backdrop of newly emerged data.

Leprosy: Clinical aspects and diagnostic techniques

Leprosy, also known as Hansen's disease, is a curable infectious disease that remains endemic in >140 countries around the world. Despite being declared "eliminated" as a global public health problem by the World Health Organization in the year 2000, approximately 200,000 new cases were reported worldwide in 2017. Widespread migration may bring leprosy to nonendemic areas, such as North America. In addition, there are areas in the United States where autochthonous (person-to-person) transmission of leprosy is being reported among Americans without a history of foreign exposure. In the first article in this continuing medical education series, we review leprosy epidemiology, transmission, classification, clinical features, and diagnostic challenges.

Leprosy Reactions In Childhood: A Prospective Cohort Study In The Brazilian Amazon

Background and objective

In highly endemic areas, severe multibacillary forms of leprosy and reactional episodes are not rare in children. The objective of the present study was to describe the clinical and epidemiological aspects of leprosy reactions in children from the Brazilian Amazon.

Methods

This was a prospective cohort study of 34 leprosy patients aged under 15 years diagnosed at a health referral unit in northern Brazil between April 2014 and June 2015. Follow-up medical consultations were performed during multidrug therapy (MDT) and one year after the end of treatment. Participants underwent a simple neurologic examination and answered a structured questionnaire.

Results

Of the 34 recruited patients, 18 (52.9%) had leprosy reactions and/or neuritis. Among these, 10 (55.6%) had reactions at diagnosis, 13 (72.2%) had reactions after MDT, and 14 (77.8%) had two or more reactional episodes. Type I reactions occurred in 14 (77.8%) cases. Complications, such as disabilities, necrotizing erythema nodosum, or Cushing’s syndrome, occurred in six (33.3%) patients. The following variables showed significant associations (p ≤ 0.05) with leprosy reactions: age 8–14 years, number of doctors seen (≥3), multibacillary classification, number of skin lesions (≥10), or borderline and lepromatous clinical forms. The high frequency of type I reactions resulted in prolonged corticosteroid therapy, which may cause deficient bone maturation in childhood.

Conclusion

Older age in children, consulting many physicians for diagnosis, severe clinical forms, and numerous skin lesions were positively associated with reaction development. Reactions after MDT highlight the need for continuity in healthcare of children with leprosy.

A unique case of borderline lepromatous leprosy with psoriasis-like lesions all over the body and mycosis fungoides-like lesions on the face

Clinical manifestations of leprosy are various and may resemble other skin diseases. Skin lesions of leprosy mimicking psoriasis and mycosis fungoides (MF) that simultaneously occurs in one patient are rare. We reported a unique case of borderline lepromatous (BL) leprosy with severe reversal reaction manifested as psoriasis-like lesions and MF-like lesions in a 43-year-old-man. Psoriasis-like lesions all over the body accompanied by plaques and tumor-like lesions mimicking MF on the face could be found in this patient. Histopathological examination on an MF-like lesion from the face and psoriasis-like lesions from the posterior trunk and lower extremities revealed granulomatous reaction with epithelioid cells, Langhans giant cells, and foam cells which supported the diagnosis of BL leprosy. The patient was treated with multidrug therapy multibacillary (MDT-MB) regimen and 40 mg prednisone daily which was tapered off. Clinical improvement was observed on the 32nd day of observation as psoriasis-like and MF-like lesions became hyperpigmented macules and plaques, respectively. Due to the rarity of the multitype skin lesions of leprosy in one patient, a diagnosis of leprosy should be suspected by the clinicians in any patients with previously described skin disorders, especially in an endemic area.

Molecular characterization and immunogenic function of ML1899 (LipG) of Mycobacterium leprae

Introduction. ML1899 is conserved in all mycobacterium sp. and is a middle member of mle-ML1898 operon involved in mycolic acid modification.Aim. In the present study attempts were made to characterize ML1899 in detail.Methodology. Bioinformatics tools were used for prediction of active-site residues, antigenic epitopes and a three-dimensional model of protein. The gene was cloned, expressed and purified as His-tagged protein in Escherichia coli for biophysical/biochemical characterization. Recombinant protein was used to treat THP-1 cells to study change in production of nitric oxide (NO), reactive oxygen species (ROS), cytokines and chemokines using flowcytometry/ELISA.Results. In silico analysis predicted ML1899 as a member of α/β hydrolase family with GXSXG-motif and Ser126, His282, Asp254 as active-site residues that were confirmed by site-directed mutagensis. ML1899 exhibited esterase activity. It hydrolysed pNP-butyrate as optimum substrate at pH 8.0 and 50 °C with 5.56 µM^-1 min^-1 catalytic efficiency. The enzyme exhibited stability up to 60 °C temperature and between pH 6.0 to 9.0. K _m, V _max and specific activity of ML1899 were calculated to be 400 µM, 40 µmoles min^-1 ml^-1 and 27 U mg^{- 1}, respectively. ML1899 also exhibited phospholipase activity. The protein affected the survival of macrophages when treated at higher concentration. ML1899 enhanced ROS/NO production and up-regulated pro-inflammatory cytokines and chemokine including TNF-α, IFN-γ, IL-6 and IL-8 in macrophages. ML1899 was also observed to elicit humoral response in 69 % of leprosy patients.Conclusion. These results suggested that ML1899, an esterase could up-regulate the immune responses in favour of macrophages at a low concentration but kills the THP-1 macrophages cells at a higher concentration.

Invasion of human microvascular endothelial cells by Mycobacterium leprae through Mce1A protein

In patients with lepromatous leprosy, Mycobacterium leprae is often observed inside the human microvascular endothelial cells (HMVEC) surrounding Schwann cells (SC) at the site of lesions in the peripheral nerves. Based on this observation, it is considered that the nasal mucous may be the invasion pathway for M. leprae and HMVEC serve as an important reservoir for the bacteria before they invade SC. In light of previous research which revealed that Mce1A protein mediates bacterial invasion into nasal epithelial cells and HMVEC, we conducted a study to determine whether the invasion of M. leprae into HMVEC can be suppressed by blocking the Mce1A protein. In this study, we analyzed bacterial invasive activity by adding recombinant Escherichia coli, which express the active region (InvX:72 a.a.) of Mce1A protein on their external membrane, into cultured HMVEC, using the adhesin involved in the diffuse adherence mechanism. The number of bacteria that invaded into the cells was then measured by a colony counting method. The active region of Mce1A was divided into four sections, and hyperimmune antisera was prepared for each section for analyzing the inhibitory effect against invasion. The invasive activity was suppressed by antibodies against InvX regions 1-24 a.a., 25-46 a.a. and 58-72 a.a. This suggests that the InvX regions 1-24 a.a., 25-46 a.a. and 58-72 a.a. of Mce1A protein play an important role in the invasion of M. leprae into HMVEC and that it may be possible to suppress entry of M. leprae in HMVEC with antibodies against these regions.

Murine experimental leprosy: Evaluation of immune response by analysis of peritoneal lavage cells and footpad histopathology

This study evaluated the immune response of nude and BALB/c mice inoculated in the footpads (FP) with Mycobacterium leprae after 3, 5 and 8 months. At each timepoint peritoneal cells, peripheral blood, FP and popliteal lymph nodes (PLN) were collected. Peritoneal cell cultures were performed to measure the H₂ O₂ , O₂ ^- , NO, IL-2, IL-4, IL-10, IL-12, IFN-γ and TNF levels. Serum levels of anti-PGL-I antibodies were also quantified. The results showed that the infection was progressive in nude mice with bacterial multiplication, development of macroscopic lesions in the FP and presence of bacilli in the PLN at 8 months. In BALB/c mice, the infection reached a plateau of bacillary multiplication at 5 months and regressed at 8 months. Histopathological analysis of FP revealed a mononuclear inflammatory infiltrate with a large number of neutrophils at 5 months, with a higher number in nude mice. At 8 months, the number of neutrophils decreased and the infiltrate was predominantly mononuclear in both mouse strains. There was no H₂ O_2, O₂ ^- , IL-2, IL-4, IL-10 and IFN-γ production in the course of infection in nude mice; however, in BALB/c, O₂ ^- and IL-12 production was higher at 5 months and NO, IFN-γ and TNF production was higher at 8 months when there was a decrease in the number of bacilli. The level of anti-PGL-I antibodies was higher in BALB/c mice. Thus, nude and BALB/c mice can be used as experimental models for the study of various aspects of leprosy.

Leprosy services in primary health care in India: comparative economic cost analysis of two public-health settings

Objectives

The WHO recommends inclusion of post‐exposure chemoprophylaxis with single‐dose rifampicin in national leprosy control programmes. The objective was to estimate the cost of leprosy services at primary care level in two different public‐health settings.

Methods

Ingredient‐based costing was performed in eight primary health centres (PHCs) purposively selected in the Union Territory of Dadra and Nagar Haveli (DNH) and the Umbergaon block of Valsad district, Gujarat, India. All costs were bootstrapped, and to estimate the variation in total cost under uncertainty, a univariate sensitivity analysis was performed.

Results

The mean annual cost of providing leprosy services was USD 29 072 in the DNH PHC (95% CI: 22 125–36 020) and USD 11 082 in Umbergaon (95% CI: 8334–13 830). The single largest cost component was human resources: 79% in DNH and 83% in Umbergaon. The unit cost for screening the contact of a leprosy patient was USD 1 in DNH (95% CI: 0.8–1.2) and USD 0.3 in Umbergaon (95% CI: 0.2–0.4). In DNH, the unit cost of delivering single‐dose of rifampicin (SDR) as chemoprophylaxis for contacts was USD 2.9 (95% CI: 2.5–3.7).

Conclusions

The setting with an enhanced public‐health financing system invests more in leprosy services than a setting with fewer financial resources. In terms of leprosy visits, the enhanced public‐health system is hardly more expensive than the non‐enhanced public‐health system. The unit cost of contact screening is not high, favouring its sustainability in the programme.

Inflammatory cytokines in leprosy reactions and periodontal diseases

The inflammatory cytokines involved in the immune response to chronic periodontal disease (CPD) in the context of leprosy reactions (LR) were analyzed in 57 new cases of multibacillary leprosy (MBL). They were stratified by the presence of CPD and LR. Messenger RNA (mRNA) expression of inflammatory mediators was determined by qRT-PCR using skin biopsy and by ELISA using serum samples, maintaining 5% of significance level in ANOVA and correlation analyses. Twenty-three (40.4%) patients presented the first LR, whereas 22 (45.0%) patients presented CPD. IL-4 and IL-6 serum levels were significantly lower in patients with CPD and LR than in patients without CPD but with LR; IFN-γ serum levels were higher in patients with CPD and LR than in patients with no CPD and no LR; IL-4 serum levels were negatively correlated with TNF-α gene expression, while IL-6 serum levels were positively correlated with IFN-γ gene expression, in the skin of subjects with CPD and LR. The presence of DPC in individuals with LR immunoregulated IL-6, IFN-γ, and IL-4 concentrations. The presence of DPC decreased serum levels of IL-6 and IL-4 in reactional individuals. CPD concomitant to LR resulted in increased IFN-γ serum levels.

Analysis of the epidemiological situation of leprosy in an endemic area in Brazil: spatial distribution in the periods 2001 - 2003 and 2010 - 2012

INTRODUCTION

In Brazil, the spatial distribution of leprosy is heterogeneous. Areas with high transmission of the disease remain in the North, Center-west and Northeast. Areas with high transmission of the disease remain in the Northern, Central-Western and Northeastern regions of the country.

OBJECTIVE

to describe the spatial distribution of leprosy in municipalities with high risk of transmission, in the periods from 2001 - 2003 and 2010 - 2012.

METHODS

This was an ecological study using data from the Notifiable Diseases Information System (SINAN). They included all municipalities in the states of Mato Grosso, Tocantins, Rondônia, Pará and Maranhão. The following leprosy indicators were calculated per 100,000 inhabitants: incidence rate of leprosy, incidence rate in children aged less than 15 years and rate of new cases with grade 2 disabilities. The spatial scan statistic was used to detect significant clusters (p ≤ 0.05) in the study area.

RESULTS

In the period 2001 - 2003, the scan spatial statistics identified 44 significant clusters for the leprosy incidence rate, and 42 significant clusters in the period 2010 - 2012. In the period 2001 - 2003, it was possible to identify 20 significant clusters to the incidence rate in children aged less than 15, and 14 significant clusters in the period 2010 - 2012. For the rate of new cases with grade 2 disability, the scan statistics identified 19 significant clusters in the period 2001 - 2003, and 14 significant clusters in the period 2010 - 2012.

CONCLUSIONS

Despite the reduction in the detection of leprosy cases, there is a need intensify disease control actions, especially in the clusters identified.

Complement C1q expression in Erythema nodosum leprosum

Complement C1q is a soluble protein capable of initiating components of the classical pathway in host defence system. In earlier qualitative studies, C1q has been implicated in the pathogenesis of Erythema Nodosum Leprosum (ENL). However, little is known about the role of this complement in ENL reaction. In the present study we described the protein level of C1q production and its gene expression in the peripheral blood and skin biopsies in patients with ENL reaction and lepromatous leprosy (LL) patient controls before and after treatment. Thirty untreated patients with ENL reaction and 30 non-reactional LL patient controls were recruited at ALERT Hospital, Ethiopia. Peripheral blood and skin biopsies were obtained from each patient before and after treatment. The level of circulating C1q in the plasma was determined by enzyme-linked immunosorbent assay. The mRNA expression of the three C1q components, C1qA, C1qB, and C1qC in the peripheral blood and skin biopsies was determined by qPCR. Circulating C1q in the peripheral blood of untreated ENL patients was significantly decreased compared to LL patient controls. Untreated ENL patients had increased C1q gene expression in the peripheral blood compared to LL controls. Similarly, C1qA and C1qC gene expression were substantially increased in the skin biopsies of untreated ENL patients compared to LL controls. However, after treatment none of these genes show significant difference in both groups. In conclusion, while circulating C1q is inversely correlated with active ENL reactions, its gene expression is directly correlated with ENL. The decreased circulating C1q may suggest the utilization of C1q in immune-complex formation in these patients. Therefore, C1q could be a potential diagnostic marker for active ENL reactions as well as for monitoring ENL treatment.

Extensive Lepromatous Lymphadenitis Preceding Lesions on the Face and Earlobes: An Unusual Presentation of Leprosy in Singapore

Leprosy is also known as Hansen disease, as in some countries the diagnosis of leprosy carries a negative stigma and patients fear being shunned as outcasts. Presently, leprosy is primarily limited to specific geographical regions in resource-poor countries. As a result, there is increased difficulty for the younger generation of physicians today to correctly identify leprosy due to a lack of exposure and a low-index of suspicion, particularly in developed countries. In this case, the indurated lesions over the face demonstrated a preference for the outer lateral aspects over the maxillary areas, the nose bridge, and the pinna of the ears consistent with the organism's preference for cooler regions of the body. This was also evident in the other skin lesions affecting the more acral regions of the limbs in the early stage of disease progression. There is a need to keep this infective condition as an alternate diagnosis to all unusual cutaneous lesions.

A pleiotropic effect of the APOE gene: association of APOE polymorphisms with multibacillary leprosy in Han Chinese from Southwest China

BACKGROUND

Patients with leprosy have a very low risk of Alzheimer disease (AD) and β-amyloid (Aβ) deposition is significantly lower in the brain tissue of elderly patients with leprosy compared with age-matched controls. Apolipoprotein E (ApoE) plays a critical role in lipid metabolic pathways and in the brain, facilitating the proteolytic clearance of Aβ. We hypothesized that APOE confers risk of leprosy as lipid metabolism is involved in Mycobacterium leprae infection.

OBJECTIVES

To investigate the potential genetic associations between APOE and leprosy in two independent Chinese case-control cohorts from the Yuxi and Wenshan prefectures, Yunnan Province of Southwest China.

METHODS

Five APOE single-nucleotide polymorphisms (SNPs) were analysed in 1110 individuals (527 patients and 583 controls) from the Yuxi prefecture using a SNaPshot assay. Genetic variations in the entire APOE exons were screened in 1788 individuals (798 patients and 990 controls) from the Wenshan prefecture using next-generation sequencing technology.

RESULTS

The AD-associated SNPs rs405509 and rs439401 increased the risk of leprosy per se and multibacillary leprosy (P < 0·005), but the APOE-ε4 allele did not. The SNPs rs405509 and rs439401 were cis expression quantitative trait loci (eQTL) for APOE expression in human skin. Differential APOE mRNA expression was observed in skin lesions of patients with type I reaction leprosy and those with multibacillary leprosy. APOE and related lipid genes are involved in an interaction network with leprosy susceptibility genes.

CONCLUSIONS

The APOE gene is associated with leprosy, most likely by regulating lipid-metabolism-related genes.

Household expenditure on leprosy outpatient services in the Indian health system: A comparative study

BACKGROUND

Leprosy is a major public health problem in many low and middle income countries, especially in India, and contributes considerably to the global burden of the disease. Leprosy and poverty are closely associated, and therefore the economic burden of leprosy is a concern. However, evidence on patient's expenditure is scarce. In this study, we estimate the expenditure in primary care (outpatient) by leprosy households in two different public health settings.

METHODOLOGY/PRINCIPAL FINDINGS

We performed a cross-sectional study, comparing the Union Territory of Dadra and Nagar Haveli with the Umbergaon block of Valsad, Gujrat, India. A household (HH) survey was conducted between May and October, 2016. We calculated direct and indirect expenditure by zero inflated negative binomial and negative binomial regression. The sampled households were comparable on socioeconomic indicators. The mean direct expenditure was USD 6.5 (95% CI: 2.4-17.9) in Dadra and Nagar Haveli and USD 5.4 (95% CI: 3.8-7.9) per visit in Umbergaon. The mean indirect expenditure was USD 8.7 (95% CI: 7.2-10.6) in Dadra and Nagar Haveli and USD 12.4 (95% CI: 7.0-21.9) in Umbergaon. The age of the leprosy patients and type of health facilities were the major predictors of total expenditure on leprosy primary care. The higher the age, the higher the expenditure at both sites. The private facilities are more expensive than the government facilities at both sites. If the public health system is enhanced, government facilities are the first preference for patients.

CONCLUSIONS/SIGNIFICANCE

An enhanced public health system reduces the patient's expenditure and improves the health seeking behaviour. We recommend investing in health system strengthening to reduce the economic burden of leprosy.

Leprosy As a Complex Infection: Breakdown of the Th1 and Th2 Immune Paradigm in the Immunopathogenesis of the Disease

Leprosy is a chronic infectious disease whose evolution involves complex immune mechanisms of the host that influence the clinical presentation of the disease. For many years, the main interpretation of the host defense response was based on characterization of the established immune paradigm between T helper (Th) 1 and Th2 lymphocytes. However, with advances in the knowledge of immunology, new approaches have emerged along with the development of new immunological pathways that have changed the interpretation of the long-established paradigm of the polar forms of the disease, especially with the identification of new subtypes of T lymphocytes such as Th9, Th17, Th22, and Tregs. Thus, this review discusses the role of these new subtypes of T helper lymphocytes and how the development of the immune response of these cells modifies the pattern of the Th1/Th2 response in the immunopathogenesis of leprosy.

Regulatory T cells: Friends or foe in human Mycobacterium leprae infection?

Regulatory T cells (Tregs) are known to control immune responses by suppressing the antigen-presenting and effector T cells. Some mechanisms adopted by Tregs in combating Mycobacterium infections have been proposed. Nevertheless, in M. leprae infection, also known as leprosy or Hansen's disease, the role of Tregs has not been completely elucidated. Using multicolor flow cytometry, we evaluated the expression of different cell surface and intracellular molecules present in Tregs from peripheral blood samples of leprosy patients. Before initiating treatment, thirteen new cases of leprosy were grouped according to the Ridley-Jopling classification in to the paucibacilary (PB) or multibacilary (MB) group. Fifteen non-infected individuals (NI) were included as control subjects. Tregs were higher in the MB group than in the NI group. Tregs also co-expressed high amounts of PD1 and PDL-1, indicating that these cells could induce apoptosis of effector cells and simultaneously prevent their own apoptosis. Our data showed that compared to the NI group, Tregs from the PB group expressed higher levels of CD95L, which may be associated with other apoptotic pathways that may decrease Tregs in these patients. Correlation analysis reinforced that PD1 and CD95L are efficient apoptosis' pathway that decreased levels of Tregs in the NI and PB groups. We also observed significant differences in cytokine expression of Tregs from the PB and MB groups. Compared to the NI group, Tregs from the MB group showed higher IL-17 expression; however, compared to the PB group, the expression of IL-10 in Tregs from the MB group was lower, suggesting inefficient control of inflammation. Therefore, we concluded that different pathways were involved in Treg-induced suppression of leprosy. Moreover, Treg-mediated regulation of inflammation via IL-10 and IL-17 expression in leprosy patients was inefficient. Thus, we propose that during M. leprae infection, Tregs may impair the immune responses elicited against this bacillus, favor bacterial replication, and aid in persistence of a disseminated multibacillary disease.

Clinico-pathological features of erythema nodosum leprosum: A case-control study at ALERT hospital, Ethiopia

BACKGROUND

Leprosy reactions are a significant cause of morbidity in leprosy population. Erythema nodosum leprosum (ENL) is an immunological complication affecting approximately 50% of patients with lepromatous leprosy (LL) and 10% of borderline lepromatous (BL) leprosy. ENL is associated with clinical features such as skin lesions, neuritis, arthritis, dactylitis, eye inflammation, osteitis, orchitis, lymphadenitis and nephritis. ENL is treated mainly with corticosteroids and corticosteroids are often required for extended periods of time which may lead to serious adverse effects. High mortality rate and increased morbidity associated with corticosteroid treatment of ENL has been reported. For improved and evidence-based treatment of ENL, documenting the systems affected by ENL is important. We report here the clinical features of ENL in a cohort of patients with acute ENL who were recruited for a clinico-pathological study before and after prednisolone treatment.

MATERIALS AND METHODS

A case-control study was performed at ALERT hospital, Ethiopia. Forty-six LL patients with ENL and 31 non-reactional LL matched controls were enrolled to the study and followed for 28 weeks. Clinical features were systematically documented at three visits (before, during and after predinsolone treatment of ENL cases) using a specifically designed form. Skin biopsy samples were obtained from each patient before and after treatment and used for histopathological investigations to supplement the clinical data.

RESULTS

Pain was the most common symptom reported (98%) by patients with ENL. Eighty percent of them had reported skin pain and more than 70% had nerve and joint pain at enrolment. About 40% of the patients developed chronic ENL. Most individuals 95.7% had nodular skin lesions. Over half of patients with ENL had old nerve function impairment (NFI) while 13% had new NFI at enrolment. Facial and limb oedema were present in 60% patients. Regarding pathological findings before treatment, dermal neutrophilic infiltration was noted in 58.8% of patients with ENL compared to 14.3% in LL controls. Only 14.7% patients with ENL had evidence of vasculitis at enrolment.

CONCLUSION

In our study, painful nodular skin lesions were present in all ENL patients. Only 58% patients had dermal polymorphonuclear cell infiltration showing that not all clinically confirmed ENL cases have neutrophilic infiltration in lesions. Very few patients had histological evidence of vasculitis. Many patients developed chronic ENL and these patients require inpatient corticosteroid treatment for extended periods which challenges the health service facility in resource poor settings, as well as the patient's quality of life.

Expression of interleukin-1β and interleukin-6 in leprosy reactions in patients with human immunodeficiency virus coinfection

Previous studies suggest that coinfection of leprosy and human immunodeficiency virus (HIV) does not decrease the frequency and intensity of leprosy reactions. However, the immunological aspects of leprosy reactions in coinfected patients remain obscure, with a limited number of studies showing contradictory results. Observational study using tissue samples collected during leprosy reactions from 15 patients coinfected with leprosy and HIV and from 15 patients with leprosy alone. Patients were part of a prior larger cohort study of leprosy patients with and without HIV coinfection. Specific antibodies were used to detect IL-1β and IL-6 expression in skin biopsy tissue cells. IL-1β and IL-6 expression was similar between leprosy patients with and without HIV coinfection (p>0.05). Coinfected and non-coinfected tissues showed similar levels of IL-1β and IL-6 expression for type 1 reactions. A trend towards increased levels of IL-1β and IL-6 expression was observed in tissue from coinfected patients (p=0.0024). The expression of IL-1β and IL-6 during leprosy reactions did not differ significantly between tissues obtained from leprosy patients with and without HIV coinfection. Therefore, we conclude that HIV coinfection does not affect the immunological pattern of leprosy reactions.

Nerve Damage in Young Patients with Leprosy Diagnosed in an Endemic Area of the Brazilian Amazon: A Cross-Sectional Study

OBJECTIVE

To describe nerve damage and its association with clinical and epidemiologic characteristics in young patients with leprosy diagnosed in an endemic area of the Brazilian Amazon.

STUDY DESIGN

All 45 patients with leprosy younger than 15 years of age and diagnosed at a health referral unit in northern Brazil were invited to participate in a cross-sectional, descriptive, analytical study. Subjects were submitted to a templated simple neurologic examination of the peripheral nerves and answered a structured questionnaire.

RESULTS

Of 41 cases, referral was the mode of detection in 33 participants (80.5%); 19 (46.3%) had been seen by 3 or more physicians to obtain a diagnosis, and 26 (63.4%) had received other diagnoses. The interval between the onset of symptoms and diagnosis was more than 1 year in 30 cases (73.2%). Borderline leprosy was the predominant clinical form (48.8%); 63.4% of the participants had multibacillary leprosy, 31.7% had nerve damage, and 17.1% exhibited disabilities. The following variables showed a statistically significant association (P???.05) with nerve damage at diagnosis: home visit by the community health worker, number of doctors seen, number of skin lesions (>5), and lesions along the path of nerve trunks.

CONCLUSION

Centralized healthcare, a low frequency of home visits by community health workers, and the difficulty in diagnosing leprosy in children are factors that contribute to late treatment initiation and an increased risk of peripheral nerve damage. In addition, multiple skin lesions and lesions along the path of nerve trunks require rigorous monitoring.

A Negative Feedback Loop Between Autophagy and Immune Responses in Mycobacterium leprae Infection

The obligate intracellular bacterium Mycobacterium leprae is the causative agent of leprosy and primarily infects macrophages, leading to irreversible nerve damage and deformities. So far, the underlying reasons allowing M. leprae to persist and propagate in macrophages, despite the presence of cellular immunity, are still a mystery. Here, we investigated the role of autophagy, a cellular process that degrades cytosolic materials and intracellular pathogens, in M. leprae infection. We found that live M. leprae infection of macrophages resulted in significantly elevated autophagy level. However, macrophages with high autophagy levels preferentially expressed lower levels of proinflammatory cytokines, including interleukin (IL)-1β, IL-6, IL-12, and tumor necrosis factor-α, and preferentially primed anti-inflammatory T cells responses, characterized by high IL-10 and low interferon-γ, granzyme B, and perforin responses. These anti-inflammatory T cells could suppress further induction of autophagy, leading to improved survival of intracellular M. leprae in infected macrophages. Therefore, these data demonstrated that although autophagy had a role in eliminating intracellular pathogens, the induction of autophagy resulted in anti-inflammatory immune responses, which suppressed autophagy in a negative feedback loop and allowed the persistence of M. leprae.

Leprae reaction resembling rheumatologic disease as presenting feature of leprosy

Leprosy is a chronic granulomatous infection caused by Mycobacterium leprae with predominant involvement of skin and nerves. We present a 70-year-old man with leprosy whose initial presentation resembled rheumatologic disease, due to leprae reaction. He presented with an 8-week history of worsening neuropathic pain in the right forearm, associated with necrotic skin lesions on his fingers that had ulcerated. Physical examination revealed two tender necrotic ulcers at the tip of the right middle finger and the dorsal aspect of the left middle finger. The patient had right wrist tenosynovitis and right elbow bursitis. Apart from raised inflammatory markers, the investigations for infection, connective tissue disease, vasculitis, thromboembolic disease and malignancy were negative. During the fourth week of hospitalization, we noticed a 2-cm hypoesthetic indurated plaque on the right inner arm. Further examination revealed thickened bilateral ulnar, radial and popliteal nerves. A slit skin smear was negative. Two skin biopsies and a biopsy of the olecranon bursa revealed granulomatous inflammation. He was diagnosed with paucibacillary leprosy with neuritis. He responded well to multidrug therapy and prednisolone; his symptoms resolved over a few weeks. This case illustrates the challenges in diagnosing a case of leprosy with atypical presentation in a non-endemic country.