Sensory Polyneuropathy as Initial Manifestation of Endemic Leprosy in Spain

Autochthonous leprosy in Europe: a case report and literature review

Leprosy is currently uncommon in Europe: the diagnosed cases are almost all imported from endemic areas. We report on an autochthonous case of borderline lepromatous leprosy in a 71-year-old Portuguese woman. The case was complicated by a reversal reaction and then by erythema nodosum leprosum. A literature review identified 18 reported cases of European autochthonous leprosy since 2000; all but one were observed in Mediterranean countries. Therefore, active clusters of leprosy persist in Europe, particularly in Spain, Greece, Portugal, and Italy.

Mycobacterium leprae transmission characteristics during the declining stages of leprosy incidence: A systematic review

BACKGROUND

Leprosy is an infectious disease caused by Mycobacterium leprae. As incidence begins to decline, the characteristics of new cases shifts away from those observed in highly endemic areas, revealing potentially important insights into possible ongoing sources of transmission. We aimed to investigate whether transmission is driven mainly by undiagnosed and untreated new leprosy cases in the community, or by incompletely treated or relapsing cases.

METHODOLOGY/PRINCIPAL FINDINGS

A literature search of major electronic databases was conducted in January, 2020 with 134 articles retained out of a total 4318 records identified (PROSPERO ID: CRD42020178923). We presented quantitative data from leprosy case records with supporting evidence describing the decline in incidence across several contexts. BCG vaccination, active case finding, adherence to multidrug therapy and continued surveillance following treatment were the main strategies shared by countries who achieved a substantial reduction in incidence. From 3950 leprosy case records collected across 22 low endemic countries, 48.3% were suspected to be imported, originating from transmission outside of the country. Most cases were multibacillary (64.4%) and regularly confirmed through skin biopsy, with 122 cases of suspected relapse from previous leprosy treatment. Family history was reported in 18.7% of cases, while other suspected sources included travel to high endemic areas and direct contact with armadillos. None of the countries included in the analysis reported a distinct increase in leprosy incidence in recent years.

CONCLUSIONS/SIGNIFICANCE

Together with socioeconomic improvement over time, several successful leprosy control programmes have been implemented in recent decades that led to a substantial decline in incidence. Most cases described in these contexts were multibacillary and numerous cases of suspected relapse were reported. Despite these observations, there was no indication that these cases led to a rise in new secondary cases, suggesting that they do not represent a large ongoing source of human-to-human transmission.

Epidemiology of Leprosy in Spain: The Role of the International Migration

Background

Although incidence of leprosy in Spain has declined steadily over the years, the fivefold increase in immigration since the turn of the century—much of it from countries where leprosy is still prevalent—has been linked to an uptick in registered cases.

Objective

To describe the epidemiologic trends of incident leprosy cases detected in Spain among Spanish- and foreign-born population groups.

Methods

Observational, retrospective study of suspected leprosy cases in Spain, as reported through the System of Compulsory Notification of Diseases from 2003 to 2013, with results disaggregated by country of birth. We collected statistical data on leprosy burden for other countries from WHO to estimate the expected number of imported cases.

Results

Of the 168 leprosy cases registered during the study period, 40 (24.6%) were in Spanish patients, while 128 (76.2%) were detected in legally resident immigrants. We identified a significantly higher number of imported leprosy cases during the 2008–2010 and 2011–2013 trienniums compared to the reference biennium 2003–2004 (OR 5.38, 95% CI 1.83–14.88 and OR 4.80, 95% CI 1.41–16.33, respectively). Most imported cases were diagnosed in Latin American immigrants (71.9%), especially Brazilians, but also Paraguayans, Bolivians and other nationalities from South and Central America. However, registered incidence was lower than expected for each year. For example, in 2003, the expected new cases in immigrants was 47.12, compared to only four cases that were actually detected (a 91% difference). Likewise, we expected to find 49.6 incident cases among immigrants in 2009, but only 15 new cases were reported (60% fewer than expected).

Conclusion

Imported cases of leprosy are responsible for most leprosy incidence in Spain, and we cannot rule out some under-diagnosis. Clinicians should be made more aware of the potential for leprosy incidence among patients from countries where the disease is endemic.

Most of cases of leprosy that are diagnosed in Europe come from other parts of the world. This study describes the epidemiologic trends of incident leprosy cases detected in Spain among Spanish- and foreign-born population groups from 2003 to 2013. We show that new cases of leprosy will continue to appear in the country regardless of the control measures taken at a domestic level, as people from leprosy-endemic areas will continue to migrate. That said, we also found that the actual number of incident cases registered through the national reporting system was far below the expected cases estimated from WHO statistical data on countries of origin. Nevertheless, leprosy should be considered among the differential diagnoses in patients presenting in Spanish health centres with suspected cutaneous and neurological signs and symptoms, especially if they are from Brazil, Paraguay, Bolivia or other areas where leprosy is prevalent. Given the high proportion of Latin American immigrants in Spain, our findings are very relevant, and it is advisable that the Spanish Medical University Programme reinstate the inclusion of leprosy in training for junior doctors.