Oral coinfection can stress peripheral lymphocyte to inflammatory activity in leprosy

Time to revisit the purported link of leprosy reactions with infective triggers: An unnecessary economic burden for patients

Existing literature on factors triggering leprosy reactions is based only on case reports and case series, and thus probably gives a biased view. We undertook a case-control study to investigate such purported trigger factors in 42 leprosy reaction patients and 40 non-reactional controls, and the cost of investigations required for the same. Detailed history, clinical evaluation and investigations for triggers were carried out. Infections (typhoid, dental caries) were the most common triggers found, followed by pregnancy. Trigger factors were commoner in the type 2 reaction (T2R) group compared to type 1 (T1R) reaction group. There was however no statistical difference between the two groups. The average estimated cost of investigations was higher in the reactional group and this difference was statistically significant. Hence, except for essential investigations required for initiating steroids, an extensive battery of investigations is unjustified unless the medical history suggests a definitive infective trigger.

A rare case of type 1 leprosy reactions following tetanus infection in a borderline tuberculoid leprosy patient and a literature review

Background

Type 1 leprosy reaction, also known as “reversal reaction”, is related to cellular immune responses to Mycobacterium leprae antigens. The risk factors that trigger type 1 leprosy reactions are poorly understood. Leprosy with concurrent tetanus is rare, and there are no publicly available reports of a leprosy patient infected with tetanus that induced type 1 leprosy reactions.

Case presentation

A 56-year-old Chinese Han female presented to our hospital with symptoms of erythematous plaques and pain over her left upper limb for 2 days and foreign object sensation in her throat for 3 days. The patient had a 6-year history of leprosy. Type 1 leprosy reactions were initially considered, followed by treatment with methylprednisolone. Two days later, the patient’s symptoms were aggravated, with neck muscle tension and difficulty in opening her mouth, and the erythematous plaques had spread over most of her left upper limb. After further careful examinations, we confirmed the diagnosis of tetanus with concurrent type 1 leprosy reactions. The patient was given anti-tetanus treatment for 12 days and anti-leprosy reaction treatment for 4 months; the diseases were eventually controlled.

Conclusions

This report suggests that tetanus infection may be a trigger for type 1 leprosy reactions.

Electronic supplementary material

The online version of this article (10.1186/s40249-018-0441-4) contains supplementary material, which is available to authorized users.

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.

Oral health conditions in leprosy cases in hyperendemic area of the Brazilian Amazon

Leprosy is a hyperendemic chronic condition in the Rondônia State . Despite the significant impact of oral health on the quality of life and clinical evolution of leprosy patients, systematic evaluation of oral health status has been neglected. To analyze the dental-clinical profile, self-perceived oral health and dental health service access of leprosy cases in the municipality of Cacoal in Rondônia State , North Brazil, from 2001 to 2012. A descriptive, cross-sectional study design was performed based on dental evaluation and standardized structured instruments. We investigated clinically assessed and self-perceived oral health status, as well as dental health service access. A total of 303 leprosy cases were included; 41.6% rated their oral health as good, and 42.6% reported being satisfied with their oral health. Self-reported loss of upper teeth was 45.5%. The clinical evaluation revealed that 54.5% had active caries. Most (97.7%) cases reported having been to the dentist at least once in their life and 23.1% used public health services. The poor standard of oral health in this population may increase the risk for leprosy reactions, consequently reducing quality of life. Low access to public health dental services and poor self-perceived oral health reinforce the need to achieve comprehensive health care in this population.

The oral cavity in leprosy: what clinicians need to know

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, a bacillus that has a tropism for skin and peripheral nerves. Leprosy treatment is based on a multidrug therapy established by the World Health Organization in 1982 and, despite its widespread use, Brazil ranks second worldwide in numbers of cases. Oral involvement in leprosy has been poorly described in the literature, and few studies have shown that although the bacillus is found in mucosa, specific leprosy lesions are rare and affect patients with advanced stages of the disease. This review aimed to assess the literature on oral manifestations in leprosy and the aspects involving oral cavity in leprosy pathogenesis.

Knowledge and Attitude about Leprosy among Indian Dental Students in Faridabad

INTRODUCTION

Role of dentists in prevention and sustainable care of leprosy is known. Changing leprosy scenario has led to requirement of change in leprosy education. However, knowledge and attitude of dental students on leprosy remains unknown.

AIM

Hence a study was conducted to assess knowledge and attitude of dental students about Leprosy.

MATERIALS AND METHODS

A questionnaire based, cross-sectional survey was conducted among 350 undergraduate and the postgraduate dental students of two dental colleges in Faridabad, India. The score for knowledge ranged from 0 to 16 and scores for attitude ranged from 0 to 26. These scores were further coded as poor, fair and good.

RESULTS

Mean knowledge score for the sample was 7.64±3.23. A total of 32.29% participants were under poor knowledge category; 57.42% had fair knowledge about Leprosy while 10.29% had good knowledge. Mean attitude score was 15.5 ± 5.98. A total of 30.57% had poor attitude scores, 42.57% had fair scores while 26.86% had good attitude scores. Univariate analysis showed year of training to be a significant predictor for knowledge level (t=7.12; p<0.001).

CONCLUSION

The results indicate need for three important changes towards Leprosy in Dentistry. These changes are need for incorporation of leprosy education in Dentistry, need for incorporation of problem based as well as evidence based learning in Dentistry integrated with general health and need for reestablishing public health programs for Leprosy utilizing dental workforce.

Viral Co-infection and Leprosy Outcomes: A Cohort Study

Background

The role of the host immunity in determining leprosy clinical forms and complications is well recognized, implying that changes in the immune status may interfere with several aspects of the disease. Therefore, we hypothesized that the presence of viral co-infections and associated immunological changes will have a clinical impact on leprosy outcomes. The aim of our study was to determine the clinical impact of human immunodeficiency virus (HIV), human T cell lymphotrophic virus type 1 (HTLV-1), hepatitis B virus (HBV) and hepatitis C virus (HCV) co-infection on the development of reactions, neuritis, neuropathy and relapses.

Methodology/Principal Findings

Cohort study in 245 leprosy subjects from Bahia, Brazil. Patients were followed from the time of diagnosis until at least the end of multidrug therapy. Viral co-infection was detected in 36 out of the 245 patients (14.7%). Specific co-infection rates were 10.6% for HBV, 2.9% for HIV, 2.5% for HTLV-1 and 0.8% for HCV. All four groups of co-infected patients had higher rates of neuritis and nerve function impairment compared to non co-infected leprosy subjects. The relapse rate was also higher in the co-infected group (8.3%) versus patients without co-infection (1.9%); relative risk 4.37, 95% confidence interval 1.02–18.74.

Conclusions/Significance

Leprosy patients should be screened for HBV, HCV, HIV and HTLV-1 co-infections. Besides contributing to better health care, this measure will facilitate the early detection of severe complications through targeting of higher risk patients.

The clinical and social impact of leprosy, a disease caused by Mycobacterium leprae, is due to the deformities and disabilities that are consequences of skin and peripheral nerve inflammation. We believe that leprosy patients who also have an associated viral infection will have a worse outcome. This can be due to alterations in the immune system triggered by the virus co-infection, leading to an increasing inflammation of the skin or peripheral nerves affected by Mycobacterium leprae, or to a depression of the mechanisms that control the infection. We have verified if the presence of specific viral infections in leprosy subjects is associated with a higher risk of developing a worse outcome like nerve inflammation, impairment in the nerve function or relapse. We have screened the patients for human immunodeficiency virus, human T cell lymphotrophic virus type 1, hepatitis B and hepatitis C virus. These subjects were followed up during all the period of leprosy treatment (at least 6 months) in order to detect the emergence of any complication. We have found that leprosy patients with viral co-infection are at higher risk to develop nerve inflammation and damage, as well as relapse, compared to subjects without viral co-infection.

Inflammatory Mediators of Leprosy Reactional Episodes and Dental Infections: A Systematic Review

Reactional episodes in leprosy are a result of complex interactions between the immune system, Mycobacterium leprae, and predisposing factors, including dental infections. To determine the main inflammatory mediators in the immunopathological process of dental infections and leprosy reactions, we conducted a systematic review of primary literature published between 1996 and 2013. A three-stage literature search was performed (Stage I, "leprosy reactions" and "inflammatory mediators"; Stage II, "dental infections" and "inflammatory mediators"; and Stage III, "leprosy reactions," "dental infections," and "inflammatory mediators"). Of the 911 eligible publications, 10 were selected in Stage I, 68 in Stage II, and 1 in Stage III. Of the 27 studied inflammatory mediators, the main proinflammatory mediators were IL-6, IFN-γ, TNF-α, IL-1β, and IL-17; the main anti-inflammatory mediators were IL-10 and IL-4. Serum IL-6 and TNF-α concentrations were significant during periodontal and reactional lesion evolution; IFN-γ and IL-1β were associated with types 1 and 2 reactions and chronic periodontal disease. The proinflammatory mediators in dental infections and leprosy reactions, especially IL-6 and TNF-α, were similar across studies, regardless of the laboratory technique and sample type. IFN-γ and IL-1β were significant for leprosy reactions and periodontal diseases. This pattern was maintained in serum.