Identification of clinical, epidemiological and laboratory risk factors for leprosy reactions during and after multidrug therapy

Leprosy: The age-old companion of humans - Re-evaluation and comparative analysis of Avar-period cases with Hansen's disease from the Danube-Tisza Interfluve, Hungary

In recent years, our knowledge of leprosy in the past has substantially been enriched. Nonetheless, much still remains to be discovered, especially in regions and periods from where no written sources are available. To fill in some research gaps, we provide the comparative analysis of eight Avar-period leprosy cases from the Danube-Tisza Interfluve (Hungary). In every case, to reconstruct the biological consequences of leprosy, the detected bony changes were linked with palaeopathological and modern medical information. To reconstruct the social consequences of being affected by leprosy, conceptualisation of the examined individuals' treatment in death was conducted. In every case, the disease resulted in deformation and disfigurement of the involved anatomical areas (rhinomaxillary region, feet, and/or hands) with difficulties in conducting certain physical activities. These would have been disadvantageous for the examined individuals and limited or changed their possibilities to participate in social situations. The most severe cases would have required continuous support from others to survive. Our findings indicate that, despite their very visible disease and associated debility, the examined communities did not segregate leprosy sufferers but provided and cared for them, and maintained a strong enough social network that made their survival possible even after becoming incapable of self-sufficiency.

Evaluation of hematological parameters in patients with leprosy in Southern Nigeria

Introduction

Leprosy is a chronic granulomatous infectious disease caused by Mycobacterium leprae that mostly result in immunological reactions that affect the skin, peripheral nervous system and mucosa of the upper respiratory tract. This study aimed to evaluate hematological parameters among subjects with leprosy and deduce biomarkers for onset of leprosy reaction.

Methods

This was a cross-sectional study performed from September 1, 2018 to August 1, 2019. Sixty patients with leprosy (30 on multidrug therapy (MDT) and 30 that had completed MDT) and 30 apparently healthy controls were enrolled. Hematology auto-analyzer (Sysmex KX-21N by Sysmex Corporation Kobe, Japan) was used in sample analysis. ANOVA and Kruskal Wallis were used for mean comparison. Eta squared was used to assess effect size. Sensitivity and specificity were assessed using receiver operator characteristic (ROC) curve. Association was checked using bivariate logistics regression.

Results

The majority (68.3%) of the patients with leprosy were males and a larger proportion were either farmers or unemployed. The prevalence of leprosy reaction in the studied population was 40%. The following parameters were significantly (p<0.05) reduced: red cell count, hemoglobin and hematocrit in patients with leprosy compared to controls. Total white cell count, absolute lymphocyte, neutrophil, monocyte and eosinophil counts were significantly elevated in patients with leprosy compared to controls. The hemoglobin and mean corpuscular volume of patients with leprosy on treatment were significantly higher compared to those who had completed treatment, while the mean corpuscular hemoglobin concentration was significantly reduced. Overall, 65% of patients with leprosy were anemic. Eosinophil count showed good biomarker potential for leprosy reaction onset with AUC 0.709. Sex and absolute eosinophil count were associated with leprosy reaction (OR=11.194; 95%CI: 1.775-70.586).

Conclusions

This study has shown a high frequency of anemia in patients with leprosy, both those on treatment and those that had completed MDT, necessitating incorporation of post treatment plan in the management of leprosy. This study has reported absolute eosinophil as potential biomarker of leprosy reaction.

Hansen's disease and COVID-19 co-infection in Brazil

BACKGROUND

The implications of COVID-19 co-infection in patients under treatment for Hansen's disease (HD, leprosy) remain uncertain. We aimed to describe clinical characteristics, treatments, and outcomes in patients with HD and COVID-19 in Brazil.

METHODS

Cross-sectional study recruiting adult HD patients with PCR-confirmed COVID-19 from five HD treatment centers in Brazil between March 1, 2020, and March 31, 2021. At the time of this study, no patient had received COVID-19 vaccine.

RESULTS

Of 1377 patients under treatment for HD, 70 (5.1%) were diagnosed with COVID-19. Of these, 41 (58.6%) had PCR-confirmed COVID-19, comprising 19 men and 22 women, aged 24-67 (median 45) years. HD was multibacillary in 39/41 patients. Eight patients ceased WHO Multi-Drug Therapy for HD, three for lack of drugs, two because of COVID-19, and three for other reasons. Of the 33 who continued treatment, 26 were on the standard regimen and seven an alternative regimen. Seventeen patients were receiving oral prednisone, including nine patients with type 1 reaction, four with type 2 reaction, three with neuritis, and one with rheumatologic disease. Twelve patients were hospitalized for COVID-19, and six patients died, of whom three had hypertension and one also had type 2 diabetes and obesity.

CONCLUSIONS

COVID-19 and Hansen's disease co-infection did not appear to change the clinical picture of either disease in this cross-sectional study. The wider impact of the pandemic on persons affected by HD requires follow-up and monitoring.

Leprosy morbidity and mortality in Brazil: 2008-2018

Introduction

Leprosy is an infectious disease caused by Mycobacterium leprae. This study aimed to understand the distribution and impact of Hansen's disease in different regions of Brazil and the outcome of cases in recent years.

Methodology

An ecological study was conducted throughout the Brazilian territory for 11 years (2008–2018). The mortality rates, new cases of the disease, and proportion of physical disability and cure were assessed. Data were obtained using DATASUS. GraphPad Excel and “Prisma” programs were used for tabulation and data processing. To present an accurate perspective from all regions, the data were normalized according to the population.

Results

Overall, the results demonstrated a significant reduction in the number of leprosy cases in Brazil over the last decade (p < 0.05). North and Midwest regions showed higher mortality rates standardized by age (p < 0.05). The largest number of cases were found in Tocantins and Mato Grosso, inner states of Brazil (p < 0.05). The cure rates in the Southeast and South regions were negatively correlated with the mortality rate in these regions (p < 0.05).

Conclusions

Actions to control the spread and unfavorable outcomes of leprosy have been effective in the last decade in most Brazilian states. On the other hand, the states of Tocantins and Mato Grosso, in the North and Midwest regions of Brazil, need to intensify the fight against the disease. Notwithstanding, measures against leprosy should continue and be intensified in regions with greater aggravations, aiming at an effective homogeneous control of the disease.

Risk Factors of Type 1 Leprosy Reaction in Leprosy Patients attending Leprosy Division of Dermatology and Venereology Outpatient Clinic of Dr Soetomo General Hospital in 2017–2019: A Retrospective Study

BACKGROUND: Type 1 leprosy reaction is a delayed hypersensitivity reaction caused by increased response of cellular-mediated immunity to Mycobacterium leprae. Manifestations include skin and nerve lesions, edema, and permanent disabilities. There are several risk factors that should be recognized to prevent disabilities. AIM: The aim of this study was to analyze the relationship of risk factors to the occurrence of type 1 leprosy reaction in leprosy patients treated at the Outpatient Clinic of Dr. Soetomo General Hospital. METHODS: This study was an analytical study with retrospective observational study design. Data were secondary from the medical records of leprosy patients at the Outpatient Clinic of Dr. Soetomo General Hospital from January 2017 to December 2019. RESULTS: Out of 364 patients in the Outpatient Clinic, 190 (52.2%) had leprosy without a reaction and 65 (17.9%) had type 1 reaction. Analysis showed that age, leprosy type, and treatment regimen were significantly associated with the incidence of type 1 reaction (p = 0.023; 0.003 and 0.004, respectively), with the leprosy type as the most dominant risk factor. Age 15–34 years old; leprosy types BB, BL, and BT; and the MB MDTL therapeutic regimen are risk factors for the occurrence of type I leprosy reaction. CONCLUSION: There is a statistically significant correlation between the risk factor and the occurrence of type 1 leprosy reaction in leprosy patient. The risk factor that has significant correlation is age 15–34 years; leprosy types BB, BL, and BT; and the MB MDTL therapeutic regimen. The most significant risk factor for the occurrence of type 1 leprosy reaction from our study is the type of leprosy (BB, BL, and BT).

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.

Leprosy: Treatment and management of complications

In the second article in this continuing medical education series, we review the treatment of leprosy, its immunologic reactions, and important concepts, including disease relapse and drug resistance. A fundamental understanding of the treatment options and management of neuropathic sequelae are essential to reduce disease burden and improve patients' quality of life.

The Burden of Helminth Coinfections and Micronutrient Deficiencies in Patients with and without Leprosy Reactions: A Pilot Study in Minas Gerais, Brazil

Leprosy reactions are immune-mediated complications occurring in up to 50% of patients. The immune consequences of helminth infections and micronutrient deficiencies suggest a potential role in type 1 reactions (T1R) or type 2 reactions (T2R). We conducted a case-control study in Minas Gerais, Brazil, to evaluate whether comorbidities and other factors are associated with reactions in patients with multibacillary leprosy. Stool and serum were tested for helminth infections. Deficiencies of vitamin A, D, and iron were measured using serum retinol, 25-hydroxyvitamin D, and ferritin, respectively. Logistic regression models identified associations between reactions and helminth infections, micronutrient deficiencies, and other variables. Seventy-three patients were enrolled, 24 (33%) with T1R, 21 (29%) with T2R, 8 (15%) with mixed T1R/T2R, and 20 (27%) without reactions. Evidence of helminth infections were found in 11 participants (15%) and included IgG4 reactivity against Schistosoma mansoni, Strongyloides, and Ascaris antigens. Thirty-eight (52%) had vitamin D deficiency, eight (11%) had vitamin A insufficiency, 21 (29%) had anemia, and one (1.4%) had iron deficiency. Multivariable logistic regression showed no statistically significant associations between helminth coinfections and total reactions (adjusted odds ratios [aOR]: 1.36, 95% CI: 0.22, 8.33), T1R (aOR: 0.85, 95% CI: 0.17, 4.17), or T2R (aOR: 2.41, 95% CI: 0.29, 20.0). Vitamin D deficiency and vitamin A insufficiency were also not statistically associated with reactions. However, vitamin deficiencies and helminth infections were prevalent in these patients, suggesting a potential role for additional treatment interventions. Studying reactions prospectively may further clarify the role of comorbidities in the clinical presentation of leprosy.

Low performance of operational indicators for leprosy control in the state of Bahia: spatiotemporal patterns, 2001-2014

OBJECTIVE

To characterize spatiotemporal patterns of operational indicators for leprosy control in the state of Bahia from 2001 to 2014.

METHODS

This is a population-based ecological study, with spatial distribution and autocorrelation of operational indicators for leprosy control.

RESULTS

From 2001 to 2007, 42.7% (n=178) of the municipalities presented a cure rate lower than 75%, increasing to 61.4% (n =291) from 2009 to 2014. Between 2001 and 2007, 32.5% (n=54) of the municipalities reported more than 10% of the total number of relapses in the state, increasing to 36.9% (n=75) between 2008 and 2014. From 2001 to 2014, 38% (n=159) of the municipalities presented an assessment index of disability grading at the time of diagnosis within the regular performance parameter. Between 2009 and 2014, the number of municipalities with a high incidence of grade 2 disability (G2D) at the time of diagnosis increased, reaching 55.3% (n=230) of the municipalities. Most municipalities in the state of Bahia showed poor performance in the implementation of planned actions for leprosy control, with little change or relative worsening in the patterns of operational indicators throughout the historical series.

CONCLUSION

The operational context in Bahia indicates significant institutional vulnerability, leading to the need for expansion and qualification of the surveillance and health care network in the different regions and conditions analyzed in the public health system (Sistema Único de Saúde - SUS).

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.

Differential Expression of IFN-γ, IL-10, TLR1, and TLR2 and Their Potential Effects on Downgrading Leprosy Reaction and Erythema Nodosum Leprosum

Leprosy reactions are acute immunological events that occur during the evolution of chronic infectious disease causing neural damage and disabilities. A study using blood samples of 17 leprosy reaction patients and 17 reaction-free was carried out by means of associations between antigens, receptors, and expression of cytokines, using path analysis providing new insights into the immunological mechanisms involved in triggering leprosy reactions. Toll-like receptors (TLR) such as TLR1 and TLR2, presented balanced expression in the reaction-free multibacillary (MB) group (TLR1: 1.01 ± 0.23, TLR2: 1.22 ± 0.18; p = 0.267). On the other hand, downgrading type 1 reaction (T1R) (TLR1: 1.24 ± 0.17, TLR2: 2.88 ± 0.37; p = 0.002) and erythema nodosum leprosum (ENL) (TLR1: 1.93 ± 0.17, TLR2: 2.81 ± 0.15; p = 0.004) revealed an unbalance in relation to the expression of these receptors. When the path analysis was approached, it was noted that interleukin 10 (IL-10) expression showed a dependence relation with phenolic glycolipid I (PGL-I) in downgrading T1R (direct effect = 0.503 > residual effect = 0.364), whereas in ENL, such relationship occurred with lipoarabinomannan (LAM) (direct effect = 0.778 > residual effect = 0.280). On the contrary, in the reaction-free leprosy group, interferon-gamma (IFN-γ) levels were dependent on the association between TLR2 and TLR1 (0.8735). The high TLR2 expression associated with IL-10 levels, in the leprosy reaction groups, may be hypothetically related to the formation of TLR2/2 homodimers and/or TLR2/6 heterodimers linked to evasion mechanisms in downgrading reactions and pathophysiology of ENL.

Leprosy in elderly people and the profile of a retrospective cohort in an endemic region of the Brazilian Amazon

Background

Leprosy has a global presence; more than 180 thousand new cases were registered in 2013, 15% of which were found in the Americas. The elderly are a very susceptible demographic in terms of developing illnesses, mainly because of characteristics natural to the senescence of the human organism. This study’s goals were to analyze leprosy in an elderly population from a hyperendemic region of the Brazilian Amazon in a historical series from 2004 to 2013 and to determine the clinical and epidemiological profile of a series of leprosy cases of elderly people in the period spanning from 2009 to 2013.

Methods

To achieve these goals, an observational, longitudinal, retrospective and descriptive study was put together to analyze leprosy in elderly people from data acquired from the Notification Aggravations Information System. Furthermore, a profile of the disease from a retrospective cohort based on data collected from medical records was developed.

Results

The number of new cases and the leprosy detection rate decreased across the observed period but remained stable among the elderly. The trend for the next ten years indicates decreases in the number of cases and in the detection rate in the general population and an increase in only the elderly. The overall profile was characterized by a predominance of males (64.32%), the multibacillary clinical form (87.57%), Type 1 reaction episodes (37.50%) and some physical incapacity at diagnosis (49.19%). The risk of reaction was greater in the first six months of multidrug therapy, and the positive result from the skin smear was associated with the greater chance of reactional condition development.

Conclusions

The resulting data demonstrate that leprosy amongst the elderly deserves attention because of the increased susceptibility to disability in this age group, with their higher risk of reaction and their greater level of co-morbidity.

Leprosy, despite being an ancient disease, still represents a challenge to public health systems today. There are still just a few studies about it, particularly among the elderly. It is known that they constitute a very heterogeneous group in terms of immune response to infections, alterations to the peripheral nervous system and predisposition to situations of vulnerability and functional dependency. The Amazon region is a hyperendemic region for leprosy and has been trying to address, along with the rest of Brazil, a rapid increase in the population’s life expectancy. This article surveys medical records from elderly people diagnosed with leprosy in a five-year period at the metropolitan region of Belém, state of Pará (Brazil), identifying a predominance of the multibacillary forms of the disease, a high prevalence of leprosy reactions mainly during treatment with multidrug therapy, and the presence of some physical incapacity in most of the people evaluated. It is expected that this study will contribute to knowledge about the clinical and epidemiological characteristics of leprosy among the elderly and stimulate the making of new studies on the theme.

Occult hepatitis B virus infection in patients with leprosy

Leprosy patients may present with immune system impairment and have a higher hepatitis B virus (HBV) seroprevalence, justifying the investigation of occult HBV infection in these individuals. The aim of this study was to verify the frequency and the clinical factors associated with occult HBV infection in leprosy patients. Between 2015 and 2016, leprosy patients from a reference center in Brazil were interviewed to assess clinical data. Blood samples were collected for the screening of HBV serological markers using enzyme-linked immunosorbent assay. Patients with negative hepatitis B surface antigen (HBsAg) that had positive anti-HBc and/or anti-HBs were selected for HBV DNA detection using real-time polymerase chain reaction. SPSS was used for data analysis. Among 114 selected patients, six were identified with occult infection (5.3%) and five of them with multibacillary leprosy. Three patients with occult infection had a history of a type 2 reaction (P = 0.072; OR, 4.97; 95% CI, 0.87-28.52). Only two patients with occult infection had isolated anti-HBc, while three had isolated anti-HBs, including those with the highest HBV DNA titers. In conclusion, in leprosy patients with negative HBsAg and positive anti-HBc and/or anti-HBs, occult HBV infection occurs in 5.3% and can be found even in patients with isolated anti-HBs.

Grade 2 disabilities in leprosy patients from Brazil: Need for follow-up after completion of multidrug therapy

Background

Leprosy continues to be a public health problem in many countries. Difficulties faced by health services include late diagnosis, under-reporting of new cases, adequate monitoring of disabilities and treatment. Furthermore, systematic follow-up after completion of treatment is important, when new disabilities may occur, or existing disabilities may get worse. The objective of the present study was to determine the prevalence of leprosy-associated grade 2 disabilities (G2D) after completion of multidrug therapy (MDT) and to identify factors associated with G2D.

Methods

We performed a cross-sectional study of 222 leprosy cases registered in Vitória da Conquista, Bahia state, Brazil from 2001–2014. We performed a clinical examination of the study participants and collected socio-economic and clinical information by interview. We identified factors associated with grade 2 disability (G2D) using logis tic regression.

Results

In total, 38 (17.1%) participants were diagnosed with G2D, and 106 (47.7%) with grade 1 disabilities (G1D). The following independent factors were significantly associated with G2D: occurrence of leprosy reaction (adjusted OR = 2.5; 95%CI = 1.09–5.77), thickening and/or tenderness of one or more nerve trunks (adjusted OR = 3.0; CI = 1.13–8.01) and unemployment (adjusted OR = 7.17; CI = 2.44–21.07).

Conclusions

This study shows that physical disabilities remain after completion of MDT and frequently occur in an endemic area in Brazil. Finding new ways to reduce the burden of disability are urgently needed, and may include systematic follow-up of patients after treatment completion combined with evidence-based preventative measures.

Leprosy is a Neglected Tropical Disease that is still common in many countries. Patients who have had leprosy often suffer long-term physical disabilities. For some patients, disabilities occur after finishing treatment or existing disabilities may get worse. We contacted 222 leprosy patients who had previously completed multidrug therapy (MDT) in a typical endemic area in Brazil and assessed leprosy-associated disabilities, and the associated clinical or sociodemographic factors. We found that 17.1% of the participants had severe (grade 2) disabilities. Disabilities were more common among patients who had had a leprosy reaction, thickening and/or tenderness of one or more nerve trunks and were unemployed. The findings are important because we show that physical disabilities occur frequently after treatment completion in this area, and that patients need long-term follow-up by the health system. Integrated measures that consider clinical and socio-economic aspects are also needed to reduce leprosy burden after completion of treatment, such as devising of public policies, implementation of clinical monitoring and the development of evidence-based guidelines for follow-up after release from MDT.

Anti-Lipoarabinomannan-Specific Salivary IgA as Prognostic Marker for Leprosy Reactions in Patients and Cellular Immunity in Contacts

Leprosy causes the most common peripheral neuropathy of infectious etiology, posing an important public health problem worldwide. Understanding the molecular and immunological mechanisms of nerve damage induced by M. leprae is mandatory to develop tools for early diagnosis and preventive measures. The phenolic glycolipid 1 (PGL-1) and lipoarabinomannan (LAM) antigens are major components of the bacterial surface and are implicated on leprosy immunopathogenesis and neural damage. Although the anti-PGL-1 serum IgM is highly used for operational classification of patients, the anti-LAM salivary IgA (sIgA) has not been investigated as diagnostic or prognostic marker in leprosy. Our aim was to assess the presence of anti-LAM sIgA in leprosy patients and their contacts in order to demonstrate whether such expression was associated with leprosy reactions. Distinct patterns of anti-LAM slgA were observed among groups, which were stratified into treatment-naïve patients (116), patients who completed multidrug therapy—MDT (39), household contacts (111), and endemic controls (11). Both anti-LAM sIgA and anti-PGL-I serum IgM presented similar prognostic odds toward leprosy reactions [(odds ratio) OR = 2.33 and 2.78, respectively]. Furthermore, the anti-LAM sIgA was highly correlated with multibacillary (MB) forms (OR = 4.15). Contrarily, among contacts the positive anti-LAM sIgA was highly correlated with those with positive Mitsuda test, suggesting that the presence of anti-LAM slgA may act as an indicator of cellular immunity conferred to contacts. Our data suggest that anti-LAM slgA may be used as a tool to monitor patients undergoing treatment to predict reactional episodes and may also be used in contacts to evaluate their cellular immunity without the need of Mitsuda tests.

Genetic polymorphisms of the IL6 and NOD2 genes are risk factors for inflammatory reactions in leprosy

The pathways that trigger exacerbated immune reactions in leprosy could be determined by genetic variations. Here, in a prospective approach, both genetic and non-genetic variables influencing the amount of time before the development of reactional episodes were studied using Kaplan-Meier survival curves, and the genetic effect was estimated by the Cox proportional-hazards regression model. In a sample including 447 leprosy patients, we confirmed that gender (male), and high bacillary clinical forms are risk factors for leprosy reactions. From the 15 single nucleotide polymorphisms (SNPs) at the 8 candidate genes genotyped (TNF/LTA, IFNG, IL10, TLR1, NOD2, SOD2, and IL6) we observed statistically different survival curves for rs751271 at the NOD2 and rs2069845 at the IL6 genes (log-rank p-values = 0.002 and 0.023, respectively), suggesting an influence on the amount of time before developing leprosy reactions. Cox models showed associations between the SNPs rs751271 at NOD2 and rs2069845 at IL6 with leprosy reactions (HRGT = 0.45, p = 0.002; HRAG = 1.88, p = 0.0008, respectively). Finally, IL-6 and IFN-γ levels were confirmed as high, while IL-10 titers were low in the sera of reactional patients. Rs751271-GT genotype-bearing individuals correlated (p = 0.05) with lower levels of IL-6 in sera samples, corroborating the genetic results. Although the experimental size may be considered a limitation of the study, the findings confirm the association of classical variables such as sex and clinical forms with leprosy, demonstrating the consistency of the results. From the results, we conclude that SNPs at the NOD2 and IL6 genes are associated with leprosy reactions as an outcome. NOD2 also has a clear functional pro-inflammatory link that is coherent with the exacerbated responses observed in these patients.

Whole genome sequencing distinguishes between relapse and reinfection in recurrent leprosy cases

BACKGROUND

Since leprosy is both treated and controlled by multidrug therapy (MDT) it is important to monitor recurrent cases for drug resistance and to distinguish between relapse and reinfection as a means of assessing therapeutic efficacy. All three objectives can be reached with single nucleotide resolution using next generation sequencing and bioinformatics analysis of Mycobacterium leprae DNA present in human skin.

METHODOLOGY

DNA was isolated by means of optimized extraction and enrichment methods from samples from three recurrent cases in leprosy patients participating in an open-label, randomized, controlled clinical trial of uniform MDT in Brazil (U-MDT/CT-BR). Genome-wide sequencing of M. leprae was performed and the resultant sequence assemblies analyzed in silico.

PRINCIPAL FINDINGS

In all three cases, no mutations responsible for resistance to rifampicin, dapsone and ofloxacin were found, thus eliminating drug resistance as a possible cause of disease recurrence. However, sequence differences were detected between the strains from the first and second disease episodes in all three patients. In one case, clear evidence was obtained for reinfection with an unrelated strain whereas in the other two cases, relapse appeared more probable.

CONCLUSIONS/SIGNIFICANCE

This is the first report of using M. leprae whole genome sequencing to reveal that treated and cured leprosy patients who remain in endemic areas can be reinfected by another strain. Next generation sequencing can be applied reliably to M. leprae DNA extracted from biopsies to discriminate between cases of relapse and reinfection, thereby providing a powerful tool for evaluating different outcomes of therapeutic regimens and for following disease transmission.

Number of leprosy reactions during treatment: clinical correlations and laboratory diagnosis

INTRODUCTION:

The occurrence of leprosy reactions, a common event during treatment, may be mostly related to the action of multidrug therapy on Mycobacterium leprae. The clinical and laboratory monitoring of patients with reactions is important, since collecting data that assists in predicting the risk of reactions may help to prevent disability.

METHODS:

This was a sectional study, in order to correlate clinical and laboratory diagnosis with the number of reactions during treatment. Spearman's correlation was used to verify the degree of association between the assessed variables.

RESULTS:

This study was conducted with 211 patients with leprosy reactions during treatment of M. leprae. The borderline tuberculoid group was the most prevalent clinical form (74/211; 35.1%) and the type one reaction showed the highest frequency (136/211; 64.5%). It was observed that 73.5% (155/211) of reactions occurred within 3 months of the initiation of multidrug therapy. The diagnostic values, including the bacterial indices (BIs) of dermal smears (r = 0.21, p < 0.05) and skin biopsies (r = 0.20; p < 0.05), showed a positive correlation with the number of reactions during treatment.

CONCLUSIONS:

This research showed a positive correlation between bacillary load markers and the number of leprosy reactions. This study provided scientific support to future research aiming to elucidate the influence of antigenic load on the number of leprosy reactions during treatment.

Leprosy reactions: The predictive value of Mycobacterium leprae-specific serology evaluated in a Brazilian cohort of leprosy patients (U-MDT/CT-BR)

Background

Leprosy reactions, reversal reactions/RR and erythema nodosum leprosum/ENL, can cause irreversible nerve damage, handicaps and deformities. The study of Mycobacterium leprae-specific serologic responses at diagnosis in the cohort of patients enrolled at the Clinical Trial for Uniform Multidrug Therapy Regimen for Leprosy Patients in Brazil/U-MDT/CT-BR is suitable to evaluate its prognostic value for the development of reactions.

Methodology

IgM and IgG antibody responses to PGL-I, LID-1, ND-O-LID were evaluated by ELISA in 452 reaction-free leprosy patients at diagnosis, enrolled and monitored for the development of leprosy reactions during a total person-time of 780,930 person-days, i.e. 2139.5 person-years, with a maximum of 6.66 years follow-up time.

Principal findings

Among these patients, 36% (160/452) developed reactions during follow-up: 26% (119/452) RR and 10% (41/452) had ENL. At baseline higher anti-PGL-I, anti-LID-1 and anti-ND-O-LID seropositivity rates were seen in patients who developed ENL and RR compared to reaction-free patients (p<0.0001). Seroreactivity in reactional and reaction-free patients was stratified by bacilloscopic index/BI categories. Among BI negative patients, higher anti-PGL-I levels were seen in RR compared to reaction-free patients (p = 0.014). In patients with 0<BI<3, (36 RR, 36 reaction-free), higher antibody levels to PGL-I (p = 0.014) and to LID-1 (p = 0.035) were seen in RR while difference in anti-ND-O-LID positivity was borderline (p = 0.052). Patients with BI≥3 that developed ENL had higher levels of anti-LID-1 antibodies (p = 0.028) compared to reaction-free patients. Anti-PGL-I serology had a limited predictive value for RR according to receiver operating curve/ROC analyses (area-under-the-curve/AUC = 0.7). Anti LID-1 serology at baseline showed the best performance to predict ENL (AUC 0.85).

Conclusions

Overall, detection of anti-PGL-I, anti-LID-1 and anti-ND-O-LID antibodies at diagnosis, showed low sensitivity and specificity for RR prediction, indicating low applicability of serological tests for RR prognosis. On the other hand, anti-LID-1 serology at diagnosis has shown prognostic value for ENL development in BI positive patients.

Trial Registration

ClinicalTrials.gov NCT00669643

Leprosy is a debilitating dermato-neurologic disease caused by Mycobacterium leprae. One of the main difficulties in the clinical management of leprosy patients is the development of leprosy reactions which are immune inflammatory episodes that can cause irreversible handicaps, incapacities and deformities. There are two major types of leprosy reactions: reversal reaction (RR) and erythema nodosum leprosum (ENL). Currently, there is no laboratory test able to predict the emergence of leprosy reactions among recently diagnosed patients. In order to investigate laboratory markers for the occurrence of leprosy reactions, we investigated the prognostic value of serologic responses to M. leprae antigens (PGL-I, LID-1, ND-O-LID) in 452 leprosy patients enrolled at the Clinical Trial for Uniform Multidrug Therapy Regimen for Leprosy Patients in Brazil/U-MDT/CT-BR. At diagnosis higher anti-PGL-I, anti-LID-1 and anti-ND-O-LID seropositivity rates were seen in patients who developed ENL and RR compared to reaction-free patients. The anti-PGL-I serology at diagnosis show low sensitivity to predict RR and anti-LID-1 serology at diagnosis has shown prognostic value for ENL development.

Can baseline ML Flow test results predict leprosy reactions? An investigation in a cohort of patients enrolled in the uniform multidrug therapy clinical trial for leprosy patients in Brazil

BACKGROUND

The predictive value of the serology to detection of IgM against the Mycobacterium leprae-derived phenolic glycolipid-I/PGL-I to identify leprosy patients who are at higher risk of developing reactions remains controversial. Whether baseline results of the ML Flow test can predict leprosy reactions was investigated among a cohort of patients enrolled in The Clinical Trial for Uniform Multidrug Therapy for Leprosy Patients in Brazil (U-MDT/CT-BR).

METHODS

This was a descriptive study focusing on the main clinical manifestations of leprosy patients enrolled in the U-MDT/CT-BR from March 2007 to February 2012 at two Brazilian leprosy reference centers. For research purposes, 753 leprosy patients were categorized according to a modified Ridley-Jopling (R&J) classification and according to the development of leprosy reactions (reversal reaction/RR and erythema nodosum leprosum/ENL), and whether they had a positive or negative bacillary index/BI.

RESULTS

More than half of the patients (55.5 %) reported leprosy reaction: 18.3 % (138/753) had a RR and 5.4 % (41/753) had ENL. Leprosy reactions were more frequent in the first year following diagnosis, as seen in 27 % (205/753) of patients, while 19 % (142/753) developed reactions during subsequent follow-up. Similar frequencies of leprosy reactions and other clinical manifestations were observed in paucibacillary (PB) and multibacillary (MB) leprosy patients treated with U-MDT and regular MDT (R-MDT) (P = 0.43 and P = 0.61, respectively). Compared with PB patients, leprosy reactions were significantly more frequent in MB patients with a high BI, and more patients developed RR than ENL. However, RR and neuritis were also reported in patients with a negative BI. At baseline, the highest rate of ML Flow positivity was observed in patients with a positive BI, especially those who developed ENL, followed by patients who had neuritis and RR. Among reaction-free patients, 81.9 % were ML Flow positive, however, the differences were not statistically significant compared to reactional patients (P = 0.45).

CONCLUSIONS

MB and PB patients treated with R-MDT and U-MDT showed similar frequencies of RR and other clinical manifestations. Positive ML Flow tests were associated with MB leprosy and BI positivity. However, ML Flow test results at baseline showed limited sensitivity and specificity for predicting the development of leprosy reactions.

International open trial of uniform multidrug therapy regimen for leprosy patients: Findings & implications for national leprosy programmes

BACKGROUND & OBJECTIVES

Uniform therapy for all leprosy patients will simplify leprosy treatment. In this context, we evaluated six-month multidrug therapy (MDT) currently recommended for multibacillary (MB) patients as uniform MDT (U-MDT) in a single-arm open trial under programme conditions. Primary objective was to determine efficacy to prevent five-year cumulative five per cent relapse. Secondary objectives were to assess acceptability, safety and compliance.

METHODS

Newly detected, treatment-naive leprosy patients were enrolled in India (six sites) and P. R. China (two sites). Primary outcome was clinically confirmed relapse of occurrence of one or more new skin patches consistent with leprosy, without evidence of reactions post-treatment. Event rates per 100 person years as well as five-year cumulative risk of relapse, were calculated.

RESULTS

A total of 2091 paucibacillary (PB) and 1298 MB leprosy patients were recruited from the 3437 patients screened. Among PB, two relapsed (rate=0.023; risk=0.11%), eight had suspected adverse drug reactions (ADRs) (rate=0.79) and rate of new lesions due toreactions was 0.24 (n=23). Rates of neuritis, type 1 and type 2 reactions were 0.39 (n=37), 0.54 (n=51) and 0.03 (n=3), respectively. Among MB, four relapsed (rate=0.07; risk=0.37%) and 16 had suspected ADR (rate=2.64). Rate of new lesions due to reactions among MB was 1.34 (n=76) and rates of neuritis, type 1 and type 2 reactions were 1.37 (n=78), 2.01 (n=114) and 0.49 (n=28), respectively. Compliance to U-MDT was 99 per cent. Skin pigmentation due to clofazimine was of short duration and acceptable.

INTERPRETATION & CONCLUSIONS

We observed low relapse, minimal ADR and other adverse clinical events. Clofazimine-related pigmentation was acceptable. Evidence supports introduction of U-MDT in national leprosy programmes. [CTRI No: 2012/ 05/ 002696].

Pauci- and Multibacillary Leprosy: Two Distinct, Genetically Neglected Diseases

After sustained exposure to Mycobacterium leprae, only a subset of exposed individuals develops clinical leprosy. Moreover, leprosy patients show a wide spectrum of clinical manifestations that extend from the paucibacillary (PB) to the multibacillary (MB) form of the disease. This "polarization" of leprosy has long been a major focus of investigation for immunologists because of the different immune response in these two forms. But while leprosy per se has been shown to be under tight human genetic control, few epidemiological or genetic studies have focused on leprosy subtypes. Using PubMed, we collected available data in English on the epidemiology of leprosy polarization and the possible role of human genetics in its pathophysiology until September 2015. At the genetic level, we assembled a list of 28 genes from the literature that are associated with leprosy subtypes or implicated in the polarization process. Our bibliographical search revealed that improved study designs are needed to identify genes associated with leprosy polarization. Future investigations should not be restricted to a subanalysis of leprosy per se studies but should instead contrast MB to PB individuals. We show the latter approach to be the most powerful design for the identification of genetic polarization determinants. Finally, we bring to light the important resource represented by the nine-banded armadillo model, a unique animal model for leprosy.

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.

IL-10 and NOS2 modulate antigen-specific reactivity and nerve infiltration by T cells in experimental leprosy

Background

Although immunopathology dictates clinical outcome in leprosy, the dynamics of early and chronic infection are poorly defined. In the tuberculoid region of the spectrum, Mycobacterium leprae growth is restricted yet a severe granulomatous lesion can occur. The evolution and maintenance of chronic inflammatory processes like those observed in the leprosy granuloma involve an ongoing network of communications via cytokines. IL-10 has immunosuppressive properties and IL-10 genetic variants have been associated with leprosy development and reactions.

Methodology/Principal Findings

The role of IL-10 in resistance and inflammation in leprosy was investigated using Mycobacterium leprae infection of mice deficient in IL-10 (IL-10−/−), as well as mice deficient in both inducible nitric oxide synthase (NOS2−/−) and IL-10 (10NOS2−/−). Although a lack of IL-10 did not affect M. leprae multiplication in the footpads (FP), inflammation increased from C57Bl/6 (B6)<IL-10−/−<NOS2−/−<10NOS2−/−. While IL-10−/− mice exhibited modest FP induration compared to B6, NOS2−/− and 10NOS2−/− mice developed markedly enlarged FP marking distinct phases: early (1 month), peak (3–4 months), and chronic (8 months). IFN-γ-producing CD4+CD44+ cells responding to M. leprae cell wall, membrane, and cytosol antigens and ML2028 (Ag85B) were significantly increased in the evolved granuloma in NOS2−/− FP compared to B6 and IL-10−/− during early and peak phases. In 10NOS2−/− FP, CD4+CD44+ and especially CD8+CD44+ responses were augmented even further to these antigens as well as to ML0380 (GroES), ML2038 (bacterioferritin), and ML1877 (EF-Tu). Moreover, fragmented nerves containing CD4+ cells were present in 10NOS2−/− FP.

Conclusions/Significance

The 10NOS2−/− strain offers insight on the regulation of granuloma formation and maintenance by immune modulators in the resistant forms of leprosy and presents a new model for investigating the pathogenesis of neurological involvement.

Despite effective antimicrobial therapy, 30–50% of leprosy patients develop immunological complications called leprosy reactions before, during or even years after being cured. Leprosy reactions are a major risk for neuritis that leads to peripheral nerve damage, disfigurement and disability. Unfortunately, why and how leprosy reactions occur is not well understood. Based on the latest human genetic leprosy susceptibility research and mouse infection models, we generated a double knockout mouse strain (10NOS2−/−) which has deficiencies in two key immune factors, interleukin-10 (IL-10) and inducible nitric oxide synthase (NOS2). We investigated the dynamics of the immune response to Mycobacterium leprae infection and chronicled the types of immune cells recruited to the site of infection. 10NOS2−/− mice developed a substantial induration in response to infection, as well as an increased interferon-gamma response to components of the leprosy bacillus. Interestingly, these animals also exhibited CD4+ T cell infiltration into the nerves, a phenomenon which has not been previously reported in leprosy mouse models. This new model provides insight into potential mechanisms whereby immune modulators may regulate leprosy reactions and neuritis and could aid the development of tests for monitoring and treatment of leprosy patients.

Pre-miR-146a (rs2910164 G>C) single nucleotide polymorphism is genetically and functionally associated with leprosy

Mycobacterium leprae infects macrophages and Schwann cells inducing a gene expression program to facilitate its replication and progression to disease. MicroRNAs (miRNAs) are key regulators of gene expression and could be involved during the infection. To address the genetic influence of miRNAs in leprosy, we enrolled 1,098 individuals and conducted a case-control analysis in order to study four miRNAs genes containing single nucleotide polymorphism (miRSNP). We tested miRSNP-125a (rs12975333 G>T), miRSNP-223 (rs34952329 *>T), miRSNP-196a-2 (rs11614913 C>T) and miRSNP-146a (rs2910164 G>C). Amongst them, miRSNP-146a was the unique gene associated with risk to leprosy per se (GC OR = 1.44, p = 0.04; CC OR = 2.18, p = 0.0091). We replicated this finding showing that the C-allele was over-transmitted (p = 0.003) using a transmission-disequilibrium test. A functional analysis revealed that live M. leprae (MOI 100∶1) was able to induce miR-146a expression in THP-1 (p<0.05). Furthermore, pure neural leprosy biopsies expressed augmented levels of that miRNA as compared to biopsy samples from neuropathies not related with leprosy (p = 0.001). Interestingly, carriers of the risk variant (C-allele) produce higher levels of mature miR-146a in nerves (p = 0.04). From skin biopsies, although we observed augmented levels of miR-146a, we were not able to correlate it with a particular clinical form or neither host genotype. MiR-146a is known to modulate TNF levels, thus we assessed TNF expression (nerve biopsies) and released by peripheral blood mononuclear cells infected with BCG Moreau. In both cases lower TNF levels correlates with subjects carrying the risk C-allele, (p = 0.0453 and p = 0.0352; respectively), which is consistent with an immunomodulatory role of this miRNA in leprosy.

In spite of the successful drug therapy, leprosy is still affecting people worldwide. It is well known that host genetic background influences leprosy development and that genetic variants have been associated with the disease. Therefore we conducted a study to evaluate the role of microRNAs (miRNAs) polymorphisms in leprosy. We observed that a polymorphism in miR-146a is associated with the risk to develop leprosy in Brazilians. Based on the analysis of clinical specimens, we found that the genetic variant was correlated with elevated levels of miR-146a and it is also a negative regulator of tumor necrosis factor (TNF), an important inflammatory mediator in the leprosy context. These findings provide tenable evidences that miR-146a is important in the control of gene expression during M. leprae infection and also may contribute with leprosy development by controlling TNF levels.