The diagnosis of leprosy is delayed in the United Kingdom

Factors associated with delayed diagnosis of leprosy in an endemic area in Northeastern Brazil: a cross-sectional study

This study aimed to investigate the factors related to the individual and the health system that contribute to delayed diagnosis of leprosy in an endemic area in the Northeastern Brazil. This is a cross-sectional study of 120 individuals with leprosy. Demographic and clinical data and information on the factors related to the individual and the health system that contribute to delayed diagnosis of leprosy were obtained. Delayed diagnosis in months was estimated for each participant by interviews. A multivariate Poisson's regression analysis was performed between the outcome and the independent variables. The median delay in the diagnosis of leprosy was 10.5 (4.0-24.0) months. Approximately 12.6% of participants had grade 2 disability (G2D) at the time of diagnosis. In the multivariate Poisson regression analysis, males, older age, low schooling level, residing in urban areas, multibacellar or tuberculoid leprosy, not seeking healthcare immediately after symptom onset, suspected leprosy, excessive referrals, and the need for three or more consultations to confirm the diagnosis were associated with longer diagnostic delay. This study found a significant delay in the diagnosis of leprosy in Arapiraca, Northeastern Brazil, which may explain the continuously high rate of G2D among new cases. Factors related to the individual and the health system were associated with longer diagnostic delay. Interventions to raise awareness of the disease among the general population and strengthen primary health care are urgently needed.

Leprosy with type 1 reaction in a patient from Ontario, Canada without recent travel misdiagnosed as vasculitic neuropathy: a case report

BACKGROUND

Leprosy is rare within non-endemic countries such as Canada, where cases are almost exclusively imported from endemic regions, often presenting after an incubation period of as many as 20 years. Due to its rarity and prolonged incubation period, diagnosis is often delayed, which may result in neurologic impairment prior to the initiation of treatment. In this report we describe a case that is novel in its incubation period, which is the longest reported to-date and may have contributed to diagnostic delay. The case also uniquely demonstrates the challenges of distinguishing leprosy reactions from new rheumatologic manifestations in a patient with established autoimmune disease.

CASE PRESENTATION

We describe an 84-year-old male patient with rheumatoid arthritis on methotrexate and hydroxychloroquine, with no travel history outside Canada for 56 years, who presented in 2019 with new-onset paresthesias and rash. His paresthesias persisted despite a short course of prednisone, and his rash recurred after initial improvement. He underwent skin biopsy in May 2021, which eventually led to the diagnosis of leprosy. He was diagnosed with type 1 reaction and was started on rifampin, dapsone, clofazimine and prednisone, with which his rash resolved but his neurologic impairment remained.

CONCLUSION

This case report serves to highlight the potential for leprosy to present after markedly prolonged incubation periods. This is especially relevant in non-endemic countries that is home to an aging demographic of individuals who migrated decades ago from endemic countries. The importance of this concept is emphasized by the persistent neurologic impairment suffered by our case due to untreated type 1 reaction. We also demonstrate the necessity of skin biopsy in distinguishing this diagnosis from other autoimmune mimics in a patient with known autoimmune disease.

Leprosy in an Adopted Woman Diagnosed by Molecular Tools: A Case Report from a Non-Endemic Area

Coupled with its rarity in non-endemic areas, the clinical heterogeneity of leprosy makes diagnosis very challenging. We report a diagnosis of multibacillary leprosy in a 22-year-old Indian woman, adopted at the age of 10 and living in Italy. The patient presented with painful skin lesions on the face, trunk, and lower and upper extremities, associated with dysesthesia and a motor deficit in her left leg following corticosteroid therapy interruption. Histopathology results from the skin lesions suggested leprosy, but no acid-fast bacilli were identified. Molecular biology in a center specializing in tropical diseases confirmed the diagnosis, allowing prompt and adequate treatment. Genotype analysis allowed the identification of a genotype 1D of M. leprae, facilitating the epidemiological investigation of the plausible infection origin. No resistances to rifampicin, dapsone, or ofloxacin were detected. Leprosy will continue to exist in high-income nations, and the incidence may rise over time due to increasing migration and globalization. CARE guidelines were followed.

Diagnosing and treating leprosy in a non-endemic setting in a national centre, London, United Kingdom 1995-2018

Background

Leprosy is rare in the United Kingdom (UK), but migration from endemic countries results in new cases being diagnosed each year. We documented the clinical presentation of leprosy in a non-endemic setting.

Methods

Demographic and clinical data on all new cases of leprosy managed in the Leprosy Clinic at the Hospital for Tropical Diseases, London between 1995 and 2018 were analysed.

Results

157 individuals with a median age of 34 (range 13–85) years were included. 67.5% were male. Patients came from 34 different countries and most contracted leprosy before migrating to the UK. Eighty-two (51.6%) acquired the infection in India, Sri Lanka, Bangladesh, Nepal and Pakistan. 30 patients (19.1%) acquired leprosy in Africa, including 11 from Nigeria. Seven patients were born in Europe; three acquired their leprosy infection in Africa, three in South East Asia, and one in Europe. The mean interval between arrival in the UK and symptom onset was 5.87 years (SD 10.33), the longest time to diagnosis was 20 years.

Borderline tuberculoid leprosy (n = 71, 42.0%), and lepromatous leprosy (n =, 53 33.1%) were the commonest Ridley Jopling types. Dermatologists were the specialists diagnosing leprosy most often. Individuals were treated with World Health Organization recommended drug regimens (rifampicin, dapsone and clofazimine).

Conclusion

Leprosy is not a disease of travellers but develops after residence in an leprosy endemic area. The number of individuals from a leprosy endemic country reflect both the leprosy prevalence and the migration rates to the United Kingdom. There are challenges in diagnosing leprosy in non-endemic areas and clinicians need to recognise the symptoms and signs of leprosy.

This study describes the presentation of individuals with leprosy in a non-endemic setting. They came from 34 leprosy endemic countries to the United Kingdom where they were diagnosed with leprosy. Most patients were young adults and male. The number of individuals from a leprosy endemic country reflect both the leprosy prevalence and the migration rates to the United Kingdom. The highest numbers of affected individuals in our cohort were from India, Sri Lanka, Bangladesh, Brazil, and Nigeria. The diagnosis was delayed in many patients and needed to be made by specialists. Patients were treated with World Health Organization recommended multi-drug regimens of rifampicin, dapsone and clofazimine and/or rifampicin, ofloxacin and minocycline. Clinicians in non-endemic settings need to develop and maintain skills in suspecting and diagnosing leprosy. Dedicated services are needed to provide the specialist care individuals affected by leprosy require.

Multibacillary leprosy with an incubation period exceeding 50 years

Leprosy is a chronic granulomatous infection predominantly involving the skin and peripheral nervous system. The condition is caused by infection with the obligate intracellular bacillus Mycobacterium leprae and the clinical phenotype is largely dependent on the host immune response to the organism. Transmission is suspected to occur via respiratory secretions with infection usually requiring prolonged periods of contact. The incubation period is highly variable with disease manifestations appearing up to several decades after the initial exposure. The disease can be broadly divided into ‘paucibacillary’ and ‘multibacillary’, and treatment with multidrug therapy including dapsone, clofazimine and rifampicin offers high rates of cure. Here, we report of a case of leprosy with a suspected incubation period in excess of 50 years following occupational exposure in rural Australia. To our knowledge, this incubation period is the longest reported to date.

Molecular Surveillance of Antimicrobial Resistance of Mycobacterium leprae from Leprosy Patients in Zhejiang Province, China

Purpose

Reports on antimicrobial resistance (AMR) of Mycobacterium leprae (M. leprae) in Zhejiang Province are limited. Thus, this study aimed to investigate the drug resistance of new leprosy cases within several years and analyse the emergence of AMR mutations from Zhejiang Province.

Methods

This study enrolled 34 leprosy cases in Zhejiang Province, China, from 2018 to 2021. Gene mutation of WHO-recommended DRDRs (folP1, rpoB and gyrA) and genes of compensatory AMR-associated DRDRs, including nth, rpoA, rpoC, gyrB and 23S rRNA, were detected by amplification. Clinical data analysis was performed to investigate the epidemiological association of leprosy.

Results

Of the 34 samples, 2 (5.9%) strains showed drug resistance, which were mutated to dapsone and ofloxacin, separately. Two single mutations in gyrB were detected in different strains (5.9%), whereas one of the rpoC mutation was also detected in one strain each (2.9%), which were proved to be polymorphs. No correlation of drug resistance proportion was identified in male vs female, nerve vs no nerve involvement, deformity vs no deformity and reaction vs non-reaction cases.

Conclusion

Results showed well control of leprosy patients in Zhejiang Province. Gene mutations of WHO-recommended DRDRs folP1 and gyrA confirmed the resistance to dapsone and ofloxacin. Compensatory AMR-associated mutations confirmed to be polymorphs still require further study to determine their phenotypic outcomes in M. leprae. The results demonstrated that drug-resistant strains are not epidemic in this area. Given the few cases of leprosy, analysing the AMR of M. leprae in Zhejiang Province more comprehensively is difficult. However, regular MDT treatment and population management in the early stage may contribute to the low prevalence of leprosy.

Leprosy chemoprophylaxis of household contacts: A survey of Canadian infectious disease and tropical medicine specialists

BACKGROUND

Leprosy is uncommon in Canada. However, immigration from leprosy-endemic areas has introduced the infection to a Canadian context, in which most doctors have little knowledge of the disease. Although post-exposure chemoprophylaxis (PEP) is reported to decrease leprosy transmission, no Canadian guidelines advise clinical decision making about leprosy PEP. Here, we characterize the practice patterns of Canadian infectious disease specialists with respect to leprosy PEP and screening of household contacts by yearly physical examinations.

METHODS

Canadian infectious disease specialists with known experience treating leprosy were identified using university faculty lists. An online anonymous survey was distributed. Certain questions allowed more than one response.

RESULTS

The survey response rate was 46.5% (20/43). Thirty-five percent responded that PEP is needed for household contacts, 40.0% responded that PEP is not needed for household contacts, and 25.0% did not know whether PEP is needed (multinomial test p = 0.79). Twenty-five percent responded that PEP should be given to all household contacts, 62.5% responded that PEP should be given to contacts of multibacillary cases, and 25.0% responded that PEP should be given to contacts who are genetically related to the index case. For specialists who prescribe PEP, 57.1% use rifampicin, ofloxacin (levofloxacin), and minocycline; 14.3% prescribe single-dose rifampicin; and 28.6% prescribe multiple doses of rifampicin (multinomial test p = 0.11). In addition, 68.4% recommend yearly screening of household contacts, whereas 31.6% do not (multinomial test p = 0.17).

CONCLUSION

Consensus among Canadian infectious diseases specialists is lacking regarding leprosy PEP and screening of household contacts.

Individual and community factors determining delayed leprosy case detection: A systematic review

Background

The number of new leprosy cases is declining globally, but the disability caused by leprosy remains an important disease burden. The chance of disability is increased by delayed case detection. This review focusses on the individual and community determinants of delayed leprosy case detection.

Methods

This study was conducted according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). The study protocol is registered in PROSPERO (code: CRD42020189274). To identify determinants of delayed detection, data was collected from five electronic databases: Embase.com, Medline All Ovid, Web of Science, Cochrane CENTRAL, and the WHO Global Health Library.

Results

We included 27 papers from 4315 records assessed. They originated in twelve countries, had been published between January 1, 2000, and January 31, 2021, and described the factors related to delayed leprosy case detection, the duration of the delayed case, and the percentage of Grade 2 Disability (G2D). The median delay in detection ranged from 12 to 36 months, the mean delay ranged from 11.5 to 64.1 months, and the percentage of G2D ranged from 5.6 to 43.2%. Health-service-seeking behavior was the most common factor associated with delayed detection. The most common individual factors were older age, being male, having a lower disease-symptom perception, having multibacillary leprosy, and lack of knowledge. The most common socioeconomic factors were living in a rural area, performing agricultural labor, and being unemployed. Stigma was the most common social and community factor.

Conclusions

Delayed leprosy case detection is clearly correlated with increased disability and should therefore be a priority of leprosy programs. Interventions should focus on determinants of delayed case detection such as health-service-seeking behavior, and should consider relevant individual, socioeconomic, and community factors, including stigmatization. Further study is required of the health service-related factors contributing to delay.

Leprosy remains an important public health problem with many new leprosy patients diagnosed with visible physical deformities, indicating a long delay in the detection of cases. For effective prevention programs, it is important to know the factors at the level of the individual and the community that contribute to the delay. We reviewed all published studies that reported individual and community factors related to delayed case detection in leprosy and included 27 studies in our analysis, published between January 1, 2000, and January 31, 2021. Health-service-seeking behavior was the most common factor associated with delay in case detection. The most common individual factors were older age, being male, having a lower disease-symptom perception, having multibacillary leprosy, and lack of knowledge about leprosy. The most common socioeconomic factors were living in a rural area, performing agricultural labor, and being unemployed. Stigma was the most common social and community factor associated with detection delay.

The presence of physical disability in newly diagnosed leprosy patients is clearly related to the delay in detecting these patients. Leprosy control interventions should take factors related to detection delay into account more comprehensively. Also, there is a need to study health service-related factors that contribute to detection delay of leprosy patients.

In search of biomarkers for leprosy by unraveling the host immune response to Mycobacterium leprae

Mycobacterium leprae, the causative agent of leprosy, is still actively transmitted in endemic areas reflected by the fairly stable number of new cases detected each year. Recognizing the signs and symptoms of leprosy is challenging, especially at an early stage. Improved diagnostic tools, based on sensitive and specific biomarkers, that facilitate diagnosis of leprosy are therefore urgently needed. In this review, we address the challenges that leprosy biomarker research is facing by reviewing cell types reported to be involved in host immunity to M leprae. These cell types can be associated with different possible fates of M leprae infection being either protective immunity, or pathogenic immune responses inducing nerve damage. Unraveling these responses will facilitate the search for biomarkers. Implications for further studies to disentangle the complex interplay between host responses that lead to leprosy disease are discussed, providing leads for the identification of new biomarkers to improve leprosy diagnostics.

Utilization of government healthcare services by adult leprosy patients in the Western Province, Sri Lanka

Background

The leprosy services utilization by the patients at the clinic and field level should be high to achieve the target of eliminating leprosy as a public health problem in Sri Lanka. Furthermore, assessing patient and health system delay of a diagnosis and patient knowledge on disease are of equal importance to reveal the accurate picture.

Methods and findings

A descriptive cross-sectional study was conducted to assess the utilization of government healthcare services by 672 adult leprosy patients in Western Province (WP). Paucibacillary patients diagnosed at least six months and above, and Multibacillary patients diagnosed at least 12 months and above were selected by consecutive sampling method. An interviewer-administered questionnaire (IAQ) was used for data collection.

Clinic utilization by leprosy patients was 87.8%. The mean patient-related delay (time taken from the onset of symptoms to the encounter of a doctor/health facility for the first time) was 16.8 months and health care system delay (time taken from the date of clinic registration to start of treatment) was 21.2 days. The overall delay was 17.5 months. Services provided by the Medical Officer of Health (MOH) office for families affected with leprosy was known by 53.8% (n = 298) of patients. Majority of family contacts were examined at the hospitals (n = 299, 44%), 30.8% (n = 207) by the Public Health Inspectors (PHI) and 7% (n = 46) at the MOH offices. PHIs had visited 56.7% (n = 401) of the patient’s houses and 54% (n = 363) had received health education by PHI. Mean knowledge score was 50.7 (SD = 17.9). More than half (57.9%, n = 389) of the study sample had a good or very good knowledge level.

Conclusions

Utilization of clinic services was satisfactory. However, a considerable patient-related delay was found. Half of the patients were aware of available field services and a majority of contact screening was conducted at hospitals. Patient knowledge on leprosy was satisfactory.

Neuropathies of leprosy

Neuropathies form an integral part of the symptomatology of leprosy. Neuropathies of leprosy take various forms and shapes. At one end is the cutaneous nerve involvement adjacent to the anaesthetic skin patch and the other is of symmetrical pansensory neuropathy and the devastating sensory ataxia of leprous ganglionits. Lepra reactions add to the spectrum. Hosts immunological status largely decides the clinical manifestations seen in nerves and skin. A wide array of diagnostic techniques like ultrasonography, magnetic resonance neurography, serological markers, molecular tests, skin biopsy and in selected cases, the nerve biopsy with special stains and electron microscopy are obtainable to help the clinical diagnosis. The unsuspecting clinician, lack of community awareness and limited availability of diagnostic tests are important adverse factors in the total outcome. Multi drug therapy is efficacious and corticosteroids reduce the impact of nerve damage in leprosy. The efficacy, dose and duration of corticosteroid therapy are presently inexact and other immune suppressants like azathioprine are being evaluated. Chronic disabilities and residual deficits require attention of multiple specialties. In the coming time, focus on prevention could lead to favourable results. This review will discuss the classification systems, common and uncommon clinical features, diagnostic armamentarium and therapeutic and preventive aspects of neuropathies of leprosy.

Mycobacterium leprae: Pathogenesis, diagnosis, and treatment options

Mycobacterium leprae is known to cause leprosy, a neurological and dermatological disease. In the past 20 years, 16 million leprosy cases have been recorded and more than 200,000 new cases were registered each year, indicating that the disease is still progressing without hindrance. M. leprae, an intracellular bacterium, infects the Schwann cells of the peripheral nervous system. Several types of leprosy have been described, including indeterminate, tuberculoid, borderline tuberculoid, mid-borderline, borderline lepromatous and lepromatous, and three different forms of leprosy reactions, namely type 1, 2 and 3, have been designated. Microscopic detection, serological diagnostic test, polymerase chain reaction and flow tests are employed in the diagnosis of leprosy. The recommended treatment for leprosy consists of rifampicin, dapsone, clofazimine, ofloxacin and minocycline and vaccines are also available. However, relapse may occur after treatment has been halted and hence patients must be educated on the signs of relapse to allow proper treatment and reduce severity. In this review, we depict the current understanding of M. leprae pathogenicity, clinical aspects and manifestations. Transmission of leprosy, diagnosis and treatment are also discussed.

Leprosy in Refugees and Migrants in Italy and a Literature Review of Cases Reported in Europe between 2009 and 2018

Leprosy is a chronic neglected infectious disease that affects over 200,000 people each year and causes disabilities in more than four million people in Asia, Africa, and Latin America. The disease can appear with a wide spectrum of clinical forms, and therefore the clinical suspicion is often difficult. Refugees and migrants from endemic countries affected by leprosy can remain undiagnosed in Europe due to the unpreparedness of clinicians. We retrospectively describe the characteristics of 55 refugees/migrants with a diagnosis of leprosy established in Italy from 2009 to 2018. Continents of origin were Africa (42%), Asia (40%), and South and Central America (18%). The symptoms reported were skin lesions (91%), neuropathy (71%), edema (7%), eye involvement (6%), fever (6%), arthritis (4%), and lymphadenopathy (4%). Seven patients (13%) had irreversible complications. Overall, 35% were relapses and 66% multibacillary leprosy. Furthermore, we conducted a review of 17 case reports or case series and five nationwide reports, published in the same decade, describing 280 migrant patients with leprosy in Europe. In Europe, leprosy is a rare chronic infectious disease, but it has not completely disappeared. Diagnosis and treatment of leprosy in refugees and migrants from endemic countries are a challenge. European guidelines for this neglected disease in this high-risk population would be beneficial.

Leprosy in a patient infected with HIV

A 60-year-old Nigerian man, who had lived in Europe for 30 years but had returned home frequently, presented with right frontalis muscle weakness and right ulnar nerve palsy, without skin lesions. Neurophysiology showed a generalised neuropathy with demyelinating features. Blood tests were positive for HIV, with a normal CD4 count. There was nerve thickening both clinically and on MRI. Nerve biopsy showed chronic endoneuritis and perineuritis (indicating leprosy) without visible mycobacteria. His neuropathy continued to deteriorate (lepra reaction) before starting treatment with WHO multidrug therapy, highly active antiretroviral therapy and corticosteroids. There are 10 new cases of leprosy diagnosed annually in the UK. Coinfection with HIV is rare but paradoxically does not usually adversely affect the outcome of leprosy or change treatment. However, permanent nerve damage in leprosy is common despite optimal therapy. Leprosy should be considered in patients from endemic areas who present with mononeuritis multiplex.

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.

Imported and autochthonous leprosy presenting in Madrid (1989-2015): A case series and review of the literature

BACKGROUND

Leprosy remains infrequent in non-endemic areas. The objective of this study was to describe the cases of leprosy reviewed at a referral unit for imported diseases in Europe and to compare these findings with published data on imported leprosy.

METHODS

Cases of leprosy evaluated at a referral centre are described and salient features of autochthonous and imported cases are compared. A review of the literature on imported leprosy was performed.

RESULTS

During the study period, 25 patients with leprosy were followed-up (10 were autochthonous cases and 15 were considered to be imported). Regarding imported cases, the majority were diagnosed in Latin American immigrants (10/15, 67%), mean age was 42 years, there were no differences in gender distribution, estimated average time from arrival in Spain to first visit at the unit was 3 years and from symptom onset to diagnosis was 2 years. Over 80% of imported cases had multibacillary disease and over one third of patients had been previously diagnosed with leprosy. One third had received alternate incorrect diagnoses initially, <50% of patients with imported leprosy completed standard therapy and were considered cured and over one third were lost to follow-up.

CONCLUSIONS

Leprosy remains a complex disease for healthcare professionals unfamiliar with this infection. Manifestations are polymorphic so misdiagnoses and consequent delays in diagnosis are not infrequent and may lead to resulting disabilities. Early diagnosis and management are essential to prevent sequelae and possible transmission. Improving access to health care, especially for vulnerable groups, would be necessary to advance in the control of this disease.

Delayed Diagnosis, Leprosy Reactions, and Nerve Injury Among Individuals With Hansen's Disease Seen at a United States Clinic

Background.  Hansen's disease (HD), or leprosy, is uncommon in the United States. We sought to describe the characteristics of patients with HD in a US clinic, including an assessment of delays in diagnosis and HD reactions, which have both been associated with nerve damage. Methods.  A retrospective chart review was conducted on patients seen at an HD clinic in the southern United States between January 1, 2002 and January 31, 2014. Demographic and clinical characteristics were summarized, including delays in diagnosis, frequency of reactions, and other complications including peripheral neuropathy. Results.  Thirty patients were seen during the study time period. The majority of patients were male (73%) and had multibacillary disease (70%). Brazil, Mexico, and the United States were the most frequent of the 14 countries of origin. Hansen's disease "reactions", severe inflammatory complications, were identified among 75% of patients, and nerve damage was present at diagnosis in 36% of patients. The median length of time between symptom onset and diagnosis was long at 12 months (range, 1-96), but no single factor was associated with a delay in diagnosis. Conclusions.  The diagnosis of HD was frequently delayed among patients referred to our US clinic. The high frequency of reactions and neuropathy at diagnosis suggests that further efforts at timely diagnosis and management of this often unrecognized disease is needed to prevent the long-term sequelae associated with irreversible nerve damage.

The demographic and clinical characteristics of leprosy in Saudi Arabia

Leprosy is a chronic disease caused by Mycobacterium leprae. Although the occurrence of leprosy has declined in Saudi Arabia, it has not yet been eradicated. To our knowledge, this descriptive retrospective study is the first to assess the clinical presentation of leprosy at the time of diagnosis in Saudi Arabia. All study subjects were leprosy patients admitted to Ibn Sina hospital, the only referral hospital for leprosy in Saudi Arabia, between January 2000 and May 2012. A total of 164 subjects, the majority of whom (65%) were between 21 and 50 years of age, were included, and the male-to-female ratio was 2.8:1. Of these 164 patients, 63% were Saudis, and 77% of all admitted patients were from the western region. Lepromatous leprosy was observed most frequently (33%), and 31% of cases had a positive history of close contact with leprosy. At the time of diagnosis, 84% of all subjects presented with skin manifestation. The prevalence of neurological deficit at the time of diagnosis was 87%. Erythema nodosum leprosum (E.N.L.) developed in only 10% of all subjects. Further studies are needed to determine the clinical characteristics pertaining to each type of leprosy in the region, and training courses in caring for and diagnosing patients with leprosy should be organized for health workers.

Leprosy as a multilayered biosocial phenomenon: The comparison of institutional responses and illness narratives of an endemic disease in Brazil and an imported disease in Portugal

This paper questions the relation between human health and society from the case study of leprosy. To discuss the cultural and social mediator factors of both the experience of leprosy and outcomes of medical practices, it examines the biomedical twist in the dialectic between citizenship and public good that aimed to turn leprosy into a disease like any other, with the advent of multidrug therapy during the 1980s. Such analysis is based on a multisited ethnography, developed between 2008 and 2013 in two divergent contexts from the global South and North: Brazil, which remains the country in the world with the highest relative cases of leprosy, and Portugal, in which leprosy has become an imported disease. The main results of this research point to the limits of a pharmaceuticalized governmentality of leprosy and to heterogeneous medicalization's processes, which evince the determinacy of historical intersections between the State and civil society, as well as the corollaries of the former in medical care. This paper concludes with an analysis of the partition between biomedical cure and the healing of leprosy, which unveils the intermediation of institutional and extrainstitutional factors in access to health and in the cure of leprosy. It is finally argued that such intermediation requires a public health approach that might resocialize leprosy through a paradigmatic shift toward intersectoral and participatory operational strategies.

Detection of antibodies to both M. leprae PGL-I and MMP-II to recognize leprosy patients at an early stage of disease progression

Antibodies to phenolic glycolipid (PGL)-I and major membrane protein (MMP)-II were evaluated for serodiagnosis of leprosy in Southwest China, and the role in predicting the occurrence of the disease in household contacts (HHCs) of leprosy was examined. Using PGL-I (natural disaccharide-octyl-bovine serum albumin) antigen-based diagnosis (IgM antibodies), we could detect 94.9% of multibacillary (MB) leprosy and 38.9% paucibacillary (PB) leprosy patients, whereas using MMP-II (IgG antibody), 88.1% of MB and 61.1% of PB patients were positive. By combining the 2 tests and considering either test positive as positive, 100% of MB patients and 72.2% of PB patients were found to test positive. Of the HHCs of leprosy, 28.3% and 30% had positive levels of PGL-I and MMP-II Abs, respectively. Seven out of 21 HHCs, who had high Ab titer to either antigen, developed leprosy during the follow-up period of 3 years. These data suggest that the measurement of both anti-PGL-I as well as anti-MMP-II antibodies could facilitate early detection of leprosy.

Leprosy in the 21st century

Despite significant improvements in leprosy (Hansen's disease) treatment and outlook for patients since the introduction of multidrug therapy (MDT) 3 decades ago, the global incidence remains high, and patients often have long-term complications associated with the disease. In this article, we discuss recent findings related to genetics, susceptibility, and disease reservoirs and the implications of these findings for Hansen's disease control and health outcomes for patients. We describe the continued difficulties associated with treatment of inflammatory episodes known as "leprosy reactions," which cause much of the disability associated with the disease and can affect people for many years after MDT is complete. We also discuss some of the contemporary challenges for physicians and patients, including international and internal migration of people affected by the disease. We suggest some important areas of focus for future Hansen's disease research.

Social participation of diabetes and ex-leprosy patients in the Netherlands and patient preference for combined self-care groups

Introduction: Earlier, we showed that neuropathic complications limit social participation of ex-leprosy patients, even in a non-endemic leprosy setting like the Netherlands. Self-care groups for ex-leprosy patients can strengthen self-worth of participants, prevent further handicap, and enable the exchange of coping strategies. For non-endemic leprosy settings with a very low rate of leprosy patients, a self-care group exclusively for (ex)leprosy patients is not likely to be feasible. A combined group with patients facing comparable morbidity would be more efficient than disease-specific self-care groups. Here, we studied the comparability in social constraints of diabetic patients and ex-leprosy patients. Moreover, we investigated if combined self-care groups for ex-leprosy patients and diabetic patients would be desirable and acceptable for possible participants.

Methods: Social participation was studied based on in-depth interviews and Participation Scale information collected from 41 diabetic patients and compared with the data of 31 ex-leprosy patients from a prior study. Moreover, we made an inventory of potential strengths and limitations and attitudes toward combined self-care groups for diabetic patients with neuropathy.

Results: The following themes emerged among diabetic patients: disease confrontation, dependency, conflict with partner or relatives, feelings of inferiority, stigma, abandoning social activities, fear of the future, lack of information, and hiding the disease. These themes were very similar to those voiced by the previously interviewed ex-leprosy patients. The latter more often mentioned stigma and disease ignorance among Dutch health care workers. Whereas ex-leprosy patients perceived stigma on multiple fronts, diabetic patients only mentioned feeling inferior. Diabetic patients experienced some form of participation restriction in 39% of the cases as opposed to 71% of the ex-leprosy patients. Diabetic patients did acknowledge the comparability with leprosy as far as their neuropathic complaints concerned. Yet only 17% showed interest in combined self-care groups. The majority preferred disease-specific self-care groups only focused on diabetic patients. This might have been caused partly by the perception that a self-care group is yet another disease-related demand on their time, rather than an opportunity to become less dependent on health care services.

Conclusion: The physical complications and social problems in ex-leprosy and diabetic patients with neuropathy are similar. Both groups show social participation limitations, yet in contrast to diabetic patients, ex-leprosy patients perceive stigma in more domains in life. Despite the fact that diabetic patients preferred disease-specific, homogeneous self-care groups, we believe that the option of combined groups with ex-leprosy patients and possibly even other people needing chronic wound care is a promising strategy. Therefore, further research is warranted into the acceptance and impact of self-care groups as a strategy to reduce social constraints by diseases causing neuropathy.

The potential for vaccination in leprosy elimination: new tools for targeted interventions

Despite the huge effort and massive advances toward the elimination of leprosy over the last two decades, the disease has proven stubborn; new case detection rates have stabilised over the last few years and leprosy remains endemic in a number of localised regions. The American Leprosy Missions and Infectious Disease Research Institute have undertaken a large research effort aimed at developing new tools and a vaccine to continue the push for leprosy elimination. In this paper, we outline our strategy for the integration of rapid diagnostic tests and lab-based assays to facilitate the detection of early or asymptomatic leprosy cases, as well as the efficient and focused implementation of chemoprophylaxis and immunisation to intervene in leprosy development and transmission.

Early Revelation of Leprosy in China by Sequential Antibody Analyses with LID-1 and PGL-I

Leprosy is a disabling chronic infection, with insidious onset that often evades early detection. In order to detect new leprosy cases in a timely manner, we conducted surveillance visits in some difficult-to-reach mountain areas in South West China where the disease is still prevalent. Our data confirm that Chinese multibacillary (MB) leprosy patients have strong antibody responses against Mycobacterium leprae antigens ND-O-BSA and LID-1. Contacts of clinically diagnosed patients were then monitored at regular intervals by both physical examinations and the laboratory determination of antibody responses in sera collected during these examinations. Elevations in antibody titers indicated the onset of MB leprosy in one of the contacts, and diagnosis was subsequently confirmed on physical examination. Our data indicate that rising antibody titers can be used as a trigger for physical examination or increased monitoring of particular individuals in order to provide early leprosy diagnosis.

Development of leprosy in a patient with rheumatoid arthritis during treatment with etanercept: a case report

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder. There is a clear association between some disease-modifying drugs used to treat RA and infection. The introduction of the anti-tumor necrosis factor (TNF) therapies has improved the outcome of severe RA. The TNF-antagonism may increase susceptibility to granulomatous pathogens such as Mycobacterium tuberculosis, Listeria monocytogenes, and Histoplasma capsulatum.

METHODS

We report the case of a 37-year-old woman with RA receiving an anti-TNF agent, who developed a rash on her back and both legs, which was finally diagnosed as tuberculoid leprosy.

RESULTS

This is the first case of leprosy due to anti-TNF therapy reported in Europe.

CONCLUSIONS

Clinicians should be aware of this and other types of atypical and serious infections that patients may suffer from when treated with anti-TNF agents.

Diagnosing leprosy: revisiting the role of the slit-skin smear with critical analysis of the applicability of polymerase chain reaction in diagnosis

BACKGROUND

Diagnosing leprosy is challenging, especially in early-stage cases, and the need for a sensitive diagnostic tool is urgent. Polymerase chain reaction (PCR) holds promise as a simple and sensitive diagnostic tool, but its usefulness in the Indian context requires further evaluation. Slit-skin smear (SSS) remains the conventional method of leprosy detection. Hence, this study was undertaken to evaluate and compare the diagnostic efficacy of PCR versus that of SSS.

METHODS

Punch biopsy of skin and SSS were obtained from the active margins of lesions. Cases were clinically grouped according to whether they were multibacillary (MB) or paucibacillary (PB) and classified into tuberculoid (TT), borderline tuberculoid (BT), borderline lepromatous (BL), lepromatous (LL), histoid, and indeterminate groups after clinicopathological correlation. DNA was extracted from biopsy specimens, and multiplex PCR was carried out incorporating primers intended for the amplification of a specific 372-bp fragment of a repetitive sequence of Mycobacterium leprae DNA.

RESULTS

Among 164 patients, PCR was positive in 82.3%. The sensitivity of PCR was significantly greater (P < 0.0001) than that of SSS in both the MB (85.9% vs. 59.8%) and PB (75.4% vs. 1.8%) subgroups; the difference in sensitivity in the PB subgroup is remarkable. Positivity by PCR and SSS was found in 100% of LL and histoid leprosy, but PCR had significantly greater (P < 0.0001) positivity in BT leprosy and was of definite increased value in indeterminate and TT leprosy.

CONCLUSIONS

Polymerase chain reaction had higher sensitivity compared with SSS, especially in diagnostically challenging and PB cases. Thus, the use of this costly but sensitive tool should be restricted to this subgroup, because SSS is sufficiently sensitive in the diagnosis of LL and histoid leprosy.

Chronic rhinitis: a manifestation of leprosy

Leprosy, or Hansen disease, is an infection that affects the mucous membranes of the respiratory tract and may manifest with nasal symptoms of chronic rhinitis, including nasal congestion, rhinorrhea, and intermittent epistaxis. We present a case of a woman diagnosed with leprosy as an incidental finding from a biopsy obtained during endoscopic sinus surgery for the management of chronic rhinitis. The diagnosis of leprosy should be considered in patients with nasal symptoms and presumptive chronic rhinitis who do not respond adequately to standard therapies.

Advances and hurdles on the way toward a leprosy vaccine

Prevalence rates for leprosy have declined sharply over the past 20 y, with this decline generally attributed to the WHO multi-drug therapy (MDT) campaign to provide free-of-charge treatment to all diagnosed leprosy patients. The success of this program appears to have reached its nadir, however, as evidenced by the stalled decreases in both global prevalence and new case detection rates of leprosy. Mass BCG vaccination for the prevention of tuberculosis (TB) at national levels has had a positive effect on leprosy decline and is often overlooked as an important factor in current leprosy control programs. Because BCG provides incomplete protection against both TB and leprosy, newer more effective TB vaccines are being developed. The impact that application of these vaccines will have on current leprosy control programs is unclear. In this review, we assess the need for vaccines within leprosy control programs. We summarize and discuss leprosy vaccine strategies that have been deployed previously and discuss those strategies that are currently being developed to augment recent breakthroughs in leprosy control.

Imported leprosy in Italy

BACKGROUND

Leprosy is far from being eliminated with more than 200,000 new cases detected (NCD)/year.

OBJECTIVE

Retrospective analysis between 2003 and 2009 to compare the New Case Detected Rate (NCDR) observed in Italy in the immigrant population with the NCDR of the same population in their country of origin to verify if the cases observed are those expected or not.

METHODS

Leprosy statistics were retrieved from the Italian leprosy register and from official WHO data.

RESULTS

The NCD in Italy were lower than expected, from 2003 when the expected number of NCD was 40.5 between the legally resident immigrants, but only one case was diagnosed (98% of lower from the expected), to 2009 when four NCD were diagnosed and 41 were expected (90% lower from expected).

CONCLUSIONS

This study points out a discrepancy between the observed and the expected cases of leprosy in Italy. Specifically, the number of NCD was less than expected for each studied year. Of course our data do not represent a validation, but only an indication of the leprosy diagnosis in Italy. Difficulty in accessing the health systems, fear of segregation, ignorance and illegal immigrant status with consequent fear of police arrest are possible explaining factors. The critical issue anyhow is the medical expertise. The role of the dermatologist is fundamental. For these reasons, there is still a need for wide spread leprosy teaching programmes. Although with few limitations, this study represents a first approach to validate the accuracy in leprosy diagnosis in Italy.

Specific IgG antibody responses may be used to monitor leprosy treatment efficacy and as recurrence prognostic markers

Although curable, leprosy requires better diagnostic and prognostic tools to accompany therapeutic strategies. We evaluated the serum samples of leprosy patients from Venezuela and Brazil for reactivity against the specific recombinant proteins, ML0405 and ML2331, and the LID-1 fusion protein that incorporates both of these antigens. Antigen-specific IgG was highest in lepromatous leprosy patients (LL) and decreased across the disease spectrum, such that only a small subset of true tuberculoid patients (TT) tested positive. The impact of multidrug therapy (MDT) on these antibody responses was also examined. Several years after treatment, the vast majority of Venezuelan patients did not possess circulating anti-LID-1, anti-ML0405, and anti-ML2331 IgG, and the seropositivity of the remaining cases could be attributed to irregular treatment. At discharge, the magnitude and proportion of positive responses of Brazilian patients against the proteins and phenolic glycolipid (PGL)-I were lower for most of the clinical forms. The monthly examination of IgG levels in LL patient sera after MDT initiation indicated that these responses are significantly reduced during treatment. Thus, responses against these antigens positively correlate with bacillary load, clinical forms, and operational classification at diagnosis. Our data indicate that these responses could be employed as an auxiliary tool for the assessment of treatment efficacy and disease relapse.

The prevalence of ocular complications in leprosy patients seen in the United Kingdom over a period of 21 years

OBJECTIVE

The objective of this study was to determine the prevalence of ocular complications and blindness among leprosy patients presenting in the United Kingdom.

METHODS

Observational prospective study.

RESULTS

A total of 126 consecutive leprosy patients attending their ophthalmic visit were examined, out of which 18 patients were blind in one eye (14.3%) and five patients were blind in both the eyes (4.0%). Visual acuity of ≥ 6/18 was present in 96 patients (76.2%). A total of 65 patients (51.6%) had an ocular complication and 28 patients (22.2%) had a sight-threatening leprosy complication (lagophthalmos, severe corneal, or iris disease). The most common ocular complications were impaired lid closure (24 patients, 19%), impaired corneal sensation (20 patients, 15.9%), cataract (20 patients, 15.9%), mild corneal opacity (17 patients, 13.5%), and iris atrophy (17 patients, 13.5%). Impaired corneal sensation was associated with vision <6/18 (P<0.001, OR 13.5, 95% CI 5.14-35.44) and vision <3/60 (P=0.01 OR 6.42, 95% CI 2.15-19.15). Impaired lid closure was significantly associated with increasing age (P=0.029, OR 1.039, 95% CI 1.0-1.08) and vision <3/60 (P=0.03, OR 6.06, 95% CI 1.81-20.24).

CONCLUSION

There is a significant rate of ocular complications and blindness seen in leprosy patients in the United Kingdom, and over one in five had a potentially sight-threatening ocular complication. Health professionals and all leprosy patients, including those cured of the disease, need to be aware that new eye symptoms and signs require prompt ophthalmology review to prevent avoidable blindness, due to the life-long risk of sight-threatening ocular complications.

Leprosy: a diagnostic trap for dermatopathologists in nonendemic area

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, presenting with different clinicopathological forms. These great variety of presentations make the diagnosis of leprosy a difficult challenge in countries where the disease is not endemic. Moreover, a discordance between the clinical and histopathological diagnosis in classifying a case of leprosy can complicate the issue. We report a 43-year-old woman in whom the diagnosis of leprosy was challenging, especially, because the biopsy was sent without any clinical suspicion and Italy is a nonendemic area. The clinical informations described simply an annular lesion, and histopathology disclosed a superficial and deep moderate perivascular and periadnexal infiltrate in the dermis, predominantly made of lymphocytes with some histiocytes, in the absence of granuloma formation, foamy histiocytes, or giant cells. Only the clinicopathological correlation based upon the patient's family history, her Brazilian origin, and her anesthetic lesions led us to the suspicion of leprosy. We reviewed the slides with more serial cuts and with special stains that eventually revealed a slight perineural lymphohistiocytic infiltrate and the presence of rare bacilli in the nerves, more consistent with indeterminate leprosy. However, the clinical features and the detection of just few bacilli in the skin lesions and skin smears were more consistent with a borderline leprosy. The discordance between the clinical and histopathological diagnosis in the setting of leprosy is discussed.

Tuberculoid leprosy in a patient with AIDS: a manifestation of immune restoration syndrome

An HIV positive male from Brazil, living in Italy since 1989, developed a single non-itching, papulo-erythematous infiltrative lesion on the face after 2 months from the beginning of HAART. A diagnosis of leprosy was made, suggesting that the immunodeficiency masked the disease, until the skin manifestation became evident with immune-recovery.