Two microbiological relapses in a patient with lepromatous leprosy

A lepromatous patient treated with dapsone in the pre-MDT era to the point of smear negativity (> 6 years), relapsed 5 years after stopping treatment. He was then put on WHO-MDT for multibacillary (MB) leprosy, and was treated again; he had negative slit skin smears (3 years). He again presented with a relapse of leprosy 17 years after stopping treatment, and this time he presented with borderline leprosy in reaction.

Clinical course of erythema nodosum leprosum: an 11-year cohort study in Hyderabad, India

Erythema nodosum leprosum (ENL) or type 2 lepra reactions complicate lepromatous leprosy and borderline lepromatous leprosy. We report an 11-year retrospective case record analysis of 481 outpatients with borderline lepromatous and lepromatous leprosy at the Dhoolpet Leprosy Research Center in Hyderabad, India.. The overall prevalence of ENL was 24%, 49.4% among cases of lepromatous leprosy (LL) and 9% among cases of borderline lepromatous (BL) leprosy. Logistic regression analysis identified LL (odds ratio [OR] = 8.4, 95% confidence interval [CI] = 4.6-15.4, P < 0.001) and BL with a bacterial index > or = 4+ (OR = 5.2, 95% CI = 2.1-12.9, P = 0.001) as major risk factors. The average patient with ENL was male, 34.7 years of age, and had multiple episodes of ENL (mean = 3.1) over an 18.5-month period. Three types of ENL were identified: single acute ENL, multiple acute ENL (repeated discrete episodes), and chronic ENL (continuous episodes). Acute single ENL is rare, accounting for only 8% of cases. Chronic ENL accounted for 62.5% of the cohort. Chronic ENL was of longer duration and more severe. An age > or = 35 years was a risk factor for developing chronic ENL. Patients with chronic ENL were more compliant with multi-drug therapy, especially during the first six doses of multi-drug therapy. Distinguishing these different types of ENL would be useful for patient management and developing improved treatment of these debilitating reactions. Improved strategies for treatment and management of these reactions need to be developed.

The relapse rate in MB leprosy patients treated with 2-years of WHO-MDT is not low

A group of multibacillary patients is clearly at high risk for relapse following 2-yr WHO-MDT. Relapse is largely confined to BL or LL patients with a high BI initially, and occurs long after the discontinuation of therapy. This important group of patients at risk for treatment failure presents several important issues: the need to identify those at risk and the operational requirements needed for their long term follow-up. Also, this group of patients might well benefit from an alternative antimicrobial regimen from the outset, as well as upon relapse.

Analysis of 6000 Skin Biopsies of the National Leprosy Control Program in Mexico

Six thousand skin biopsy specimens taken from April 1978 to January 2002 under conditions as specified by the National Leprosy Control Program (NLCP), were analyzed to obtain information about the work of the program and contribute to the knowledge of this illness in the Mexico. Six-thousand request forms for histologic exam of the NLCP were reviewed. Sixty-two percent of the requests had all the required information and in 38% one or more data items were omitted. The age range was 2 to 98 yrs with a median of 50 yrs; a small number of cases was observed in the age group of 0 to 14 yrs, and the peak was in the age group of 41 to 50 yrs. Of the 6000 biopsies, 3693 were classified. Polar lepromatous (LL) was the most common form of the disease, in 60.3% of cases. Twice as many cases were multibacillary leprosy (MB) as paucibacillary (PB). MB predominated in males, and PB predominated in females. The Cohen's kappa index (kappa) of clinical-histological agreement was 0.202 (95% CI 0.184-0.219) and showed a poor grade of agreement between clinical and histologic diagnosis, with a level of significance of 0.05 (p <0.001). The results may indicate the end of leprosy in Mexico, a country in which the national goal of elimination was reached in 1994, with a prevalence since the year 2000 of 0.17/10 000.

[Perceptions regarding leprosy and resulting handicaps prior to diagnosis in Recife, Brazil]

This article reports on a case-control study conducted in Recife, Brazil, between November 1993 and July 1994, to determine how leprosy patients' perceptions and notions influence disease management and use of health services. The sample was composed of 183 residents of Recife between the ages of 20 and 70 years who sought diagnostic services in the dermatology clinics of two referral centers situated in the third, fourth, and sixth political and administrative regions. Sixty-four patients having handicaps or their precursor lesions were classified as cases; the remaining 119 were used as controls. All were diagnosed during the study period. For the analysis, adjustments were made for sex, age, schooling, and a previous history of Hansen's disease among patients. The study revealed the simultaneous presence of two types of "invisibility" of the disease in an area where endemicity is increasing: 1) for patients in both groups, the low frequency of spontaneous explanatory models related to the illness, even in the presence of disease, and 2) for health professionals, the limitations of detection methods. Since such deficiencies affect decisions bearing on individual and collective disease management, they are a risk factor in and of themselves and stand in the way of eliminating leprosy as a public health problem.

Protective effect of BCG against leprosy and its subtypes: a case-control study in southern Vietnam

A case-control study was conducted to assess the protective effect of intradermal BCG against leprosy and its subtypes in southern Vietnam. A total of 177 cases were selected with a distribution by subtypes as follows: 38 TT, 23 BT, 51 BB, 36 BL, 22 LL, and 7 indeterminate. Two controls were matched with a case for age, sex, ethnic group, socioeconomic status, and district area. The odds ratio assessing the protective effect of BCG varied from 0.44 (0.19-1.03) in the BB subtype to 3.00 (0.24-37.5) in indeterminate leprosy; whereas its overall value was 0.71 (0.45-1.10) for leprosy per se. When all borderline leprosy types were pooled, the protective effect of BCG was found significant with an odds ratio of 0.48 (0.27-0.84). In the polar forms of leprosy, TT and LL, the odds ratio was > 1 with large confidence intervals. It is possible that BCG induces a shift in the immune response to a higher level of cell-mediated immunity. When BCG vaccination is given after primary infection with Mycobacterium leprae, this shift could be the cause of an increase in the risk of the occurrence of milder and transient forms of the disease. In TT forms BCG might reinforce the preexisting subclinical immunopathological reactions, and in stable LL forms BCG might be unable to induce any protective form of immunity. These results confirm the important variability in the protection offered by BCG with respect to the different types of leprosy, and may have important implications for the design and the interpretation of vaccine trials that should take into account the respective proportions of leprosy forms observed in the study region.

Duration of multidrug therapy in paucibacillary leprosy patients; experience in the leprosy control program of the All Africa Leprosy and Rehabilitation Training Center (ALERT) in Ethiopia

Multidrug therapy (MDT), according to the recommendations of a WHO Study Group of 1982, was introduced in the leprosy control program of the All Africa Leprosy and Rehabilitation Training Center (ALERT), Ethiopia, in January 1983. Of 6042 paucibacillary patients who were put on MDT during a period of 7 years, 5485 patients (90.8%) completed the course of MDT; 437 patients (7.2%) did not fulfill the requirement for clinic attendance and either discontinued MDT themselves or the treatment was discontinued by the service. The remaining 120 patients (2.0%) either died, were transferred, left the control area or continued MDT after 9 months. The urine spot test for the presence of dapsone showed a significantly higher proportion of positive results for patients on MDT than for patients on dapsone. The analysis of the compliance with the prescribed doses of MDT showed that of 963 patients, 81.9% received six doses of MDT and 18.1%, more than six doses; 82.6% of these 963 patients attended with 100% regularity, 12.7%, 3.6%, and 1.1% missed one, two, or three clinic appointments, respectively, while fulfilling the requirement for overall clinic attendance. Of the 429 patients who had not been treated with dapsone before MDT, the skin lesions were clinically active at the time of stopping MDT in 130 patients (30.3%). In all, except one of the 114 patients (0.9%) who attended for follow-up examinations, the skin lesions had become clinically inactive within 2 years after stopping MDT. The recommended duration of MDT is discussed based on findings in the ALERT leprosy control programs and observations by others.

Effect of BCG on the risk of leprosy in an endemic area: a case control study

The effect of BCG on the risk of leprosy was measured using a case-control design in an area endemic for the disease. In this study, 397 newly diagnosed cases and 669 controls matched for age, sex and locality were selected from a defined population. Information on exposure to BCG, contact with another case of leprosy, and relevant socioeconomic variables were obtained from the subjects. Having infectious (multibacillary) and noninfectious (paucibacillary) contacts in the household increased the risk of disease 11.7 times (p less than 0.001) and 2.7 times (p less than 0.001), respectively. Overall, the protection offered by BCG was not significant (odds ratio = 0.8; p = 0.17). However, BCG appeared to increase the risk for indeterminate leprosy (adjusted odds ratio = 2.7; p = 0.09) while protecting against borderline disease (adjusted odds ratio = 0.39; p = 0.03). It is possible that BCG causes a shift in the overall cell-mediated immune response, thus increasing the risk for milder and transient forms of leprosy while protecting against more serious forms. These findings may have important implications for the design and interpretation of vaccine trials. Namely, trials should be designed to measure the protective efficacy of vaccines against the more serious forms of leprosy, which have the greatest public health significance.

Leprosy in low endemic areas of India: an appraisal and suggested measures for control

Prevalence of leprosy in the low endemic areas of India is described based on the observations of patients attending an Urban Leprosy Centre in the Union Territory of Delhi from the neighbouring states. The rising incidence in these so-called low to moderate endemic places is closely linked to factors related to urbanisation, movement of people in search of employment, etc., which necessitate fresh surveys in these areas. A significant number of leprosy patients attending the Centre were irregular (37.7%) in therapy and many absconded after the initial visit (35.3%), the reasons for which are discussed. These figures are compared to that from similar low endemic areas and known high endemic parts of the country. Suitable modifications to the control programme in these areas are suggested under the purview of the National Leprosy Eradication Programme.

[Control of the contacts: its interference on the epidemiological status of Hansen's disease]

The control situation of hanseniasis patients' contacts needs a deeper study which would show the reality in the public health centers and their consequence over the whole country. The increasing of the prevalence rate of the disease added to the bad social-economic conditions of the patients and contacts gave us subsidies to important studies to understand the present epidemiological picture. This research had the purpose of diagnosing the control situation of hanseniasis patients' contacts in a public health center which had, at the moment of this research (1983) 160 hanseniasis patients (incidence of 1.2/1000) and 757 contacts registered in a Subprogram of Hansen's Disease Control.