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ORIGINAL ARTICLE
Year : 2014  |  Volume : 59  |  Issue : 2  |  Page : 158-162
Clinical profile of leprosy patients: A prospective study


1 Department of Dermatology, GMERS Medical College, Gotri, India
2 Preventive and Social Medicine, Medical College, Vadodara, Gujarat, India

Date of Web Publication21-Feb-2014

Correspondence Address:
Sejal Thakkar
202, Wings Ville, 41, Arunoday Society, Alkapuri, Vadodara - 09, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.127676

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   Abstract 

Introduction: Early diagnosis and early adequate drug treatment is very important aspect to reduce the load in cases of leprosy. So, correct labeling of paucibacillary and multibacillary cases is a prerequisite for the adequate treatment. Confirmation of diagnosis is an important indication for histopathological examination in doubtful cases. Objectives: The present study was carried out to know the clinical profile of leprosy patients, concordance between clinical and histopathological diagnosis in cases of leprosy, and to assess the therapeutic efficacy of antileprosy therapy. Study Design: Two hundred and fifty clinically diagnosed leprosy patients attending skin outdoor patient department (OPD) were included in the study. Slit skin smear was performed in all the cases. In that case concordance between clinical and histology can be determined only in 30 cases. All the patients were treated with MDT (multidrug therapy) as per WHO guideline. Results: A total of 250 patients attended the clinic with male to female ratio of 1.7:1. The highest incidence was noted in 17-40 years of age group. In the clinical disease spectrum, 40% patients were in the borderline spectrum followed by tuberculoid leprosy (TT) (29.2%), lepromatous leprosy (LL) (26.8%), and 3.9% of indeterminate leprosy (IL). A total of 18% of patients were of primary neuritic leprosy. A total of 8.3% patients had definite history of contact in the family or neighborhood. Clinicopathological correlation was noted in 60% of patients with maximum disparity (52.9%) in the borderline group of patients. A total of 52.8% were MB (Multibacillary) and 47.2% were PB (Paucibacillary) cases. Morphological index became negative after 6 months in all patients. Mean fall of bacteriological index after 6 months was 0.19, while after 1 year, it was 1.05. Conclusion: Timely diagnosis and adequate treatment of cases with MDT is most effective. Histopathological examination is must in doubtful cases of leprosy.


Keywords: Clinicopathological correlation, leprosy, multidrug therapy


How to cite this article:
Thakkar S, Patel SV. Clinical profile of leprosy patients: A prospective study. Indian J Dermatol 2014;59:158-62

How to cite this URL:
Thakkar S, Patel SV. Clinical profile of leprosy patients: A prospective study. Indian J Dermatol [serial online] 2014 [cited 2019 Jun 20];59:158-62. Available from: http://www.e-ijd.org/text.asp?2014/59/2/158/127676

What was known?
1. Maximum parity in clinicopathological correlation in the polar group of leprosy is very well known 2. Timely diagnosis and adequate treatment of cases with MDT, before nerve damage has occurred, is the most effective.



   Introduction Top


Leprosy still continues to be one of the major public health problems in many countries including India. Though in 2010-2011, Annual New Case Detection Rate (ANCDR) has been reduced to 4.12% from 10.93 during 2009-2010, there are still 48.6% of MB cases detected in 2010-2011. [1] The principle of reducing the load of infection is the cornerstone of leprosy control. Early diagnosis and early adequate drug treatment is very important aspect to reduce the load. For this, most of the times, clinical judgment and skin smear examination is adequate. But in some cases, to label only on clinical bases is difficult. So, confirmation of diagnosis in doubtful cases of leprosy is an important indication for histopathological examination. Moreover, correct labeling of paucibacillary and multibacillary cases is a prerequisite to treat them adequately which reduces the chances of occurrence of resistant cases. So, clinicopathological correlation of leprosy assumes a pivotal role for early diagnosis and proper labeling of the case for adequate treatment. To offset the problems like resistance, relapse, and bacterial persistence, WHO has suggested different types of multidrug regimens, should be given in full dosages for an adequate period and without interruption in leprosy patients.

The present study was carried out to know the clinical profile of leprosy patients, to assess the concordance between clinical and histopathological diagnosis and the therapeutic efficacy of antileprosy therapy in leprosy patients.


   Materials and Methods Top


The present study was a prospective observational study, carried out during August 1996 to July 1998 in Gujarat. A total of 250 leprosy cases were enrolled for the study attending the Skin OPD. Predesigned and pretested proforma was filled after taking informed consent. Privacy and confidentiality were maintained.

The freshly diagnosed untreated paucibacillary as well as multibacillary cases were taken for the study. Detailed history and thorough clinical examination were carried out in each patient. Information was recorded using semistructured questionnaire guidelines by using local vernacular language. Family/contact history was also noted. A family contact was defined as a person suffering from leprosy in the immediate family; like parents, siblings, and grandparents living in the same house. The cases in the neighborhood were defined as other than family contact and these were people living in the immediate neighborhood. Patients were diagnosed clinically on the basis of IAL consensus classification. [2] Slit skin smear was performed in each case at the time of diagnosis and 6 monthly thereafter. Skin biopsy was taken in 30 cases randomly and subjected to the histopathological examination. Apart from this, four cases of uncharacteristic leprosy were also subjected for the skin biopsy. Patients were classified as PB and MB according to WHO guidelines [3] and treated with the respective regimens.

In cases of lepra reactions, type 1 or type 2, patients were treated accordingly with glucocorticoids, nonsteroidal anti-inflammatory drugs, zinc, and multivitamin therapy. The patients having deformities were graded according to WHO guidelines [4] and advised for physiotherapy and appropriate splints like gutter splint, adductor band, and micro cellular rubber shoes. Few patients were also advised for surgical interventions like skin grafting for trophic ulcers and tendon transposition. All the patients were followed up monthly till the completion of the therapy and 6 monthly thereafter.


   Results Top


Of the 250 patients studied, 158 were males and 92 females. Age ranged from 2 to 80 years. Maximum cases, 132 (52.8%) were in the age group of 17-40 years. Thirty-one (12.3%) cases belonged to the pediatric age group in which, six cases were of MB category. Twenty-one (8.3%) cases showed positive family/contact history in neighborhood [Table 1]. Nearly half (48.3%) of childhood leprosy cases had a household contact with leprosy.
Table 1: Demographic profile of leprosy patients

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In this study, out of 250 patients, 205 patients were with primary cutaneous manifestations while 45 patients presented with primary neuritic leprosy. In patients with primary cutaneous manifestations, major part of the spectrum was formed by the borderline group which included 82 (40%) patients. [Figure 1] Maximum patients 40 (19.5%) were of borderline tuberculoid (BT) leprosy [Table 2]. TT [Figure 2] and LL patients comprised 29.2% and 26.8% respectively. Four of the cases were presented as localized borderline lepromatous (BL) cases. In patients with primary neuritic leprosy, 16 (35.3%) patients of polyneuritic leprosy were recorded, while 14 (31.1%) patients presented with cutaneous lesions of TT (35.71%) and BT (64.29%) at the time of diagnosis. History regarding previous complaint revealed the presence of neuritic symptoms prior to the examination. These patients were diagnosed as patients of neuritic leprosy with TT/BT in their course of the disease. Among these, 132 (52.8%) were of the MB group while 118 (47.2%) were of the PB group. Deformities were observed in 42.8% of patients which comprised 29.2% patients of grade 1 and 13.6% of grade 2. Lepra reactions were seen in 9.6% of patients which showed 3.2% of type 1 reactions and 6.4% of type 2 lepra reactions.
Table 2: Clinical profile of leprosy patients

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Figure 1: Borderline lepromatous leprosy: Multiple erythematous annular plaques

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Figure 2: Tuberculoid leprosy: A well - defined, annular, anesthetic plaque. Slit skin smear has been taken

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Among 30 patients in whom skin biopsy was done and histopathological examination performed, clinicopathological correlation was seen in 60% of cases. Maximum disparity (75%) was observed in the borderline group of patients. The polar forms, i.e., TT and LL, had a disparity of 28.6% and 20% respectively [Table 3].
Table 3: Clinicopathological correlation in leprosy patients

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Four uncharacteristic cases presented with 1-2 well-defined hypopigmented lesions with mild-to-moderate sensory impairment having slit skin smear positive only from the lesion were subjected for the biopsy and showed the features of BL leprosy.

One hundred and thirty two (52.8%) patients were treated with MB-MDT while 118 (47.2) were treated with PB-MDT according to WHO guideline. [3] The response was noted clinically as partial or marked regression of the lesion and/or sensory improvement in the PB group of patients. In the MB group of patients, fall of mean BI after 6 months was 0.19 while after 12 months; it was 1.05.


   Discussion Top


Leprosy, also known as Hansen's disease, is a chronic, granulomatous, infectious disease that primarily affects the skin and the peripheral nerves. It is a spectral disease in which the clinical and pathological features reflect the cell-mediated immunity of the host, so it needs an appropriate classification because of its varied manifestations. The WHO classification [3] of dividing leprosy into PB (<5 lesions) and MB (≥5 lesions) is recommended for routine use and either Indian or Ridley-Jopling classification for research workers. [5] Pure neuritic leprosy has been recognized as a separate group in Indian classification of leprosy and its modified version. [2] Diagnosis of leprosy is based on different clinical parameters which involves detailed examination of skin lesions and peripheral nerves. Demonstration of acid-fast bacilli in slit skin smears by Ziehl-Neelsen's staining also aids in diagnosis of leprosy. A reliable diagnosis hinges around a good histopathological diagnosis and demonstration of bacilli in histopathological sections.

The study included 250 patients ranging from 2 to 80 years which showed slightly higher preponderance in males (M:F - 1.71:1). This indicates their more vulnerability because of greater mobility and increased opportunities for contact in big population. Though majority patients were middle aged (132), 12.3% were children up to 16 years of age. Positive family/contact history (8.3%) was comparable with the study of Salodkar and Kalla which showed it in 9.5% of the cases. [6] Clinical spectrum of leprosy cases in the present study revealed maximum cases in borderline (40%) in the borderline group (BT + BB + BL), followed by TT (29.2%), LL (26.8%), and least in the IL group (3.9%) and similar predominance of cases in the borderline group was also observed by Sharma and Sharma, [7] Shenoi and Sidappa, [8] Nadkarni and Rege, [9] and Moorthy et al. [10] Uncharacteristic presentation was seen in four cases with the findings of localized BL. All of these four patients showed smear negative from the other sites but +1 or +2 from the lesions which were one or two in number. Histopathology suggested the findings of BL. This highlights the value of slit skin smear as well as histopathology in suspected cases.

In the present study, 18% of the patients presented with primary neuritic leprosy among which 14 (31.1%) patients presented with cutaneous lesions of TT (35.71%) and BT (64.29%) leprosy at the time of diagnosis. These patients were diagnosed as patients of neuritic leprosy with TT/BT in their course of the disease. Panikar and Arunthathi showed 23.5% of cases presenting with neuritic leprosy with TT/BT. [11] In another study by Jacob and Arunthathi, 67% of primary neuritic leprosy patients developed skin lesions on long-term follow-up. [12] Follow-up of the patients with pure neuritic leprosy shows the development of skin lesions in 35% of cases over 3-5 years with or without treatment. [13] This suggests that neuritic symptoms probably are the earliest symptoms of leprosy before development of skin lesions and that is why, patients of pure neuritic leprosy must be followed up for the long term. Deformities were observed in 42.8% of the cases (grade 1-29.2%, grade 2-13.6%). Leprosy, a social stigma, would really mean deformities and disabilities by an affected person. One of the important measures to prevent such impairments is to diagnose the disease early and institute proper treatment promptly. So recent strategy has focused on new case detection with intense screening of deformities. [14] The present study showed 24 (9.6%) patients of lepra reactions which included 8 (3.2%) of type 1 and 16 (6.4%) of type 2 reactions. Two out of eight cases belonged to the PB group and rest six of type 1 as well as all 16 cases of type 2 reactions belonged to the MB group. Salodkar and Kalla showed 11.1% patients of lepra reactions amongst which 19.9% of type 1 and 80.1% of type 2 reactions. [6]

Leprosy cases showed so many diversities between the clinical and histopathological features. In the present study, the histopathological characteristics were consistent with the clinical diagnosis in 18 out of 30 (60%) patients. In a study conducted by Shenoi and Siddappa and Singh et al., the histopathological features were consistent with clinical diagnosis in 47% and 47.6% respectively. [8],[15] Maximum disparity was found in borderline cases, which is in concordance to the observations recorded by Shenoi and Siddappa, [8] Nadkarni and Rege, [9] Moorthy et al., [10] Kalla et al., [16] Shankar Naryan et al., [17] and Singhi et al.[18]

Maximum parity is seen in the polar group, because they are stable and showed a fixed histopathology, while the borderline group may have different histopathology in different sites and lesions. The study of pathological changes in leprosy lesions has contributed a great deal to understanding of the disease and clinico-pathological correlative studies have provided further insights into the disease, its varied manifestations, and complications. Pathological examination helps to confirm a presumptive clinical diagnosis and also helps for exact typing.

Out of 118 patient treated with PB-MDT, 61% of the patients showed marked regression or sensory improvement which is comparable with the study done by Kaur and [Figure 3]. [19] The smear positive patients treated with MB-MDT were considered for morphological (MI) as well as mean bacteriological index (BI). All the smear positive patients had granular or fragmented bacilli after the 6-month course of antileprosy treatment. The fall of mean BI after 6 months was 0.19 in the present study while in the study of Singh and Tiwari, it was 0.24. [20] At the end of 1 year, the fall was 1.05 in the present study while in the study of Nandkishore and Shetty, it was 0.74. [21]
Figure 3: Response to 6 months PB-MDT in leprosy patients (compared with study by Kaur and Sharma)

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Childhood leprosy

Childhood leprosy accounted for 31 (12.3%) of cases, in which six were of the MB group. Positive family/contact history in childhood leprosy was seen in almost half (48.3%) of the cases. All patients (8) of IL had positive family history. Four of them had been detected on screening during treatment of the adults (MB cases) of those families. The study by Sachadeva et al. also noted positive history of leprosy in neighborhood in 35% of cases. [5] It indicates that familial contacts play a significant role in development of the disease.


   Conclusion Top


Childhood leprosy forms a significant group. Higher incidence of positive contacts in children emphasizes systematic screening to detect the disease earlier. Pure neuritic leprosy patients should be kept under close surveillance for a longer period. Clinical judgment and skin smear examination are required for early diagnosis and adequate treatment to make the patient noninfectious. But in some early and borderline cases of leprosy, it is difficult to label only on clinical basis. So histopathological examination is must for confirmation of diagnosis in doubtful cases of leprosy. Moreover, correct labeling of paucibacillary and multibacilllary cases is a prerequisite. No multibacilllary case should be treated as paucibacillary case. Timely diagnosis and adequate treatment of cases with MDT, before nerve damage has occurred, is the most effective.

 
   References Top

1.Central Leprosy Division, Directorate General of Health Services, Nirman Bhawan, New Delhi - 110011, India. NLEP - Progress Report for the year 2010-11 ending on 31 st March 2011.  Back to cited text no. 1
    
2.Indian association of Leprologists-approved classification. Lepr India 1982;54:22-32.  Back to cited text no. 2
    
3.World Health Organizion. Chemotherapy of leprosy for control programmes. WHO Tech Rep Ser 675. Geneva: WHO; 1982.  Back to cited text no. 3
    
4.WHO Expert Committee Report on Leprosy. Sixth Report. TRS 768. Geneva: WHO; 1988.  Back to cited text no. 4
    
5.Sachdeva S, Amin SS, Khan Z, Alam S, Sharma PK. Childhood leprosy: A retrospective study. J Public Health Epidemiol 2010;2:267-71.  Back to cited text no. 5
    
6.Salodkar AD, Kalla G. A clinicoepidemiological study of leprosy in arid North west Rajasthan, Jodhpur: Ind J Lepr 1995;57:161-6.  Back to cited text no. 6
    
7.Sharma A, Sharma RK, Goswsami KC, Bardwaj S. Clinico-Histopathological Correlation in Leprosy. JK Science 2008;10:120-3.  Back to cited text no. 7
    
8.Shenoi SD, Siddappa K. Correlation of clinical and histopathologic features in untreated macular lesions of leprosy: A study of 100 cases. Ind J Lepr 1988;60:202-6.  Back to cited text no. 8
    
9.Nadkarni NS, Rege VL. Significance of histopathological classification in leprosy. Ind J Lepr 1999;7:325-32.  Back to cited text no. 9
    
10.Moorthy BN, Kumar P, Chatura KR, Chandrasekhar HR, Basavaraja PK. Histopathological correlation of skin biopsies in leprosy. Ind J Dermatol Ven Leprol 2001;67:299-301.  Back to cited text no. 10
    
11.V Pannikar VK, Arunthathi S, Chacko CJ, Fritschi EP. A clinicopathological study of primary neuritic leprosy. Ind J Lepr 1983;55:212-21.  Back to cited text no. 11
    
12.Jacob M, Arunthathi S. A study of primary neuritic leprosy (Abst): In Proc XIII Int Lep Congr (September 11-17); The Wague; 1988, 313.  Back to cited text no. 12
    
13.Girdhar BK. Neuritic leprosy. Indian J Lepr 1996;68:35-42.  Back to cited text no. 13
[PUBMED]    
14.Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy (Plan Period: 2011-2015) World Health Organization SEA-GLP-2009.3.  Back to cited text no. 14
    
15.Singh K, Iyengar B, Singh R. Variation in clinical and histopathological classification of leprosy: A report and plausible explanation. Lepr India 1983;55:472-9.  Back to cited text no. 15
[PUBMED]    
16.Kalla G, Salodkar A, Kachhawa D. Clinical and histopathological correlation in leprosy. Int J Lepr 2000;68:184-5.  Back to cited text no. 16
    
17.Shanker Narayan NP, Ramu G, Desikan KV, Vallishayee RS. Correlation of clinical, histological and immunological features across the leprosy spectrum. Ind J Lepr 2001;73:329-42.  Back to cited text no. 17
    
18.Singhi MK, Kachhawa D, Ghiya BC. A retrospective study of clinico-histological correlation in leprosy. Ind J Pathol Microbiol 2003;46:47-8.  Back to cited text no. 18
    
19.Kaur S, Sharma VK, Basak P, Kaur I. Paucibacillary multidrugtherapy in leprosy: 7 1/2 year experience. Ind J Lepr 1992;64:153-61.  Back to cited text no. 19
    
20.Singh RP, Tiwari VD, Chattopadhyay SP. Comparative study of short term results in two multidrug regimens in MB leprosy. Ind J Lepr 1993;65:173-80.  Back to cited text no. 20
    
21.Kishore BN, Shetty JN. Bacterial clearance with WHO recommended MDR for MB leprosy. Ind J Lepr 1995;67:301-8.  Back to cited text no. 21
    

What is new?
Neuritic symptoms probably are the earliest symptoms of leprosy before development of skin lesions and that is why, patients of pure neuritic leprosy must be followed up for the long term.


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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