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SHORT COMMUNICATION
Year : 2021  |  Volume : 66  |  Issue : 3  |  Page : 308-313
Health burden of Hansen's disease in central India: A 4-year retrospective study


1 From the Department of Dermatology, Venereology and Leprosy, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Parel, Mumbai, India
2 Department of Dermatology, Venereology and Leprosy, Government Medical College, Nagpur, Maharashtra, India

Date of Web Publication13-Jul-2021

Correspondence Address:
Bhagyashree B Supekar
Department of Dermatology, Venereology and Leprosy, Government Medical College, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_688_19

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   Abstract 


Background: Despite the implementation of multidrug therapy by WHO to treat Hansen's disease (HD), new case detection rates are still high indicating active transmission. Aims and Objectives: To study the clinical profile of HD in central India along with its epidemiological characteristics. Materials and Methods: Medical records of clinically diagnosed Hansen's patients were recruited retrospectively during January 2015 to December 2018. Case records were evaluated with respect to demographic, clinical, histopathological, and bacteriological investigations, development of reaction, and deformities. Patients were classified based on Ridley Jopling classification and treated accordingly. Statistical analysis was done using proportion, mean, and percentage. Results: A total of 400 new patients were enrolled and males outnumbered females. Maximum cases, 115 (28.75%), were in the age group of 31–40 years. Sixteen (4%) cases belonged to the pediatric age (less than 18 years) group. Most common clinical spectrum was borderline lepromatous (n = 156, 39%) followed by lepromatous HD (n = 120, 30%). Eleven patients had pure neuritic HD and nine had histoid HD. Grade 2 deformity was found in 52 and grade 1 deformity was found in 16 patients. Most common lepra reaction was type 2 lepra reaction (n = 112, 28%). Thirteen (3.25%) patients were of relapse of HD among which maximum eight were BL HD followed by LL HD three (0.75%) and TT HD two (0.5%). Conclusion: Early diagnosis is very important for timely and proper implementation of treatment which will prevent sequelae and physical disabilities that can have an impact on the individual's social and working life, which are responsible for stigma and prejudice regarding the disease. Detection of this huge number of cases signifies a high burden of HD in this area even in the post elimination era.


Keywords: Burden, deformity, elimination, Hansen's disease, relapse, transmission


How to cite this article:
Shah VH, Singh RP, Agrawal SK, Supekar BB, Panindra L. Health burden of Hansen's disease in central India: A 4-year retrospective study. Indian J Dermatol 2021;66:308-13

How to cite this URL:
Shah VH, Singh RP, Agrawal SK, Supekar BB, Panindra L. Health burden of Hansen's disease in central India: A 4-year retrospective study. Indian J Dermatol [serial online] 2021 [cited 2021 Aug 2];66:308-13. Available from: https://www.e-ijd.org/text.asp?2021/66/3/308/321326





   Introduction Top


Hansen's disease (HD), more commonly known as Leprosy, is a chronic granulomatous disease caused by Mycobacterium leprae (M. leprae) which primarily affects the nerves and skin and secondarily other organs.[1] Leprosy still continues to be one of the major public health problems in many countries including India. There were 2,16,108 new leprosy cases registered globally in 2016, according to official figures from 145 countries from the 6 World Health Organization (WHO) Regions. The global prevalence rate was 0.29/10,000 at the end of 2016.[2] In India, a total of 1,35,485 new cases were detected during the year 2016-17, which gave Annual New Case Detection Rate (ANCDR) of 10.17 per 1,00,000 population.[3] Although India achieved the elimination target of HD of less than 1 case per 10,000 population in December 2005, even today HD continues to be a cause of significant public health concern.[4] The prevalence rates of HD in the pediatric age group in various studies vary from 5.1% to 11.43% in India.[5] HD in pediatric age group indicates a hidden reservoir of infective cases in the community, the usual source of contact being the family members, neighbours, or contact from fellow students in the schools where they are studying.[1]

Worst affected regions in India include Bihar, Orissa, Chhattisgarh, Gujarat, Jharkhand, MP, Maharashtra, Dadra and Nagar Haveli, Lakshadweep, etc. where prevalence is found to be more than 2 in many districts.[3] Accurate diagnosis of HD is of elementary importance to all aspects of the disease including social aspects, epidemiology, case management, and the prevention of disabilities. Delay in the diagnosis and misdiagnosis of HD are more common due to long incubation period and atypical clinical presentation.[6] Government has recently launched the Leprosy Case Detection Campaign (LCDC) for early detection of HD and for providing timely treatment. Hence, the current study was undertaken to study the clinical features of HD and estimate pediatric cases of HD.


   Materials and Methods Top


This was a retrospective cross-sectional study in which medical records of all Hansen's patients from prefilled proformas, attending the department of Dermato-Venereo-Leprology, during January 2015 to December 2018 were analysed. Medical records of the patients including age, sex, occupation, address, marital status, onset of lesions, duration of lesions, associated symptoms, history of previous treatment, and family history were analyzed.

Detailed cutaneous examination including morphology, peripheral nerve palpation, sensory, motor and cranial nerve examination, and investigations including slit skin smear and histopathological examination were analyzed from predesigned proformas. Based on history, clinical examination, and investigations, a diagnosis of HD was made and patients were classified based on Ridley Jopling classification as tuberculoid (TT) HD, borderline tuberculoid (BT) HD, midborderline (BB) HD, borderline lepromatous (BL) HD, and lepromatous (LL) HD. In addition to these, patients who did not have any cutaneous findings with significant nerve conduction abnormalities were classified under pure neuritic (PN) HD. All diagnosed patients were treated with Paucibacillary (PB) therapy (MDT)/Multibacillary MB-MDT based on their spectrum and patients were followed up for any lepra reaction, side effects of multidrug therapy, and deformity. Statistical analysis was done using mean, proportion, and percentage.


   Results and Observations Top


Total 400 new patients with HD were enrolled among which 250 were males and 150 were females (M:F ratio = 1.67) [Graph 1]. Age of the patients ranged from 14 to 76 years. Maximum cases (n = 115, 28.75%) were in the age group of 31–40 years. Forty-five cases belonged to the age group above 60 years, while sixteen belonged to age less than 18 years [Table 1]. Primary cutaneous manifestation was observed in 389 (97.25%). Most common clinical spectrum was BL HD (n = 156, 39%) followed by LL HD (n = 120, 11.5%). Eleven (2.75%) patients had PN HD, while nine (2.25%) had histoid HD [Table 2] and [Figure 1], [Figure 2]. BT HD was the most common spectrum reported in the pediatric age group (n = 6). Positive contact history was present in 12 (75%) children.

Table 1: Agewise distribution

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Figure 1: (a) Patch of tuberculoid Hansen's disease over forearm. (b) Patches of borderline tuberculoid Hansen's disease over back. (c) Patches of midbordeline Hansen's disease over trunk. (d) Lesions of borderline lepromatous Hansen's disease over face

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Figure 2: (a) Patches of borderline Hansen's disease over trunk, (b) leonine facies, (c) histoid lesions over abdomen, and (d) histoid lesions over forearm

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Table 2: Clinical spectrum of HD

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Overall, the most common site in TT HD was head and neck region 12 (40%) and of BT HD was upper limb 37 (55.22%). The most common site of lesion in the pediatric age group was upper limb (43.75%) [Table 3]. Most common morphological type present in LL HD was nodular 56 (46.67%) followed by plaque 37 (9.25%) and diffuse 37 (9.25%).
Table 3: Distribution of lesions in children (spectrum TT HD and BT HD)

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Most common lepra reaction reported was type 2 lepra reaction (n = 103, 25.75%) followed by type 1 lepra reaction (n = 20, 5%). Type 2 lepra reaction occurred commonly in BL spectrum (n = 53, 13.25%), whereas type 1 reaction occurred most commonly in BT spectrum (n = 15, 3.75%) [Graph 2] and [Figure 3].

Figure 3: (a and b) Type 1 Lepra reaction with involvement of face, back, and buttocks; (c) Erythema nodosum leprosum over face and trunk

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Most common deformity reported was grade 2 (n = 52, 13%) followed by grade 1 deformity (n = 16, 4%) both occurring commonly in BL HD [Graph 3]. Most common type of deformity was trophic ulcer (n = 28, 7%), followed by ulnar claw hand (n = 17, 4.25%) [Table 4] and [Figure 4].

Table 4: Yearwise distribution of deformities in HD

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Figure 4: Deformity: (a) saddle nose, (b) trophic ulcer, (c) ulnar claw hand

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In patients with cutaneous manifestations, skin biopsy was done and histopathological examination performed and it was noted that 171 (42.75%) of cases showed clinicopathological correlation (CPC). Maximum CPC 24 (80%) was observed in the TT group of patients [Table 5].
Table 5: Clinicopathological correlation

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Three hundred seventy-seven (94.25%) patients were treated with MB-MDT while twenty-three (5.75%) were treated with PB-MDT according to WHO guideline. Thirteen (3.25%) patients were of relapse of HD among which maximum eight were BL HD followed by LL HD three (0.75%) and TT HD two (0.5%). Relapse patients were diagnosed as per the criteria shown in [Table 6].[7],[8]
Table 6: Criteria for relapse

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   Discussion Top


HD produces a spectrum of clinical phenotypes. The type 1 reaction, which most commonly occurs in the BT, BB, and BL forms, is characterized by erythema and swelling in the preexisting lesions, fever, and neuritis.[9] The most common clinical presentation of type 2 reaction, i.e., erythema nodosum leprosum, is most commonly found in BL and LL HD and is characterized by the sudden manifestation of erythematous tender nodules which are frequently accompanied by fever, malaise, neuritis.[9]

This study included 400 patients which showed slightly higher preponderance in males (M:F- 1.67:1) which was similar to studies done by Thakkar and Patel, Adil et al., and Patil and Sherkhane.[4],[9],[10] This indicates that males are more vulnerable to HD because of their greater mobility and increased opportunities for contact in big population. Majority of patients belonged to age group 31–40 years (n = 107, 26.75%) which is in concordance with Adil et al. (n = 60, 26.7%).[4] Childhood leprosy accounts for 4% (16) which is lower as compared to 14.2% (32) in Adil et al. and 12.3% (31) in Thakkar and Patel.[4],[9] These differences may be due to the difference in the cut of age of these studies. Maximum cases of HD were from Nagpur, Amravati, Chandrapur, Seoni, Chindwara, and Balaghat (central India) as compared to other studies which were from different regions of India [Table 7].
Table 7: Comparison with other studies

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The present study revealed that maximum cases in the clinical spectrum of HD were BL HD (n = 156, 39%) which is similar to Adil et al. (n = 86, 38.2%).[4] Second most common spectrum found in our study was LL HD (30%) followed by TT HD (7.5%). In this study, 2.75% (11) patients were of pure neuritic HD which is in consistence with Adil et al. (n = 3, 1.33%) and very less as compared to Thakkar and Patel (n = 45, 18%) and Kolleri et al. (n = 75, 8.5%).[4],[9],[11] 2.25% (11) patients of histoid HD were diagnosed in our study which is parallel to Adil et al. (1.78%).[4] The incidence of histoid HD reported in India varies from 2.79% to 3.60%.[12] In children, BT HD (n = 6, 42.85% of total children) was most commonly reported in our study which is in concordance with Ghunawat et al. (n = 90, 71.64%).[5] Positive contact history in children was 75%. Positive contact history in childhood leprosy was seen in 48.3% and 18% by Thakkar and Patel and Mohammed et al., respectively.[9],[13] Close contacts with leprosy case are an important cause of transmission in children which may be due to lower immune status as compared to elders. An overall most common site in TT HD was head and neck region 12 (40%) and BT HD was upper limb 37 (55.22%). The most common site of lesion in the pediatric age group was extremities (87.5%) similar to the study by Nair.[1] Most common morphological type in LL HD in our study was nodular.

Deformities in this study were 17% (68) of patients which comprised commonly of grade 2 (n = 52, 13%) followed by grade 1 (n = 16, 4%). This was very less as compared to Patil and Sherkhane where 82.46% (94) of patients showed deformities, comprised 11.41% (13) patients of grade 1 and 71.05% (81) of grade 2.[10] As per Thakkar and Patel, 42.8% patients showed deformity which comprised 73% (29.2) patients of grade 1 and 34%(13.6) of grade 2.[9] Most common type of deformity in our study recorded was trophic ulcer (n = 28, 7%) in BL HD.

Lepra reactions were seen in 32.25% (129), whereas Thakkar and Patel and Adil et al. showed 9.6% (24) and 12.9% patients of lepra reactions, respectively. In lepra reactions, type 2 reaction (n = 112, 28%) is much more common than type 1 (n = 17, 4.25%) reaction in our study. Similar observations have been made by Thakkar and Patel who observed type 2 lepra reactions (n = 16,6.4%) common than type 1 reaction (n = 8,3.2%).[4],[9] We also recorded that most common spectrum showing type 2 lepra reactions was BL HD.

HD cases show diversities between the clinical and histopathological features. In the present study, the histopathological characteristics were consistent with the clinical diagnosis in 42.75% patients. In a study conducted by Arunagirinathan et al., the histopathological features were consistent with clinical diagnosis in 62.85%.[14] Thakkar and Patel showed 60% patients' histopathological characteristics consistent with the clinical diagnosis.[9] Thirteen (3.25%) patients were of relapse of HD which was most commonly recorded in BL HD.

This study gives a broad view of the scenario of HD in central India but as it was conducted in a tertiary care hospital, it is not illustrative of the circumstances on the field. The large percentage of multibacillary cases signifies that leprosy awareness and programs need to be more vigorously implemented along with facilities for investigations and rampant provision of treatment. An innovative approach to target vulnerable groups needs to be devised to achieve complete eradication of this peril from the community.


   Conclusion Top


To the best of our knowledge, this is first study of HD in central India which addresses clinicoepidemiological and histopathological characteristics and associated deformities. Detection of this huge number of cases signifies a high burden of HD in this area even in the post elimination era. In our study, males outnumbered females with borderline lepromatous as most common spectrum of HD. 2.25% of histoid HD cases in post elimination era is an eye opener for vigilant detailed history, clinical examination, and investigations. The occurrence of childhood HD disease in children is alarming and signifies active disease transmission. 3.25% of relapse cases of HD were diagnosed, which was not seen in other studies, and is a cause of concern suggesting the importance of proper counseling and treatment. Therefore, in an endemic country like India, we still need to have an open eye to recognize the varied manifestations of leprosy and treat accordingly.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Nair SP. A clinico-epidemiological study of pediatric leprosy in the urban leprosy center of a tertiary care institute. Indian J Paediatr Dermatol 2017;18:24-7.  Back to cited text no. 1
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2.
World Health Organization-Leprosy. Fact sheets. 2018. Available from: https://www.who.int/news-room/fact-sheets/detail/leprosy. [Last accessed on 2018 Feb 09].  Back to cited text no. 2
    
3.
National Leprosy Eradication Programme, Annual report. 2016-2017, p. 3. Available from: https://pdf4pro.com/tag/ed94d/nlep-annual-report-2016-2017.html. [Last accessed on 2017 Oct 05].  Back to cited text no. 3
    
4.
Adil M, Amin SS, Mohtashim M, Mushtaq S, Alam M, Priya A. Clinico-epidemiological study of leprosy from a North Indian tertiary care hospital. Int J Res Dermatol 2018;4:518-21.  Back to cited text no. 4
    
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Ghunawat S, Relhan V, Mittal S, Sandhu J, Garg VK. Childhood leprosy: A retrospective descriptive study from Delhi. Indian J Dermatol 2018;63:455-8.  Back to cited text no. 5
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Kumar B, Dogra S. Leprosy: A disease with diagnostic and management challenges! Indian J Dermatol Venereol Leprol 2009;75:111-5.  Back to cited text no. 6
    
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Sengupta U. Immunological aspects of relapse in leprosy. Indian J Lepr 1995;67:81-3.  Back to cited text no. 7
    
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Ramu G. Clinical features and diagnosis of relapses in leprosy. Indian J Lepr 1995;67:45-59.  Back to cited text no. 8
    
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Thakkar S, Patel SV. Clinical profile of leprosy patients: A prospective study. Indian J Dermatol 2014;59:158-62.  Back to cited text no. 9
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Patil AA, Sherkhane MS. Clinico-epidemiological study of Hansen's disease patients attending a tertiary care centre in South India. Int J Community Med Public Health 2016;3:3092-5.  Back to cited text no. 10
    
11.
Kolleri JJ, Sasidharanpillai S, Vadakkayil B, Chathoth AT. A 10-year retrospective descriptive study on pure neuritic leprosy from a tertiary referral centre. Indian Dermatol Online J 2019;10:13-8.  Back to cited text no. 11
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Annigeri SR, Metgud SC, Patil JR. Lepromatous leprosy of histoid type. Indian J Med Microbiol 2007;25:70-1.  Back to cited text no. 12
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Mohammed S, Khan MP, Aakurati P, Kumar UB. Epidemiological and clinical study of childhood Hansens in a tertiary care hospital. J Evol Med Dent Sci 2015;4:14716-20.  Back to cited text no. 13
    
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Arunagirinathan M, Muniswamy V, Sivaraman J. Clinical and histopathological correlation in Hansen's disease. Ann Pathol Lab Med 2017;4:454-549.  Back to cited text no. 14
    


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