Leprosy in the United States. Risks, recognition, regimens, resources

Although leprosy is increasing in incidence in the United States, it is confined almost entirely to immigrants from developing countries and their close contacts. While the clinical disease has not changed, leprosy has diffused more widely throughout the United States as a result of migration. Primary care physicians should maintain a high index of suspicion in foreign-born individuals with skin or peripheral nerve problems. Punch biopsy of skin lesions is the most practical diagnostic method for both the multibacillary and paucibacillary types of leprosy. Because of resistance to dapsone, multi-drug treatment is now the rule; most patients are referred to or managed in consultation with a regional Hansen's disease clinic for long-term treatment. Consultation is available to any physician through the National Hansen's Disease Center in Carville, Louisiana.     

Genetic epidemiology of the susceptibility to leprosy.

To test the hypothesis that genetic factors are operative in the predisposition to leprosy (Hansen's disease) in humans, a genetic epidemiologic investigation was performed on 269 leprosy kindreds containing 552 affected individuals from an isolated population in Papua New Guinea. The community, and not the family, was the basic social unit. Leprosy, an infectious disease, was not communal but strongly familial within the Karimui. Segregation analysis, to determine whether a major gene for the susceptibility to leprosy was segregating within a single multi-generational kindred, could not differentiate between a Mendelian genetic and a purely environmental hypothesis. The composite kindred data, however, suggest a genetic hypothesis for the non-immunologically induced susceptibility to leprosy per se. Within familial kindreds leprosy invariably emanated from a common ancestral sibship, and risk was associated with the closeness of kin but not with infectivity or severity.     

Reactional states in Hansen's disease: practical aspects of emergency management

Hansen's disease (leprosy), though not a common condition in the United States, can be found in some localities among patients who come to the emergency room for treatment. Hansen's disease (HD) is a chronic systemic infectious granulomatous disease involving principally the skin, mucosa, nerves, and eyes. The causative organism, Mycobacterium leprae, is neither highly contagious nor aggressive, but rapid alterations in the immunologic response to M leprae in affected tissues can result in acute exacerbations termed "reactions." Since most of the symptoms and morbidity in HD are a consequence of these reactional states, they must be recognized and treated early to prevent permanent sequelae, especially neurologic and ophthalmologic. Drug therapy, physical therapy, and sometimes surgery all play a role in minimizing the injury caused by reactions.     

Sixty years of psychiatry at Carville

The hospital now known as the Gillis W. Long Hansen's Disease Center is the only hospital in the United States solely treating Hansen's disease (leprosy). From the time of its establishment in 1894 until 1923, the psychiatric patients presented treatment and management problems that remained unaddressed. Since 1923, however, psychiatric consultants have provided care and treatment for this segment of the Carville population. This paper presents the findings of three of these consultants for the period 1923 to 1985, and outlines similarities and differences in the diagnoses, treatments, and disposition of patients, as well as indications for future investigations.     

Leprosy in the Emergency Department

OBJECTIVES: Los Angeles County-University of Southern California Medical Center, like many large urban hospitals, has a large immigrant population from regions of the world where leprosy is endemic. Emergency physicians (EPs) in these settings can expect to encounter leprosy patients. This study reviewed the emergency department (ED) course of patients with confirmed leprosy in an attempt to describe the most common presenting patterns so that future cases can be more easily recognized. METHODS: This was a retrospective chart review of all patients followed in the Hansen's disease clinic. Demographics, leprosy type, clinical presentations to the ED, and medications were recorded. RESULTS: Of the total number of patients (415), most were of Mexican (52%), Filipino (15%), Vietnamese (14%), and Chinese (5%) origin. Leprosy was classified as lepromatous (56%), borderline (40%), and tuberculoid (4%). There were a total of 118 ED visits by 74 patients. The mean age was 46 years, with 51% male and 49% female. Dermatologic (68%), neurologic (23%), and ophthalmologic (9%) complaints were the most common reasons for ED presentation related to leprosy. The EP did not elicit a history of leprosy in 34% of those patients followed in the leprosy clinic. The ED diagnosis of leprosy was made in 3 of 15 (20%) undiagnosed cases. Of the 63 patients prescribed medications in the leprosy clinic at the time of their ED visits, 22 (35%) ED charts did not report leprosy drugs. CONCLUSION: Patients with leprosy present to U.S. EDs, and new cases can be identified. Early recognition is important given leprosy's devastating consequences, major drug side effects of medications used for treatment, and improved prognosis with multidrug therapy. A history of leprosy and associated medications are often not documented in the ED chart, which may reflect a continued fear of stigmatization among these patients.     

Methods of treating plantar ulcers

The purpose of this article is to describe the indications, precautions, and fabrication techniques for orthotic devices the authors use to facilitate the healing of plantar ulcers. The methods of fabricating and applying three types of orthotic devices developed by the staff at the Gillis W Long Hansen's Disease Center--walking casts, walking splints, and cutout sandals--are described. Patient examples are given for each of the methods. These techniques, in conjunction with patient education and the use of special footwear, provide clinicians with procedures they can use to aid in the healing of plantar ulcers secondary to leprosy, diabetes, or other neuropathic conditions.     

Is there a relationship between light touch-pressure sensation and functional hand ability?

Purpose. To investigate and compare the level of light touch-pressure sensation as tested via the Semmes Weinstein monofilament (SWM) test with the level of functional hand ability.

Methods. Twenty-seven persons with isolated sensory deficit due to leprosy and 31 healthy controls were tested in the Occupational Therapy department of a hospital for patients with Hansen's disease. Palmar light touch thresholds were determined by SMW testing. Functional hand ability was tested via the Jebsen-Taylor Hand Function Test (JTHFT) and the Functional Dexterity Test (FDT). All participants were measured by manual muscle testing (MMT) to exclude any motor impairment. Data analysis compared sensory thresholds and level of functional hand ability between the two groups and examined the relationship between the variables.

Results. In the group with sensory deficit, the sensory thresholds were significantly higher than in the control group. Significant correlations were found between the sensory thresholds measured by the SWM test and the FDT and JTHFT scores, with higher correlations found for tasks entailing manipulation of small objects.

Conclusions. The findings support the existence of a relationship between sensory light touch thresholds tested by the Semmes Weinstein monofilaments (SWMs) and hand function. However, the SWM test alone is not sufficient as an indicator of hand function and must therefore be supplemented with other hand function tests.     

A case of leprosy at Charity Hospital, New Orleans.

A 63-year-old black woman, admitted to Charity Hospital, New Orleans, for treatment of hypertension and congestive heart failure, was found clinically and histopathologically to have Hansen's disease. She had lived most of her life in Orleans Parish and had no known contact as a source of her infection.     

2013年浙江省温州地区麻风病受累者生存状况调查

目的了解浙江省温州市麻风病受累者的生存状况,为消除麻风病危害,降低麻风疾病负担提供参考依据。方法按照统一的技术标准和方法,由调查人员对温州地区内登记的麻风病受累者进行入户调查,调查内容包括人口学特征、家庭状况、劳动能力、麻风病致残状况、康复需求等生存状况,并填写调查表。结果 62例调查对象中,男性43人,女性19人,最小年龄23岁,最大91岁,平均63.7岁;18人处于独居;57人无劳动能力或仅有轻体力劳动能力;2级畸残率30.6%,畸残时长最短59个月,最长635个月,平均298.78个月,有15人缺少基本的防护措施。结论温州市麻风病受累者的生存状况较差,应为符合条件的麻风病患者提供基本生活和医疗救助,降低患者疾病负担,以消除因麻风病带来的危害。     

陕西省汉中疗养院住院麻风康复者综合健康状况调查评价

目的:探讨并评价住院麻风康复者的综合健康状况。方法:调查2016年5月至2017年7月在本院进行治疗的麻风患者100例,让患者填写自测问卷,记录多菌型麻风康复者与少菌型麻风康复者的例数及畸残等级状况,并统计两种菌型麻风康复者的主要畸残部位及各个部位形成的表现。结果:多菌型麻风康复者比少菌型麻风康复者多,且两种菌型康复者的二级畸残率最高(P<0.05)。两种菌型麻风康复者的主要畸残部位为手部、足部与眼部,并且会形成爪型手、足底溃疡、兔眼等表现(P<0.05)。结论:住院的麻风病患者在康复过程中,畸残状况不容乐观,二级畸残率较高,要合理有效地对麻风康复者的综合健康状况进行及时的调查,完善康复的手段,加强对康复者的护理。     

Common vocational training project for the handicapped (CVTPH)

CVTPH is a special project imparting vocational training to leprosy patients as well as other categories of the handicapped under the same roof, in order to combat the leprosy stigma which is the major obstacle in all leprosy work and to aid rehabilitation by making the trainees economically self-sufficient. The project, which offers training in the industrial sector to leprosy patients, orthopaedically handicapped individuals and able-bodied but socio-economically disadvantaged individuals, began in a small way in 1977, but has grown considerably since then, thus demonstrating the effectiveness of the concept. There have been several problems--chief among which are the leprosy stigma and the reluctance of the trainees themselves to move out from a sheltered environment into the world outside--but these are slowly being overcome by the formation of co-operative societies controlled by the handicapped. This project is hoped to serve as a model for similar vocational training programs.     

Large retroperitoneal schwannoma mimicking a cystic ovarian mass in a patient with Hansen's disease

We present a rare case of retroperitoneal cystic schwannoma of the pelvis in a patient with Hansen's disease that mimicked an ovarian cyst. Due to economic constraints and because the lesion was assumed to be of ovarian origin, the patient did not undergo any cross-sectional imaging other than sonography. Sonographically guided fine needle aspiration of the cystic lesion was inconclusive. A cystic schwannoma was diagnosed at laparotomy.     

Leprosy and HIV coinfection: a critical approach

An increase in leprosy among HIV patients, similar to that observed in patients with TB, was expected approximately 20 years ago. Studies conducted in the 1990s together with those reported recently seemed to indicate that a coinfection with HIV did not alter the incidence and the clinical spectrum of leprosy and that each disease progressed as a single infection. By contrast, in countries with a high seroprevalence of HIV, TB was noted to increase. Explanations may be provided by the differences in the incubation time, the biology and toxicity of Mycobacterium leprae and Mycobacterium tuberculosis. After the introduction of HAART the leprosy–HIV coinfection manifested itself as an immune reconstitution inflammatory syndrome (IRIS), typically as paucibacillary leprosy with type 1 leprosy reaction. The incidence of leprosy in HIV-infected patients has never been properly investigated. IRIS-leprosy is probably underestimated and recent data showed that the incidence of leprosy in HIV patients under HAART was higher than previously thought.     

Leprosy and HIV coinfection: a critical approach

An increase in leprosy among HIV patients, similar to that observed in patients with TB, was expected approximately 20 years ago. Studies conducted in the 1990s together with those reported recently seemed to indicate that a coinfection with HIV did not alter the incidence and the clinical spectrum of leprosy and that each disease progressed as a single infection. By contrast, in countries with a high seroprevalence of HIV, TB was noted to increase. Explanations may be provided by the differences in the incubation time, the biology and toxicity of Mycobacterium leprae and Mycobacterium tuberculosis. After the introduction of HAART the leprosy-HIV coinfection manifested itself as an immune reconstitution inflammatory syndrome (IRIS), typically as paucibacillary leprosy with type 1 leprosy reaction. The incidence of leprosy in HIV-infected patients has never been properly investigated. IRIS-leprosy is probably underestimated and recent data showed that the incidence of leprosy in HIV patients under HAART was higher than previously thought.     

An international randomized study with long-term follow-up of single versus combination chemotherapy of multibacillary leprosy.

A total of 307 patients with lepromatous leprosy and borderline lepromatous leprosy were randomized to dapsone monotherapy or to one of two types of drug combinations. A 3-year treatment phase was followed by a 5-year observation phase. The evaluation included 233 patients for whom together there were 1,404 years of observation. A total of 1,956 blinded histopathological specimens were processed centrally. When entering the trial isolates from 13 patients (5.6%) showed dapsone resistance in the mouse footpad test, and these patients were evaluated separately. Dapsone monotherapy (68 patients) had the same frequency of cure as the combination of dapsone and rifampin (77 patients) or the four-drug regimen consisting of dapsone, rifampin, isoniazid, and prothionamide (75 patients). We did not find a significant difference in the clearance of bacteria either between the monotherapy and the two-drug combination or the monotherapy and the four-drug combination. Six months after the initiation of treatment, disease in 15% of the patients who received dapsone monotherapy but none of the patients who received combined treatment were clinically progressive. After another 1 to 9 months of treatment the disease in all patients was stable or regressive. There was no difference in the type or frequency of reactions. Only after the end of the scheduled observation phase three relapses were reported. All three treatment regimens well tolerated. Dapsone monotherapy is highly effective in the treatment of multibacillary leprosy under the conditions of well-controlled treatment. Combination regimens seem only to accelerate the regression of the active disease when they are compared with monotherapy with dapsone. The mouse footpad test does not reflect the clinical resistance and cannot be recommended for use in making therapeutic decisions.     

STUDIES ON CALCIUM AND MAGNESIUM METABOLISM IN DISEASE : I. CALCIUM AND MAGNESIUM METABOLISM IN LEPROSY.

In leprosy there is a definite retention of calcium. The more advanced the stage of the disease the greater is the degree of retention. This behavior on the part of leprous individuals may be taken as an indication that the organism is in need of calcium. Magnesium may also be retained in leprosy, but .the degree of retention is much less marked than in the case of calcium. With the exception of the retention of calcium and magnesium the leprous organism responds to changes in the intake of calcium and magnesium in the same manner as normal individuals. The results of this investigation suggest that in leprosy administration of calcium may be of benefit as an additional therapeutic measure in an endeavor to retard or arrest the progress of the bone changes characteristic of the disease.     

Evaluation of major membrane protein-I as a serodiagnostic tool of pauci-bacillary leprosy

We have previously shown that the serodiagnosis using major membrane protein-II (MMP-II) is quite efficient in diagnosing leprosy. However, the detection rate of pauci-bacillary (PB) leprosy patients is still low. In this study, we examined the usefulness of major membrane protein-I (MMP-I) from Mycobacterium leprae. The MMP-I–based serodiagnosis did not show significantly high detection rate. However, when the mixture of MMP-I and MMP-II antigens was used, we detected 94.4% of multi-bacillary leprosy and 39.7% of PB patients. There were little correlation between the titers of anti–MMP-I antibodies (Abs) and that of anti-MMP-II Abs in PB patients' sera. Ten out of 46 MMP-II–negative PB leprosy patients were MMP-I positive, so that the detection rate of PB leprosy patient increased from 39.7% to 53.8% by taking either test positive strategy. We concluded that MMP-I can complement the MMP-II–based serodiagnosis of leprosy.     

Investigation of neuropathic pain in treated leprosy patients in Ethiopia: a cross-sectional study

Pain can be a significant problem for treated leprosy patients. It can be nociceptive due to tissue inflammation occurring during episodes of immune mediated reactions, or neuropathic due to leprosy affecting the somatosensory system. There are sparse epidemiological data on the prevalence and impact of neuropathic pain in treated leprosy patients. Tools for assessing neuropathic pain have not been validated in leprosy. We have examined nature of pain in a cross-sectional study to determine the prevalence of neuropathic pain (NP) in 80 recently treated leprosy patients in Ethiopia. Pain and depression were evaluated using the General Health Questionnaire (GHQ-12) and the Brief Pain Inventory (BPI) questionnaire. The Douleur Neuropathique en 4 Questions (DN4) and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) were used as screening tools for NP. Pain of any type was experienced by 60% of the patients. Pure nociceptive pain was experienced by 43%, pure NP by 11%, and mixed pain by 6%. Of the 14 patients who had NP either alone or in combination with nociceptive pain, 12 had high GHQ-12 scores, indicating possible depression. The DN4 had sensitivity and specificity of 100% and 45%, whereas the LANSS had 85% and 42%, respectively. This is the first study to differentiate nociceptive from NP in leprosy patients. The prevalence of NP is high in recently treated Ethiopian leprosy patients. We have validated the use of DN4 in leprosy and it is easier to use than LANSS. Depression is a common co-morbidity in patients with NP. The high prevalence and morbidity of NP in treated leprosy patients warrant clinical trials to assess the efficacy of pain therapies for leprosy-associated NP.     

Helping a Man with Leprosy: A Case Study

PURPOSE.  This case study illustrates nursing diagnoses and interventions for a man with leprosy.
DATA SOURCES.  Data sources were published literature on the disease of leprosy, and the experience and expertise of the authors in working with people with leprosy.
DATA SYNTHESIS.  Data were synthesized using the standardized nursing languages of North American Nursing Diagnosis Association International and the Nursing Interventions Classification. The accuracy of the diagnoses and the appropriateness of the nursing interventions were supported by the positive health outcomes of the patient.
CONCLUSIONS.  Although leprosy has been eradicated in some countries, the risk of new cases is present anywhere that Mycobacterium leprae still exists. The recommended treatment of multibacilar polychemotherapy has lowered the rate of new cases in Brazil.
IMPLICATIONS FOR NURSING PRACTICE.  Nurses need to incorporate evidence-based practice interventions for leprosy-based wound care, and nurses should encourage persons with leprosy to maintain regular medical care with multibacilar polychemotherapy.