Hypopigmented lesions in early leprosy--a clinical and histological study

26 Patients of leprosy presenting with hypopigmented lesions were divided on morphological grounds into 3 Sub groups, Group I (9 patients) with well-defined single patch with moderate to complete sensory loss; Group II (8 patients) with single ill-defined lesion having partial sensory loss; and Group III (9 patients) having multiple hypo-pigmented patches with mild to moderate sensory loss. Epidermal atrophy was a conspicuous histological finding in all groups. Only patients in Group I showed epitheloid cells in dermal infiltrate with erosion of epidermis in one case. This group may be labelled as maculoanesthetic leprosy. Patients in Group II and III showed mononuclear cell infiltrate in dermis, around neurovascular bundles and appendages. They were histologically consistent with indeterminate leprosy. Follow-up biopsy after six to eight months of treatment showed healing of the lesion of reduction in the infiltrate in most cases.     

Male gonads in leprosy--a clinico-pathological study

Sixty male leprosy patients (mean age 27.2 +/- 5.04 years) selected at random, were studied for gonadal involvement with the mean duration of illness 4.17 +/- 3.27 years. Only lerpomatous and borderline leprosy cases developed testicular and epididymal changes. Testicular pain and/or swelling (lepromatous 62.5%, borderline 30%) was the main presenting feature. Altered sexual function was observed in 34(56.6%) cases, and 11 patients revealed altered sexual hair pattern. Gynecomastia was seen in 9 cases. Reduced testicular size along with its soft feeling was present in 25% of cases while no testicular sensation was felt in 8 (13.3%) cases, and impaired testicular sensation in 9 (15%) of them. Spermogram revealed azoospermia in 19 (35%) and oligospermia in 16 (26.6%) cases. Histo-pathology revealed evidences of leprous pathology irrespective of testicular size, semen picture and clinical manifestations. There was marked variation in histopathological findings in testes and hence it was difficult to categorise them into vascular, interstitial and obliterative phase.     

Multidrug therapy in paucibacillary leprosy--a five year experience

736 paucibacillary (PB) patients were given multidrug therapy (MDT) for at least 6 months. Overall, 44% became inactive after 6 doses, and 69% after 12 doses. However, 27% remained active at the time of analysis. It is recommended that at least 12 doses of MDT be given to PB patients irrespective of the type.     

People's perception of leprosy--a study in Delhi

Leprosy is considered to cause more social than medical problems. The present study focussed on this aspect in order to investigate the level of awareness among people--about their attitude towards the disease and the afflicted. The results are based on interviews with 104 persons in Delhi. The sample data revealed that the level of knowledge of leprosy was inadequate. The cause of the disease was known to 44.2% of those interviewed, while 31.7% were completely ignorant; 6.7% believed it to be the consequence of an individual's past misdeeds, and 1.9% believed it to have been caused by divine curse. 63.1% were aware that the disease is curable. 73.1% of the persons interviewed sympathised with leprosy-afflicted beggars. 61.5% favoured leprosy patients to stay with their families and within their communities. 67.3% felt that the cured could marry, while 25% felt that the leprosy-afflicted should stay in leprosy colonies away from the society. 54.8% were reluctant to employ the leprosy-afflicted as domestic help, and 31.7% were reluctant to establish matrimonial relationship with a family having a leprosy-afflicted person. The data call for intensification ofpublic awareness regarding the aetiology of leprosy. Positive and scientific information should be disseminated to minimize the social prejudices associated with the disease.     

Correlation of clinical and histopathologic features in untreated macular lesions of leprosy--a study of 100 cases

Clinical and histopathological correlative studies carried out in 100 cases of leprosy with macular lesions revealed an overall parity in 47% of the cases. Disparity was observed in TT, BT, BB, BL and IL series but not in LL series. The variable tissue response in the disease spectrum due to the variability of CMI is responsible for the disparity in various types of leprosy, irrespective of the type of lesions, whether macular or elevated.     

Prostaglandin F2 alpha in leprosy--a preliminary study

Prostaglandin F2 alpha was estimated in the sera of fifty patients in the leprosy spectrum to find out the status of prostaglandins in response to Mycobacterium leprae. Contrary to expectation, PGF2 alpha could be detected in only twenty-eight percent of leprosy patients. This preliminary finding is discussed in detail in the paper.     

Reactions in leprosy--a prospective study of clinical, bacteriological, immunological and histopathological parameters in thirty-five Indians

The clinical manifestations of types I (lepra) and II (ENL) reactions are now well-appreciated. The correlation of clinical expression to bacterial index, lepromin response and histological features has hardly been attempted. In a study of 35 reaction patients, 18 type I (lepra) and 17 type II (ENL), the preceding parameters were studied in detail. Their incidence among leprosy patients was 20%. Males in the age group 20–30 years were frequently affected, the ratio of males to females being 6:1. The mean age at onset in type II (ENL) was younger than in type I (lepra) reactions. However, the duration of the reactions was variable. They were frequently precipitated by antileprosy drugs. The clinical features were cardinal. The bacteriological features reflected wide variations, but were considered imperative. Early Fernandez and Late Mitsuda reactions were useful adjuvants for monitoring progress. The utility of changing microscopic pathology in determining the swing towards the lepromatous or tuberculoid end of leprosy spectrum are emphasized.     

Hepatic and haematological adverse reactions associated with the use of multidrug therapy in leprosy--a five year retrospective study

This study analyses retrospectively some of the risks associated with the use of WHO-multidrug therapy (MDT) in Sri Lanka. Case records of 3,333 new cases of leprosy attending the Central Leprosy Clinic in Colombo during 1991-1995, were analysed for adverse drug reactions involving the liver and blood. There were 81 reports of suspected hepatic or haematological adverse reactions associated with the use of MDT, of which 39 were classified as haemolytic anaemia, 25 as toxic hepatitis, 2 as methaemoglobinaemia and 15 as anaemia. Dapsone, was incriminated in the majority of adverse reactions (72%). Adverse drug reactions were more common in female than male subjects (55% vs 45%; P < 0.5), but there was no significant differences between the age groups. Majority of adverse reactions was seen within the first three months of initiation of MDT. This study in no way undermines the benefits of MDT but highlights the risks and suggests measures to minimize these risks.     

Hypopigmented macules in leprosy--a histopathological and histochemical study of melanocytes.

Study of the number of melanocytes and amount of pigmentation in hypopigmented lesions and adjacent normal areas in 20 leprosy patients showed no differences in these parameters. It appears that hypopigmentation in leprosy lesions could be caused by defective transfer of melanin into keratinocytes.     

Epidemiological significance of indeterminate leprosy--a hospital based study

An epidemiological analysis of 100 cases of indeterminate leprosy attending the Department of Dermatology and Venereology of Medical College Hospital, Trivandrum, is presented. It was found that indeterminate leprosy formed 13.23% of all cases of leprosy and 1.3% of all out-patients attending this department. Only 27% of patients with indeterminate leprosy were below 15 years of age. There was a predominance of males especially over 20 years of age. There was no history of contact with leprosy in any of the patients with indeterminate leprosy. All patients with indeterminate leprosy came for hypopigmented patches, suspecting leprosy. Majority had the disease for more than 6 months. Single lesion on the outer aspect of extremity was the most common presentation. The lepromin test was positive in only 2% of patients with indeterminate leprosy, while it was positive in 80% of control subjects. Three cases of dapsone resistance were suspected in this series. The epidemiological significance of the findings is discussed.     

Cimetidine improves the therapeutic/toxic ratio of dapsone in patients on chronic dapsone therapy

We have previously shown that cimetidine, given concurrently for 2 weeks to patients on chronic dapsone therapy, reduced methaemoglobinaemia by inhibiting the formation of the toxic hydro-xylamine metabolite of dapsone. The aim of the present study was to examine the effect of this combination on the benefit/toxic ratio of dapsone over a longer period. Eight patients (six dermatitis herpetiformis, one linear IgA disease, one folliculitis decalvans) on long-term dapsone 50-100 mg daily, took cimetidine 1·6g daily concurrently for 3 months. At 3-weekly intervals, a clinical assessment was made, plasma dapsone and methaemoglobin were measured, and parameters of oxidative haemolysis were monitored. The dapsone level rose from 2298±849 ng/ml (mean+SD) at baseline to 3006±1131 ng/ml at week 3 of cimetidine (P<0·01). This rise in plasma dapsone was sustained during cimetidine administration, falling to 2446±954 ng/ml when cimetidine was stopped (P<0·02). The methaemoglobin fell from 5·5·2·2% (mean±SD) at baseline to 3·9±1·1% at week 3 (P<0·01). and remained low until week 12, when there was a return to baseline values (P<0·01). The haemoglobin did not change from the baseline of 12·7·0·3 g/dl (mean±SD), and other parameters of haemolysis were unaltered. There was a fall in the visual analogue score for headache (P<0·05), but this was not associated with any deterioration in control of the skin disorders. Hence, long-term concurrent cimetidine results in increased plasma dapsone levels without increased haemolysis, and is accompanied by reduced methaemoglobinaemia for more than 2 months. Cimetidine thus improves the therapeutic/toxic ratio of dapsone. Such a therapeutic strategy may be appropriate for patients who require high-dose dapsone, or those who are particularly susceptible to dapsone-induced haemotoxicity.     

Risk factors for developing leprosy--a population-based cohort study in Indonesia

We identified risk factors associated with increased yearly incidence rates of leprosy in five island populations. Age, sex, household size and Mycobacterium leprae-specific antibodies as well as contact factors were studied. Of 94 index patients (patients diagnosed in 2000), 43 (46%) were classified as multibacillary (MB), 17 (19%) were seropositive for PGL-1 [corrected] antibodies and 6 (7%) had M. leprae DNA in nasal swabs as determined by polymerase chain reaction (PCR) testing. All PCR positive patients were also seropositive. Forty-four of 4903 initially symptom free persons developed leprosy within 4 years, giving an incidence rate of 298 per 1000 person-years. Men had a 22 times higher risk [95% confidence interval (CI): 1.2-4.1] of developing leprosy than women. People living in households with more than 7 members had a 3.1 times higher risk (95% CI: 1.3-7.3) than households of 1-4 members. Persons who were seropositive in 2000 had a 3.8 times higher risk (95% CI: 1.1-12.6) than seronegative persons. Household contacts of MB patients had an adjusted hazard ratio (aHR) of 4.6 (95% CI: 1.6-12.9) and household contacts of PCR positive patients an aHR of 9.36 (95% CI: 2.5-34.9) compared with non-contacts. Patients with PCR positive nasal swabs, suggesting nasal excretion of M. leprae, are probably the patients with the highest transmission potential. Since all index patients who were PCR positive were also seropositive, serology seems an adequate tool to identify these patients. Preventing seropositive persons from becoming seropositive and infectious patients might break the chain of transmission.     

Cauliflower growths in trophic ulcers of leprosy--a 10 year study

A 10 year study of cauliflower growths in trophic ulcers of leprosy patients was done. Seventy five cases were seen, out of which seventy two were in foot and three in hand. Eventhough appearance was like that of malignancy, malignant change was seen only in four cases and in other seventy one cases it was pseudoepitheliomatous hyperplasia. Various surgical procedures were done. Wide excision appears to be the procedure of choice where feasible as per our studies.     

Adjuvant therapy of bullous pemphigoid with dapsone

Thirteen patients with recurrent severe widespread recalcitrant bullous pemphigoid (BP) were studied. These patients had been initially treated with prednisone and azathioprine, and clinically responded. However, they frequently continued to have flare-ups or activation of the disease while still on treatment with high doses of these drugs. The addition of dapsone, as an adjuvant to the treatment, helped to produce a complete clinical remission in 12 patients (92%). In addition, there was a statistically significant difference in the median dose of prednisone, before and after the institution of dapsone, and in the maintenance dose of prednisone. Patients were tapered off prednisone more easily than before and did not flare at lower doses of prednisone as previously. It is suggested that, in patients with severe, recalcitrant, recurrent disease, the addition of dapsone to the existing regime of corticosteroids and/or immunosuppressive drugs, may be beneficial. This may be especially valuable to patients in whom corticosteroids have been used for prolonged periods and in whom increasing the corticosteroid dose further may be associated with significant side-effects.     

Status of histoid leprosy--a clinical, bacteriological, histopathological and immunological appraisal

The study of different aspects, namely clinical, bacteriological, histopathological and immunological, of 23 cases of histoid leprosy were quite revealing. The salient features included the occurrence of histoid lesions in a proportion of untreated leprosy patients in addition to those on dapsone treatment for a variable periods of time, a high bacteriological index in spite of infrequent formation of globi, high morphological indices and the immunological status of these patients. Cell-mediated immunity, which was deficient in relation to healthy controls, appeared to be augmented when compared with active lepromatous (LL) patients. A few contributory factors to the development of such a situation are discussed.     

Patterns of ocular morbidity and blindness in leprosy--a three centre study in Eastern India

BACKGROUND: Eye disease and visual impairment due to leprosy are not uncommon, but their prevalence and the risk factors for such pathology have yet to be fully characterized. METHODS: An observational study of leprosy-affected individuals in the community, in three districts in Eastern India was performed to determine the prevalence of ocular morbidity and blindness. The subjects were chosen by stratified random sampling, according to stage of treatment, or stage of post-treatment surveillance. Each subject underwent ophthalmic examination according to a standard pro-forma. RESULTS: Thirty-three out of 1137 (2.9%) subjects were blind according to the WHO classification, and 232/1137 (20.7%) had moderate visual impairment. The prevalence of blindness and visual impairment was greatest in one centre, Jhalda. Multivariate Logistic Regression analysis showed that longer duration of disease, more advanced treatment stage and older age were independently associated with blindness. One hundred and forty-one cases (28%) in Muzaffarpur, 95 cases (63%) in Saldoha and 378 cases (78%) in Jhalda had active or treated multibacillary leprosy. DISCUSSION: The prevalence of blindness in leprosy varies in different population groups, with differing patterns of leprosy-related ocular morbidity, blindness and disease type evident even in different areas of the same region. Leprosy screening and surveillance programmes should include ocular examination as part of routine screening, particularly in individuals with a history of multi-bacillary disease. Individuals with known sight- threatening pathology should undergo continued active follow up. Local epidemiological studies would enable appropriate programme planning and efficient allocation of resources.     

Agranulocytosis caused by dapsone therapy for granuloma annulare

Dapsone has been suggested as a useful drug in the treatment of granuloma annulare; however, adverse reactions include a potentially life-threatening agranulocytosis. We report the case of a 50-year-old woman in whom agranulocytosis and septicemia developed after 7 weeks of therapy with dapsone for granuloma annulare. Full recovery followed cessation of this drug, but caution is advised in prescribing dapsone for relatively benign skin conditions.