Name
LEPROSY
DESCRIPTION
DETAIL
D.D. : - SARCOIDOSIS - LEISHMANIASIS - LUPUS VULGARIS - LYMPHOMA - SYPHILIS - YAWS - GRANULOMA ANNULAREOTHER TESTS : * BIOPSY FROM THE EDGES OF THE SKIN LESIONS OR FROM THE NODULES, PLAQUES & INDURATED AREAS. * IGM ANTIBODIES TO PHENOLIC GLYCOLIPID - 1 ( PGL-1 ) - PRESENT IN 95% . * PCR TEST - 50% DIAGNOSTIC ONLY * SKIN TEST ( LEPROMIN TEST ) - POSITIVE IN 50 % ONLY * SPUTUM FOR AFB STAINING - POSITIVE IN LEPROMATOUS LEPROSY WHICH MAY CONFUSE IT WITH TUBERCULOSIS. * FLA - ABS TEST ( FLUORESCENT LEPROSY ANTIBODY ABSORPTION TEST ) - FOR IDENTIFICATION OF SUBCLINICAL INFECTION.
TYPENOTES
GENERAL MEASURES β’ Manage with multidisciplinary approach, including orthopedic surgery, ophthalmology and physical therapy in addition to specific drugs β’ Rigid soled foot wear or walking plaster casts may prevent plantar ulcers β’ Physical therapy and casts prevent hand contractures β’ Utilize vocational retraining and rehabilitation along with psychological support β’ Immediate recognition and treatment of eye problems essential β’ Manage mild reactional states such as reversal reaction and erythema nodosum leprosum (ENL) with bed rest, analgesics and sedatives. Severe reactions require corticosteroids, thalidomide or clofazimine. Specific therapy must be continued without interruption. SURGICAL MEASURES β’ Reconstructive surgery - nerve and tendon transplants, release of contractures and other cosmetic procedures can give more functional mobility and social acceptance β’ Tarsorrhaphy or horizontal lid shortening for lagophthalmos with lid gap more than 5 mm or even lesser degree in patients with one eye. Cataract surgery with posterior chamber intraocular lens implantation to avoid glasses in patients with nasal bridge collapse. ACTIVITY Dependent on severity of disease DIET Nutritious balanced diet PATIENT EDUCATION β’ Educate about the indolent course of the disease; importance of therapeutic completion β’ Information pamphlets and awareness to ease psychological trauma and stigma, emphasizing that a cure is possible with newer drug regimen β’ Encourage case reporting since early treatment can prevent/reduce tissue damage and deformities DRUG(S) OF CHOICE . Drugs and treatment duration are based on bacterial load (in skin smear) and clinical types. Multibacillary cases: bacterial load of 10 to the 11th power and clinical types BB, BL or LL. Paucibacillary cases: bacterial load of about 10 to the 6th power and clinical types TT, BT and indeterminate. . Multibacillary standard regimen includes rifampin, clofazimine and dapsone: . Adult outside USA >35 kg - Rifampin 600 mg once a month - Clofazimine 300 mg once a mo+ 50 mg/d - Dapsone 100 mg/d . Adult outside USA < 35 kg - Rifampin 450 mg once a month - Clofazimine 300 mg once a mo+ 50 mg/d - Dapsone 50 mg/d . Children ages 10-14 - Rifampin 450 mg once a month - Clofazimine 200 mg once a mo+ 50 mg qod - Dapsone 50 mg/d . Children underweight - Rifampin 12-15 mg/kg once a mo - Clofazimine 150 mg once a mo+ 50 mg qod - Dapsone 1-2 mg/kg/d . Adults in the USA (recommended regimen) - Rifampin 600 mg/d for 3 years - Dapsone 100 mg/d for life - Clofazimine is given in dapsone-resistant cases: 50-100 mg/d for life . Paucibacillary standard regimen . Outside USA - Rifampin same doses as above - Dapsone 50-100 mg/d . In USA - Rifampin 600 mg a day for 6 mos - Dapsone 100 mg/d for 3-7 years . The WHO recommends that the standard multidrug therapy (MDT) for multibacillary patients could be shortened to 12 months ALTERNATIVE DRUGS . WHO recommended and widely used in countries where leprosy is endemic: . Rifampin 600 mg daily + ofl oxacin 400 mg/d + minocycline 100 mg/d for up to 2 years (ROM) . Shorter duration of therapy in paucibacillary cases with the same combination has been successful PATIENT MONITORING β’ Frequent follow-up visits until therapy course is stabilized, then monthly supervision β’ Periodic CBC, renal and hepatic function PREVENTION/AVOIDANCE β’ Early case fi nding and chemotherapy to suppress infectiousness and control spread β’ Examine family and other close contacts regularly for leprosy POSSIBLE COMPLICATIONS β’ Crippling of the hand and foot β’ Trauma and secondary infection leading to loss of digits and extremities β’ Corneal opacities and uveitis can lead to blindness β’ Cataracts β’ Lucio phenomenon - arteritis β’ Secondary amyloidosis β’ ENL: Rx with thalidomide 200 mg bid tapering to 50-100 mg/d in chronic patients β’ Severe reversal reaction: prednisolone 40-60 mg/day, tapering slowly EXPECTED COURSE/PROGNOSIS Generally indolent, but may be interrupted by ENL and type 1 lepra reaction. Prognosis is good with early detection and therapy, especially with ROM.
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
SERUM IGM, COMPLETE BLOOD COUNT, PCR, SPUTUM FOR AFB STAINING, BIOPSY