Mycobacterium leprae For MBBS 05 12 2017 1

Mycobacterium leprae For MBBS (05 -12 -2017) 1

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Disease of Historical importance World's oldest recorded disease Stigmatized disease Gerhard Henrick Armauer Hansen (1873 -Norway) 3

The Bacterium 4

Armauer Hansen in 1868 Morphology : Straight rods. 1 - 8 x 0. 2 - 0. 5µm Single / groups. Intracellular. Acid fast bacilli with 5% H 2 SO 4. As agglomerates, bacilli being bound together by a lipid like substance (Glia) – called GLOBI 5

– Parallel rows of bacilli in globi: CIGAR BUNDLE appearance – as in tissue section clumps of bacilli resemble cigarette ends – GLOBI is seen in Virchow’s lepra cell or foamy cells (Large undifferentiated histiocytes) 6

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Cultivation No artificial media / tissue culture available. Generation time: 12 -13 days Mouse : Intradermally into Foot pads. Granulomatous lesions in 1 - 6 months. Intact CMI : Limited replication. ↓CMI : Generalized leprosy. Armadillo: Highly susceptible. Chimpanzees, Mangabey monkey. 10

Important Experimental Animal 11

Most Important experimental Animal 12

Adaptation in artificial media: ICRC, Bombay 1962. – AFB from leprosy patients were isolated in human fetal spinal ganglion cell culture= ICRC bacillus (LJ adapted) 13

Resistance Warm humid environment 9 - 16 days. 46 days in Moist soil 2 hours in Sunlight 30 minutes U V rays 14

LEPROSY 15

Lepers are outcasts ? 16

Epidemiology Exclusively Human disease & only source is a patient Exact mode of transmission – not clear; probably via -Nasal secretions. (One nasal blow may release 8 x 108 bacilli) Entry via – respiratory tract or skin Asymptomatic infection not uncommon 17

Not very communicable – 5% spouses suffer Incubation period is 3 -5 years. (2 to 40 yrs) Continuous close contact. Rare in children < 5 Years. Confined to underdeveloped tropical countries & southern hemisphere currently India • Prevalence 0. 68/10000 population in 2012 • 32 states/UT achieved target of elimination • Chhattisgarh, Dadar & Nagar Haveli Prevalence >1/10000 18

Annual Report 2015 -16 from NLEP GOI (as on 1 st April 2016) >1/10, 000 Population (163 District out of 669) Total cases 86028 19

Annual Report 2015 -16 from NLEP GOI >1 -Chattisgarh, Dadar Nagar Haveli, Delhi, Odisha, Chandigarh, Lakshadeep 20

Classification of leprosy 21

IV. WHO classification Based on bacterial load. 1. Paucibacillary I, T T, BT 2. Multibacillary BB, BL, LL. 22

Clinically……………… 23

Leprosy Slow, chronic & progressive Granulomatous disease of Peripheral nerves, skin and Muco- cutaneous tissues (Nasal mucosa). It affects Skin, liver, testes , bones. 24

Pathogenesis Source : Nasal or Skin discharges from lesion. Portal of entry: Damaged skin -Inoculation. Nasal mucosa- Inhalation 25

Pathogenesis contd…. : Infiltration of bacilli in cooler body tissues like skin (nose, outer ear), testicles & superficial nerve endings→ (maculae) visible lesions. A non-specific or Indeterminate skin lesion is the First sign of disease. Schwann cell is target cell. Neuritis leads to Anesthesia & muscle paralysis. 26

Lepromatous leprosy Tuberculoid leprosy Regression • Lesions are large maculae on skin, superficial nerve endings. papules or nodules; Extensive destruction of skin. • CMI is intact. • Low infectivity • Extensive maculae, Progression • CMI severely depressed • High infectivity 27

Lepromatous leprosy Generalized form with decreased CMI. “Lepromata” : Granulation tissue with plenty of vacuolated cells, from MN cells to Lepra cells. Ulceration Secondary infection & Mutilation of limbs. Skin lesions are extensive and bilaterally symmetrical. 28

Sites: Commonly face, ear lobules, hands and feet. Symmetrical thickening of peripheral nerves & anesthesia Bacilli invade mucosa of Nose , Mouth and Respiratory tract → shed in secretions. Bacteremia present. RE system, Eyes, testes, kidney & bone involved 29

Lepromin test is negative. CD 8+ cells in plenty Antibodies / other Abs are seen (exaggerated humoral response) BFP= syphilis tests (STS) Infective form…. more than other types – poor prognosis Lateral part of eyebrows are lost 30

Lepromatous leprosy 31

Complications : Acute exacerbations. Testicular atrophy, Gynaecomastia Diffuse thickening of face – (Leonine face). Necrosis of nasal bones, cartilage with loss of upper incisors. Corneal ulcers. 32

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Tuberculoid leprosy Localized form in individuals with intact CMI. Skin lesions : Few hypo or hyper pigmented macular patches (anesthetic) Sharply demarcated Seen on Face, trunk and limbs. Bacilli are scanty or absent. (paucibacillary) Infectivity is low. 34

• Diagnosed with Clinical + Histological evidences. Nerves : Peripheral Nerves to bigger nerves involved. Thickened, hard and tender. Deformities in hand & feet Lepromin test is positive. Auto antibodies production is rare. CD 4+ cells. 35

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Good prognosis 37

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Complications Peripheral neuropathy. V & VII th cranial nerve : Corneal ulcers. Ulnar nerve : Claw hand. Lateral popliteal nerve : Foot drop. Posterior tibial & medial nerve: Trophic ulcers, Loss of digits. 40

Dimorphous/Borderline type : Lesions resembles both LL (bacteriology) & T T (Clinically). May turn to complete LL or T T type (depending on host resistance or chemo therpay) 41

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Borderline lepromatous Lesions are Slightly asymmetrical with or without anesthesia. Borderline tuberculoid leprosy Cirular, sharply demarcated lesions. Raised erythematous border with anesthesia. 43

Indeterminate type: Early stages : Maculoanesthetic patches. Lesions are not like T T or LL Spontaneous healing. Turn to either LL or T T type. 44

Indeterminate type 45

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Immunity : High degree of innate immunity. Induces both AMI & CMI. Antibodies are not effective. LL Pts : Large number of CD 8 cells. TT Pts : Predominantly Genetic relation: CD 4 cells. T T : HLA – DR 2 L L : HLA MTI, DQ 1 48

Differential diagnosis of Leprosy Birth mark T. versicolor T. corporis 49

Pytiriasis alba Lichen planus Vitiligo 50

Fixed drug eruption Psoriasis Lupus vulgaris Dermal leishmanoid 51

Kaposi’s sarcoma Sarcoidosis 52

Lepra reactions: Acute inflammation of the disease due to Immunological reactions against bacilli. Medical emergency. Two types: 53

Jopling type 1: CMI response against bacilli – Synonym: Reversal reaction – Occurrence: Spontaneous, Chemotherapy – Seen in BT, BB, BL. – Due to influx of lymphocytes into lesions changed to T T morphology – Lesions are painful, tender Erythema and swelling. 54

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Jopling type 2 – Synonym: Erythema Nodosum Leprosum (ENL) – Due to vasculitis (Antigen – Antibody complex). – Seen in LL & BL few months after starting the chemotherapy 57

– Characterised by: Tender, inflamed subcutaneous nodules Fever Lymphadenopathy, arthralgia. (Ag from dead bacilli – Arthus type response) Ig. G, neutrophil & C in lesions 58

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Lucio phenomenon: Cutaneous hemorrhagic infarct in LL cases. 60

Main features of lepra reactions. Type 1 CMI 1. Immunological basis : Type 2 Vasculitis with Ag – Ab deposits. 2. Type of patient : BT, BB, BL BL, LL. 3. Systemic disturbances : Not seen. Present. 4. Hematological disturbances: Not present Present 5. T Helper response TH 1 predominate 6. Proteinuria Not seen. 6. Relation to therapy Seen in first 6 months. TH 2 Frequently present. Rare in first 6 months 61

Lab diagnosis • Microscopy • Culture • Serology (Ab detection) • Molecular method • Demonstration of CMI 62

Lab diagnosis Bacteriological Diagnosis is easy in LL types but difficult in TT. Specimen: • smears collected from Nasal mucosa, Lesion, Skin (slit ( smear of ear lobule, forehead, Cheek, Chin, buttock) = 5 -6 sites • Sample from thickened nerve or Nodular lesion are collected for H/P 63

Nasal mucosa (nasal Blow or Nasal Scrapping) • A blunt, narrow scalpel is introduced into the nose and internal septum • Scraped sufficiently to remove a piece of mucous membrane, which is transferred to a slide and teased out into a uniform smear. 64

Slit Skin smear: • Taken from Edge of lesion • Skin is pinched up tight to minimize bleeding • a cut about 5 mm long made with a scalpel, deep enough to get into the infiltrated layers. • Wipe off blood or lymph that may have exuded • Scalpel blade is turned transversely to scrape the sides and bottom of the cut for tissue pulp • smeared uniformly on a slide. • About 5 -6 different areas of the skin buttocks, forehead, chin, cheek and ears. Collection of skin smears 65

• Smears are stained by the Ziehl-Neelsen technique using 5% sulphuric acid. • Biopsy Nodular lesions and thickened nerves, and lymph node puncture may be necessary 66

Z-N staining: Decolorizer =5% H 2 SO 4 • Acid fast bacilli within the undifferentiated macrophages: L L • Live bacilli : Solid, uniformly stained, parallel side, rounded ends, length five times width • Dead bacilli : Fragmented and granular 67

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Grading 1 -10 / 100 oil immersion fields : 1+ 1 -10/10 “ “ : 2+ 1 -10 / 1 “ “ : 3+ 10 -100/ field : 4+ 100 -1000 /field : 5+ >1000, clumps/globi in every field: 6+ 69

Load of bacilli: 1. Bacteriological index (BI): total no of pluses (+) scored in all the smears divided by no of smears; Minimum 4 skin lesion, nasal scrap & both ear lobule must 2. Morphological index(% of uniformly stained bacilli) = Uniformly stained bacilli X 100 Total number of bacilli (= SFGB/Total x 100) 70

Skin & Nerve biopsy. 71

Lymphohistiocytic infiltrate surrounding a nerve fiber 72

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Culture: – No Culture media – Animal inoculation: Mouse foot pad: 9 banded Armadillo – Advantage: 10 times more sensitive Drug resistance detection Evaluation of drug potency Check Viability Disadvantage: Time consuming (6 -9 months) Ethical issue: animals used 74

LESIONS DEVELOPING FOLLOWING INOCULATION IN FOOT PAD OF MICE 75

Serological test : Antibodies against phenolic glycolipid Ag -ELISA (Antibody against PGL-I) • • Sensitivity LL: 95% TT: 60% -FLA-Abs-Fluorescent leprosy Ab Absorption Test • Detect specific Ab irrespective of duration and stage of disease • 92% sensitive & 100% specific Molecular diagnosis: 76

Detection of CMI (Lepromin test) : Skin test for delayed hypersensitivity to lepra bacilli. Antigens: 1. Boiled extract of Lepromatous tissue in isotonic saline. 2. Leprosins : Ultrasonicates of tissue – free bacilli from lesions. a). leprosins – H b). leprosins – A 3. Dharmender’s antigen. 4. Soluble antigen. 77

Two types of reactions on Intradermal injection 1. Early reaction of Fernandez : Erythema & Induration within 1 - 2 days Remains for 3 - 5 days. Poorly defined with little significance. 2. Late reaction of Mistuda. Erythematous, indurated , granulomatous nodular skin lesion. Seen in 1 - 2 weeks reaches to peak in 4 weeks. Indicates CMI status in leprosy patients. 78

Significance : 1. To classify the lesions of leprosy. TT(+) LL (-) Borderline (+/-) 2. To assess prognosis & response to treatment. Positive: Good prognosis Negative: Bad prognosis 3. To assess the resistance of individuals to leprosy. 4. Identify candidate lepra bacilli 79

Treatment : Until 1982 : Dapsone only. Now MDT being given because of resistant strains. WHO recommended Multi drug therapy Paucibacillary case. (I, TT, BT) Rifampicin 600 mg/ month Dapsone 100 mg / day annually till 2 year 80

Multi bacillary case: (BB, BL, LL) Rifampicin 600 mg / month Dapsone 100 mg / day Clofazimine 300 mg / month + 50 mg / day annually till 5 years (Ethionamide/prothionamide) 81

Vaccines: BCG, MAI complex vaccine. Mycobacterium w vaccine. Chemoprophylaxis: Dapsone ; in TT variety only 82

THANKS 83