Terri Bianchi DNP ARNP Ormond Beach Dermatology Ormond

* Terri Bianchi, DNP, ARNP Ormond Beach Dermatology, Ormond Beach, FL

2009 2014

* - Power Point assistance

*Participant will: -Increase awareness leprosy -Expand differential or Ddx -Identify national resource *

*http: //abcnews. go. com/Health/leprosy-caseshit-florida-counties/story? id=29258128 *

* A century ago, Pioneering German psychiatrist 1 st suggested the differential approach to diagnosis * Ddx

*Important consideration when encountering & treating any chronic skin or rheumatological disorder *95% humans naturally immune *Pathogen incubation 9 mo – 20 years *SSx appearance may follow this time frame *Reportable federally & in most states, including FL *Armadillo host, not villain *Transmission can be fomite, such as soil * Lack of awareness! CDC reported most cases in US delay dx by 3 years (onset SSx to accurate dx)

* Gulf coast region reported 100 -150 cases each year past few years for 70% cases (2010): * Previously FL typically reported 8 -10 cases/year * 68% cases male (ages 11 -92) * Human: human transmission, droplets nose & mouth (household contact 25% risk) * Fortuitously, humans * become non-infectious w/ 1 st few doses appropriate oral abx tx *These states account *TX 36 *HI 35 *NY 34 *CA 32 *FL 30 *LA 21 and MA 15

* Morally suspect, quarantine *Mycobacterium Leprae 1873 bacterial bacillus • • Cure 1940 (sulfone drug) Out pt treatment 1982 Hansens Disease 1931 Latin ‘lepra’ or scaly

- * location: Carville, Louisiana (LA) LA Leper Home est. 1894 in an abandoned plantation home built 1859, 350 -400 acres - Nat’l Leprosarium 1894 -1999 - voluntary admission 1970 - home to 4, 500 victims of dz - Simultaneously sponsored research & lead to successful tx - Now called, Gillis W. Long Hansens Disease Center (1982 USDHHS) - 1992 Carville Historic District > Nat’l Register Historic Places - 1993 several aged elect to remain > ALF - Most suffered inflamed sores, ulcers, lesions eyes, throat & numbness peripherally Pen name, Betty Miller, NY Times Best Seller, 1950 memoir Miracle@Carville & No One Must Ever Know , 1959 Pen name, Stanley Stein Prints newsletter, STAR, mission, spread light & truth of HD (advocate 1994 founded Nat’l Hansens Disease Museum > @HRSA , Virtual Tour Leprosy > HD) (ear lobes, toes/fingers) > disfigured 1899 -1967

1928 “pale rose spots on thighs”, debutante, engaged to medical student

*Carville/National Hansens Disease Center simultaneous research *2011 Whole genome resequencing from 1 wild armadillo & 3 humans w/ dz revealed identical strain M. lepare * Autochthonous cases * Native born (SE USA), no foreign travel * No h/o foreign exposure * Important in research & current vaccine development effort 4/28/11 N Engl J Med; 364: 1626, accessed 7/25/15 www. nejm. org/doi/full/10. 1056

* 9 Banded (Dasypus novemcinctus), decendents prehistoric, South America 50 million years ago

Cannot hear or see well, great sense smell. No bite. * - Armadillos related to sloths & anteaters - Cannot thrive in very cold, very dry environments - FL is much like the Mother Land: humid, rain, & bugs galore!

*Texas – state mammal *Armadillo racing *People hunt & eat them *“Hoover hogs” during Depression *Moved w/ cattle, TX to other states, train cattle cars * *Florida *Pets, easy to catch *1936 escaped traveling circus *1924 released small zoo & escaped Cocoa, FL * FL Crackers “possum on the half shell” *FL Dept Health, leprosy reported since 1921

The Clinical Advisor April 2015, case 2 = leprosy!

- 27 yod male - Extensor forearm - Scattered ill-defined erythematous nodules & papules - Pain left leg prevented ambulation - Exam evidenced skin colored nodules on earlobes *

* Journal of Drugs in Dermatology * May 2015 * NY Hansen’s Disease Program, Dept Derm, Bellevue Hospital, NY * During RA tx for 2 years, cutaneous lesions erupted > referral derm >punch bx w/ fite stain * dx leprosy * “leprosy often presents as rheumatology d/o”: - Lupus erythematous - RA - Anticardiolipin syndrome * (aka antiphospholipid/APS) * Caution, age of biologics (immune suppressive) tx in RA, Ps

*55 yod Caucasian male *Landscaper, Florida - Sores hands off/on x 2 years, claw like hand - Sores > ulcerations - Pain on ambulation *Admit to hospital, systemic vasculitis Ddx: granulomatis w/ polyanglitis, SLE, APS Accurate Dx, Leprosy AEB skin bx! *

*Cutaneously & commonly, early on: pale, reddish skin patch w/ or w/o diminished sensation *1 or more chronic or recalcitrant maculopapular lesions *Slight, if any prodromal *90% have numbness (maybe years) before skin lesion - temp goes 1 st - light touch 2 nd - pain last to go (hence injuries hands & feet) • 4 mm punch, full thickness, +/- suture • Fite stain • Dermatopathologist! * Rare, but tragic to miss it

Cool areas of body affected - Superficial peripheral nerves - Anterior chamber eyes - Testes - Chin - Malar (cheeks) - Ear lobes - Knees, elbows - Distal BULEs * Thickened superficial peripheral nerve

* - Provides all HCPs w/ knowledge to dx & tx the disease - Introduces methods used to prevent disabilities caused by disease - Aids in dx & management, including complications

Add thank you & skin ca ad - An American’s life time risk melanoma is 1 in 36 - Melanoma #1 cancer adults ages 25 -29 - 1 blistering sun burn in youth doubles lifetime risk US incidence melanoma increased each year x last 30