Target/therapies for chronic recurrent erythema nodosum leprosum.

A Type 2 lepra reaction or erythema nodosum leprosum is an anticipated complication in the lepromatous spectrum of leprosy cases. It is an example of an immune complex-mediated complement activated disease (Type III hypersensitivity reaction). Hence, we tried to target the inflammatory mediators and the mental stressors for the possible management strategies.

A case of leprosy in Malawi. Making the final push towards eradication: a clinical and public health perspective.

Statistically speaking, Malawi has achieved the World Health Organisation's target for the elimination of leprosy (<1 case per 10 000 people), yet the disease is still considered a leading cause of long term physical disability. In this case study the authors discuss the presentation of a 39-year-old gentleman to a district hospital in Malawi with multibacillary, lepromatous leprosy. The condition was initially managed in the community as an 'allergy' which suggests that local barriers currently hinder the detection of leprosy in this developing primary care system. Leprosy is a multi-system disease and this gentleman demonstrated evidence of lepromatous orchitis. Promoting an awareness of these systemic manifestations will increase the the detection of complications and circumvent long term morbidity. Efforts to optimise systems of detection, management and public and professional education are essential to drive eradication in these at-risk populations. At an international level, we must strive to fulfil the objectives outlined by the 'Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy for 2011-2015'. At a national level, local research should delineate community factors that impede the eradication of leprosy. Developing new diagnostic and epidemiologic tools, more efficacious chemoprophylactic regimens and vaccination for endemic regions would facilitate these efforts.

A fatal case of Lucio phenomenon from India.

A 65-year-old man presented with cutaneous ulcerations involving the legs, hands, abdomen, buttocks, and pinna, along with fever, arthralgia, and anorexia for the prior 10 days. On cutaneous examination, dark, irregular-shaped bizarre erythematous purpuric spots and angulated ulcers were seen over bilateral, upper extremities and trunk including dorsum of hands, finger tips and the pinnae of both ears. Most striking were the presence of multiple deep ulcers covered with a blackish eschar and in some areas yellow slough eroding the subcutaneous tissue with ragged margins. These ulcers were distributed symmetrically over the thighs, lower legs and gluteal region. Slit-skin smear examination revealed a bacterial index (BI) of 6+ with globi from earlobes, ulcers 3+, eyebrows 3+ and normal skin 2+ and morphologically showed mainly solid (20-30%), fragmented (60-70%) and granular (5-10%) acid-fast bacilli. Biopsy from the ulcer margin revealed an ulcerated epidermis and dermis. The dermis had infiltrate of foamy macrophages, and evidence of ischemic necrotizing vasculitis, with fibrinoid necrosis and new vessel formation. There was presence of clumps of acid-fast bacilli (AFB) within macrophages, periadnexally, perivascularly, and also within endothelial cells. These clinical and histopathological features helped us to arrive at the diagnosis of Lucio phenomenon in an untreated case of Lucio leprosy which is rarely reported from areas other than Mexico.

Familial transmission of leprosy in post-war Britain--discrimination and dissent.

A Polish immigrant, who was resident in the United Kingdom (UK), presented with lepromatous leprosy and was detained in two hospitals against his wishes in the late 1940s. The public reaction to his diagnosis was remarkable, with street riots and questions in the Houses of Parliament about 'this leper'. His wife was persecuted and had to change her name. The index patient died of tuberculosis during enforced isolation in hospital, and several years later his daughter (who had never left the UK) presented with a left median nerve palsy and probable lepromatous dactylitis of the left third finger, eventually requiring amputation and prolonged dapsone treatment. Her disease resolved slowly but completely. We believe these two familial cases represent the first documented episode of autochthonous leprosy transmission in the UK since the early 1920s. They also demonstrate the ability of this disease to engender fear, dissent and discrimination amongst the public. Parallels are drawn with reactions to the cholera epidemics in nineteenth century Britain, and to HIV/AIDS, SARS and multi-drug resistant tuberculosis in more recent times.

Dimensions and process of stigmatization in leprosy.

Leprosy is a disease which has struck fear into human beings for thousands of years. This is partly because it causes considerable deformities and disabilities. In 1991, the 44th World Health Assembly adopted a resolution to eliminate the disease as a public health problem by the year 2000. However, one of the major obstacles to achieving this objective is the stigma associated with the disease. Stigma against leprosy patients affects all aspects of leprosy control. This paper describes a model of the stigmatization process in leprosy. The process of stigmatization can be divided into two stages. The first stage describes how certain cognitive dimensions of leprosy lead to a variety of affective responses towards the disease. The second stage involves how these affective responses contribute to social devaluation of the leprosy patient and consequently, the adoption of negative behaviours towards them.