Impact of integration on the profile of newly diagnosed leprosy patients attending a referral hospital in South India.

This article compares the clinical profile of new untreated leprosy patients attending a referral hospital (The Schieffelin Institute for Health Research & Leprosy Centre, formerly known as SLR&TC, Karigiri, South India, in post-integration period (2005-2007) with that during the pre-integration period (1995-1996). A total of 529 patients--259 in pre-integration and 270 in post-integration period--were seen at this hospital. The clinical data culled from records for the earlier period were compared with data gathered prospectively for the latter period and was analyzed using SPSS software. The results showed a significant increase in the mean age of registration, percent multibacillary (clinical criteria) and grade 2 diabilities in post-integration period. Increase in proportion of cases with grade 2 deformities is a matter of concern and suggests continued need for referral hospitals for their management and also population based overall assessment whether actual numbers with deformities have increased or it is peculiar to a tertiary care hospital where the cases with problems may be coming. As the proportion of bacteriological positive cases was not found to change, it is a positive sign of effective coverage in the post-integration scenario in this population.

Does clofazimine have a prophylactic role against neuritis?

A study was undertaken with the aim of testing the usefulness of clofazimine as a prophylactic agent against neuritis and nerve damage. A modified regimen, using initial high doses of clofazimine followed by regular multibacillary multidrug therapy (MB-MDT) WHO regimen, was given to a series of consecutive cases of high risk borderline leprosy patients, fulfilling defined selection criteria (n = 65). These patients were studied for the incidence of neuritis/Type I reaction, over a period of 2 years. Results were compared with a matched series of consecutive cases treated only with regular MB-MDT WHO regimen (n1 = 57). The difference in incidence rates of neuritis between the two groups was significant (p < 0.01), suggesting that clofazimine may have a useful prophylactic role against neuritis/Type I reaction and nerve damage.

Clinical and histopathological activity in paucibacillary leprosy patients after fixed-duration multidrug therapy.

In 37 clinically-diagnosed borderline-tuberculoid (BT) leprosy patients skin biopsies were done prior to starting multidrug therapy (MDT) and at the end of 6 months therapy. Clinical and histopathological activity, graded as active, resolving and inactive, were studied at the end of 6 months of MDT. Of the 37 clinically-diagnosed BT patients 24 could be confirmed by histopathology as having BT leprosy, while the other 13 biopsies showed features of indeterminate (I) leprosy. After 6 months of MDT, out of the 24 histopathologically-confirmed BT patients, 4 (17%) showed clinical activity and 8 (33%) showed histopathological activity. Of the 13 histopathologically-diagnosed indeterminate cases all were clinically inactive but histological activity persisted in 3 cases (23%). Out of the 37 clinically-diagnosed BT patients 3 showed both clinical and histopathological activity at the end of MDT. This study emphasizes the importance of performing histopathological examinations on leprosy patients undergoing research studies for the confirmation of diagnosis and for proper classification of the disease. The histopathological activity that outlasts the MDT may be due to the bacillary fragments that persist but clinical activity coupled with histopathological activity seen in 3 patients at the end of 6 months may foreshadow a relapse and these patients and others like them need to be followed up for longer durations.

Histological studies in primary neuritic leprosy: changes in the apparently normal skin.

The visually normal skin of 196 patients diagnosed clinically to have primary neuritic leprosy was studied histologically to determine whether there were any specific changes due to the disease in this site. Histological changes due to leprosy were seen in 32.1% of the patients, and included, indeterminate leprosy in 19.4%, borderline tuberculoid leprosy in 6.6% and borderline lepromatous leprosy in 6.1%. The remaining biopsies showed mild non-specific dermal inflammation, mild nerve changes or no significant lesion. The nerve inflammation and/or granulomas were mostly in the deep dermal nerves or neurovascular complexes. This study shows that there is a cutaneous component to primary neuritic leprosy and the disease is not totally confined to nerves. The absence of visible hypopigmented patches in these patients is probably related to the deep location of the dermal inflammation.

Leucocytopenia after rifampicin and ofloxacin therapy in leprosy.

New antimycobacterial agents and combined treatment regimens are being introduced for the treatment of leprosy. Ofloxacin is one such broad spectrum antimicrobial agent. In this study rifampicin plus ofloxacin were administered daily for 4 weeks (daily supervised dose). Two patients (and possibly a third patient who refused all investigations) out of 125 patients developed leucocytopenia during the third week of therapy. It was associated with fever, malaise, nausea and loss of appetite. They recovered after cessation of drug treatment. Patients receiving ofloxacin should be monitored for constitutional symptoms suggestive of this complication even though the risk of such complication may be minimal.

Histological studies in primary neuritic leprosy: changes in the nasal mucosa.

The nasal mucosae of 39 cases of primary neuritic leprosy (PNL) registered at Karigiri were studied histologically to determine nasal mucosal involvement in PNL and its relevance to the pathogenesis of the disease. Specific changes of leprosy were seen in 20 (51%) biopsies, ranging from macrophage granulomas with acid fast bacilli, to epithelioid granulomas and nerve inflammation. The remaining biopsies revealed chronic inflammatory changes of the mucosa or mild non-specific nerve changes. These findings show that there are widespread effects of the disease even in PNL patients in whom the disease is believed to be confined to the peripheral nerves. The findings also show that early leprosy involvement can be found in the nasal mucosa even before lesions become apparent in the skin or other parts of the body. The nasal mucosa could be one of the sites for the primary lesion in leprosy. Clinical and histological examination of the nasal mucosa may be useful and important in the early diagnosis of leprosy and especially in contacts.

Profile of leprosy in children: past and present.

The profile of leprosy in children currently seen in a referral hospital is compared with that of children with leprosy admitted in the 1970s. Children with leprosy under the age of 15 years in 1974 and 1979 comprised one group (Group I) while those during 1989 and 1994 constituted the second group (Group II) The variables studied included age, sex, type of leprosy, deformity and contact status. Multidrug therapy (MDT) was introduced in the treatment of leprosy in 1982. The probable change it has made in the presentation of leprosy in children is discussed.

Intraocular pressure in leprosy patients without clinically apparent anterior segment pathology.

A widely prevalent notion is that intraocular pressures are generally lower in leprosy patients than in normal individuals. Applanation intraocular pressures were recorded in one hundred sixty-six leprosy patients who had no clinically visible anterior segment pathology and in one hundred and eleven healthy controls. Mean (SD) intraocular pressures in leprosy patients (13.6 (3.0) mm Hg) did not differ significantly from that of controls (13.1 (2.7) mm Hg). Eyes of only 1.5% of the leprosy patients had pressures of 7 mm Hg or less. Correlation coefficients (r) between age, sex and intraocular pressures were not statistically significant both in leprosy patients and in controls. No statistically significant differences in mean intraocular pressures were noted when leprosy patients were grouped according to the Ridley and Jopling classification. Duration of disease also did not affect the intraocular pressures. Neither did smear positivity or differing bacterial indices. This study questions the widely held belief that low intraocular pressures are a common feature in leprosy and contends that in the era of MDT where ocular complications associated with low intraocular pressures are thought to be less, the occurrence of low intraocular pressure may not be as common a phenomenon as it is believed to be.

Climatic droplet keratopathy in leprosy.

An atypical gross form of climatic droplet keratopathy (CDK) occurring in the cornea of 24 eyes of 17 leprosy patients is described. The CDKs were situated in the lower outer quadrant of the cornea and were not associated with trauma, scars or vascularization. All patients, except one, belonged to the lepromatous group. Fifteen of the 24 eyes with this form of CDK had impaired corneal sensation. We suggest that this form of CDK is a distinctive condition found among lepromatous leprosy patients with possible infection and involvement of the corneal nerves.

Dapsone induced pulmonary eosinophilia without cutaneous allergic manifestations--an unusual encounter--a case report.

Dapsone is a drug of choice in the treatment of leprosy. In addition it is very useful in the treatment of many other dermatological conditions. The "dapsone-induced hypersensitivity" is not unknown. However, to the best of our knowledge, pulmonary eosinophilia induced by dapsone without any cutaneous allergic manifestation has not been reported in leprosy patients. Pulmonary eosinophilia (Loeffler's syndrome) induced by dapsone without cutaneous manifestation has been reported in a non leprosy patient by Janier et al. We report a case of pulmonary eosinophilia associated with dapsone therapy in a patient with lepromatous leprosy without allergic cutaneous manifestations and our experience in the management of this patient.

Leprosy in an albino.

A case of complete albinism with Borderline Lepromatous leprosy is presented being the first report from India, of the association of these conditions.

Histological changes in the nerve, skin and nasal mucosa of patients with primary neuritic leprosy.

Primary neuritic leprosy (PNL) presents as a peripheral neuropathy with no visible skin patches and skin smears negative for acid fast bacilli. The pathogenesis of PNL is poorly understood. The aim of the study was to document the histological changes in the nerve, apparently normal skin and nasal mucosa in PNL and to study its significance to the pathogenesis of leprosy lesions. The study is based on a cohort of 208 PNL patients registered at the Schieffelin Leprosy Research and Training Centre, Karigiri. All patients had a nerve biopsy, 196 had a skin biopsy and 39 had a nasal mucosal biopsy. The findings reveal that PNL patients exhibit a spectrum of disease histologically in the nerve ranging from lepromatous to tuberculoid leprosy with a significant proportion (46%) manifesting a multibacillary leprosy histology. Findings in the apparently normal skin and nasal mucosa reveal that there are widespread changes due to leprosy in tissues such as the skin and nasal mucosa even when the disease appears clinically confined to a few nerves. PNL may be an early stage in the pathogenesis of the disease before the appearance of skin lesions. The number of nerves enlarged and lepromin status did not give any clue to the nature of underlying disease.

Nocardia farcinica pleuritis in a lepromatous patient with severe necrotizing reaction: an unusual presentation.

A young, male, lepromatous leprosy patient with a severe necrotizing erythema nodosum leprosum reaction treated with prolonged oral steroids and thalidomide developed pleuritis that was caused by a rare opportunistic pathogen, Nocardia farcinica. This organism was resistant to most antibiotics but was susceptible to amikacin and minocycline. During the course of treatment the patient developed severe gastritis which necessitated the removal of clofazimine and the inclusion of an H2 receptor antagonist. Bilateral steroid-induced cataracts needed surgical correction. This case is being presented for its rare opportunistic bacterial infection and for the multiple complications which made treatment difficult.

Multibacillary nerve histology in clinically diagnosed borderline tuberculoid leprosy patients.

The classification of leprosy into multibacillary (MB) and paucibacillary (PB) patients in almost all clinics is entirely dependent on clinical examination. In a study of 21 patients clinically classified as borderline tuberculoid (BT) and, therefore, belonging to the PB group, skin smears and skin and nerve biopsies were examined. Four patients did not have any histopathological evidence of leprosy. Skin smears showed that 1 patient was positive for acid-fast bacilli (AFB), 2 skin biopsies belonged to the borderline lepromatous (BL) category and showed AFB in their lesions, and AFB were present in 10 nerve biopsies classified as BL. It is possible that reported relapses among PB patients may be in those patients with demonstrable AFB in the lesions, including nerves. A careful follow-up study of this particular group of patients after PB multidrug therapy is suggested to resolve this question.

Skin smears in leprosy: is reduction in number of sites justified?

An analysis of 377 sets of positive skin smears of leprosy patients was done to determine the minimum sites needed to detect all smear positive leprosy patients. A combination of earlobe and a selective site could pick up 95.5% of the patients. An additional smear from the forehead increased the sensitivity of 97.7%. The results suggest that the sites for skin smears may be reduced to a combination of the earlobe and one selective site smear from a skin lesion to be able to detect most smear positive leprosy patients.

A clinico-pathological study of primary neuritic leprosy.

Normally neural involvement in leprosy is an ascending neuritis from the nerve involvement in the dermal lesions. However, in some cases neural involvement is seen in the absence of any dermal lesions. In some of these pure neuritic cases, dermal lesions appear sometime later. It is, therefore, more appropriate to designate such cases as 'primary neuritic' cases. This study is aimed at diagnosing primary neuritic leprosy among patients presenting with only neuritic symptoms. An attempt is also made to classify primary neuritic leprosy on a clinical and histopathological basis. During the period 1979-80, 30 patients reported to the out patient department of Schieffelin Leprosy Research and Training Centre, Karigiri with complaints of neuritic origin. In addition to clinical examination and routine skin smears, investigations such as skin, nerve and nasal biopsies, nerve conduction velocity and lepromin testing were carried out where feasible. 17 of these patients were diagnosed as primary neuritic leprosy and in 7 patients other neurological conditions were diagnosed. The remaining 6 patients were kept under observation and have not shown evidence of leprosy during a two year period of following-up. It is interesting that 4 of the 17 primary neuritic cases developed patches during follow-up period of two years. In the final analysis 7 patients (41.2%) were classified into the lepromatous group and 10 patients (58.8%) in the non-lepromatous group (Table-6). This classification will have a bearing on duration of treatment and for their subsequent release from control.

Malignant Melanoma of Oral Cavity.

Primary malignant melanoma of oral cavity is very rare. A case of oral melanoma who died due to metastasis a year after the excision of the primary lesion is reported along with a brief review of the literature.