A Clinical Study of Efficacy of Autologous Platelet-Rich Fibrin (PRF) in Chronic Non-Healing Ulcers.

Background: Chronic ulcers are defined as the breakdown of the epidermal and dermal tissue lasting for more than 6 weeks. There will be a lack of necessary growth factors in chronic non-healing ulcers. This study is aimed at accessing the efficacy of autologous platelet-rich fibrin in chronic non-healing ulcers. Aims and Objectives: To determine the efficacy of autologous platelet-rich fibrin in chronic non-healing ulcers and to compare the rate of healing in different ulcers based on aetiology. Methods: A hospital-based prospective study was conducted at the Department of Dermatology, Venereology, and Leprosy, at a tertiary care centre in Central Karnataka with 50 cases of chronic non-healing ulcers over 2 years. In each case baseline data including age and gender was collected and thorough general physical, local, and systemic examinations were done with the help of a predesigned proforma. PRF dressing was done weekly for 4 weeks with ulcer volume measured each time and improvement accessed. Results: In this study, the mean age of the study population was 43.56 ± 14.06 years, with 84% males. Good improvement in the volume of the ulcer was seen in 6 patients out of 50, moderate improvement was seen in 20 out of 50 patients and mild in the rest of the 24 patients. Improvement was more in the educated sector, more so in females and patients with trauma as the cause of ulcers without any comorbidities. Leprosy followed by diabetes was the main cause of chronic non-healing ulcers. Conclusions: This study shows that autologous platelet-rich fibrin therapy provides faster wound healing in chronic non-healing ulcers with no adverse events.

Are sputum samples of retreatment tuberculosis reaching the reference laboratories? A 9-year audit in Tanzania.

SETTING: One reference and three zonal laboratories and 500 health facilities managing retreatment tuberculosis (TB) patients in Tanzania. OBJECTIVES: The National Tuberculosis and Leprosy Programme (NTLP) requires that all notified cases of retreatment TB in Tanzania have sputum samples sent for culture and drug susceptibility testing (DST). This study determined 1) if the number of annually notified retreatment patients corresponded to the number of sputum samples received by the reference laboratories, and 2) the number of culture-positive samples and the number of cases undergoing DST. DESIGN: Nine-year audit of country-wide programme data from 2002 to 2010. RESULTS: Of the 40 940 retreatment TB patients notified by the NTLP, 3871 (10%) had their sputum samples received at the reference and zonal laboratories for culture and DST. A total of 3761 (97%) sputum samples were processed for culture, of which 1589 (42%) were found to be culture-positive and 1415 (89%) had DST performed. CONCLUSIONS: There is a >90% shortfall between notified retreatment cases and numbers of sputum samples received, cultured and assessed for DST at reference and zonal laboratories. Steps needed to address this problem are discussed.

Trend in decline in leprosy disabilities of a LEPRA project in Malkangiri district, Odisha, India.

This a retrospective analysis of the changes in 646 disabilities occurred amongst 3979 cases registered during 19 years from 1992 to 2010 in Malkangiri district. This amounted to 16.2% of cases with disability segregated to 310 (48%) Grade 1 and 336 (52%) Grade 2. In this project, managed by LEPRA India, POD care was in practice from the year 1992 and records were updated regularly. An analysis of the annual records showed that the next year-end balance increased up to the year 2001 followed by gradual decline. Within this period the total cases with disabilities declined by about 369 (57%) due to death by aging 204 (55%), migration from the area 77 (21%) and reversing to normal 88 (24%) in cases. Deletion due to recovery to normal especially with sensory impairment is fairly good with or without steroid. Disability percentage in new cases declined steadily especially Grade 2 from 30% to 1%, initial high rate attributed mostly to backlog cases. In later years the rate is erratic high amongst low number of new cases. Absolute number indicates the situation better. Such study helps to roughly extrapolate the existing disability load in a particular area and assists in planning for care and prevention.

Absence of nucleotide-binding oligomerization domain-containing protein 2 variants in patients with leprosy and tuberculosis.

Crohn's disease-associated NOD 2 variants (Arg702Trp and 3020insC) were found to be monomorphic (wild), and 7 subjects were heterozygous for Gly908Arg SNP in 263 patients with tuberculosis, 260 patients with leprosy and 270 healthy controls residing in northern Indian states. This is the first report to suggest the minimal role of these variants in susceptibility/resistance to TB and leprosy in this population.

Leprosy among tribal population of Chhattisgarh state, India.

Chhattisgarh state is still endemic for leprosy and has a large tribal population. During 2003-2009, a total of 1530 untreated leprosy cases reported to the Leprosy Mission Referral Hospital in Champa, of which 151(9%) were classified as belonging to the scheduled tribes. The characteristics of these new tribal patients are described and compared with other patients and to the demographics of the tribals in the general population of the State. While tribals were accessing the leprosy services similar to the other social groups, the delay in reporting, high BI and other features pose more serious problems in the transmission of leprosy and in management of complications due to the harsh environment and occupational patterns of the tribals. Appropriate strategies and more community based approaches will be necessary if these groups are also targeted for eradication of leprosy.

Antibodies to myelin P0 and ceramide perpetuate neuropathy in long standing treated leprosy patients.

Anti neural antibodies are known to play a role in the immunopathogenesis of nerve damage in leprosy and HIV/AIDS. Myelin Protein zero (P0) and ceramide are two nerve components which maintain the integrity of the peripheral nerve. The present study was undertaken to identify antibodies to myelin P0 and ceramide in the sera of treated leprosy patients, HIV positive individuals and healthy subjects using enzyme linked immunosorbant assay (ELISA). The results revealed that treated leprosy patients continue to have significantly elevated myelin P0 and ceramide antibody levels as compared to healthy subjects (P < 0.05). The elevated antibody response to myelin P0 and ceramide in leprosy patients indicate a low grade autoimmune activity that perpetuates nerve damage in treated leprosy. There was no significant difference in the myelin P0 and ceramide antibody levels between HIV positive and healthy subjects (P > 0.05) suggesting that these antibodies do not play a role in early HIV infection.

Two microbiological relapses in a patient with lepromatous leprosy.

A lepromatous patient treated with dapsone in the pre-MDT era to the point of smear negativity (> 6 years), relapsed 5 years after stopping treatment. He was then put on WHO-MDT for multibacillary (MB) leprosy, and was treated again; he had negative slit skin smears (3 years). He again presented with a relapse of leprosy 17 years after stopping treatment, and this time he presented with borderline leprosy in reaction.

Performance of recombinant ESAT-6 antigen (ML0049) for detection of leprosy patients.

AIMS: The study was aimed to evaluate the Mycobacterium leprae recombinant early secreted antigenic target-6 (rESAT-6) for its serological performance in leprosy patients. METHODS AND RESULTS: Employing enzyme-linked immunosorbent assay (ELISA), serum samples were tested for prevalence of immunoglobulin G antibodies against M. leprae rESAT-6. The results revealed that the sensitivity of the assay for smear-positive leprosy patients was 82.4% (14 of 17) while for smear-negative patients it was 19.4% (six of 31). Interestingly, the performance of ESAT-6-based assay was statistically comparable with anti-phenolic glycolipid-I antibody-detecting ELISA, a most widely studied serological assay in leprosy. Regarding specificity, none of the 48 controls was positive indicating that antibody response to ESAT-6 was highly specific. Moreover, a high concordance between bacterial index and anti-ESAT-6 antibody-detecting assay was noted. CONCLUSIONS: Recombinant ESAT-6 seems to be a potential serological reagent for detection of M. leprae infection. SIGNIFICANCE AND IMPACT OF THE STUDY: ESAT-6 serology may have utility for (i) early diagnosis, particularly, of highly infectious form (multibacillary, MB) of leprosy, (ii) monitoring the response in smear-positive leprosy patients during the course of the chemotherapy, (iii) classification of leprosy patients into MB and paucibacillary groups for treatment purpose. Hence, further research on these lines is warranted.

Evaluation of recombinant serine-rich 45-kDa antigen (ML0411) for detection of antibodies in leprosy patients.

The potential of the recombinant serine-rich 45-kDa antigen (ML0411) of Mycobacterium leprae to aid in detecting M. leprae-specific serum antibodies was assessed by an enzyme-linked immunosorbent assay (ELISA) in leprosy patients and controls comprising of tuberculosis patients, other unrelated skin-diseased patients and healthy individuals from India. All 18 multibacillary (MB) and 18/38 (47.4%) of the paucibacillary (PB) leprosy patients were found positive. None of the controls was positive, yielding complete (0/49) specificity in the series tested here. On the other hand, an anti-phenolic glycolipid-1 (PGL-I) antibody-detecting assay yielded detectable responses in 94.4% (17/18) of MB and 36.8% (14/38) of PB leprosy patients. Only two of 49 (4.1%) controls were positive, giving a specificity of 95.9%. Further, there was a good concordance (agreement of 83.8%; chi(2) = 40.3, P < 0.001; kappa = 0.63) between the two assays. Thus, the 45-kDa-based assay was slightly better than anti-PGL-I antibody-detecting assay. Interestingly, when combining the results of both the assays together for all leprosy patients (MB + PB), the combined sensitivity was significantly higher than that of the anti-PGL-I antibody-detecting ELISA alone (73.2% versus 55.4%; P < 0.05), but not (P > 0.05) compared with the 45-kDa antigen-based assay alone. Similarly, in case of PB patients, using both assays in combination, the sensitivity was significantly higher compared with anti-PGL-I antibody-detecting assay alone (60.5% versus 36.8%; P < 0.05). While adopting the combinatorial approach, the specificity remained invariably high (>95%). In conclusion, the results of the present study indicate that the M. leprae 45-kDa protein is a potent B-cell antigen and may be a useful serodiagnostic reagent.

Leprosy situation in the slums of Agra City--epidemiological findings.

The present article is the result of a study of the leprosy caseload in Agra City and is based on a house-to-house survey conducted during April-July 2003 in 5 areas. During the survey 198,150 persons were examined, and 287 cases were detected, giving a prevalence rate of 14.5/10,000. A majority of them (92%) were new cases, detected and diagnosed for the first time. The patient load was found to be unevenly distributed with comparatively more number of patients in areas such as Jamuna Kinara, Shah Ganj and Lohamandi. Among the 264 newly detected cases, 14.8% were of MB type. Overall deformity of grade > or = 2 was seen in 2.8% of patients--0.4% in PB and significantly high at 18% in MB leprosy. The observations reveal that leprosy is endemic in slum areas of Agra City.

Palmar dermatoglyphics as diagnostic tool: Mayer-Rokintansky-Kuster-Hauser syndrome.

The congenital anomalies involving Mullerian duct dysgenesis, the MRKH (Mayer-Rokitansky-Kuster-Hauser) syndrome overlaps a 'community of syndromes' which share, apart from a complete absence of uterus and vagina, associated presentations that include developmental abnormalities of skeletal, renal, dental and other dysmorphias. First described more than 400 years ago, this complement of anomalies now rechristened, the MRKH syndrome has been extensively studied. Found to occur once in every 4000 females; estimated on its incidence vary from 1/5000 to 1/20,000. Despite its fairly wide prevalence, this syndrome has remained largely underdiagnosed or cryptic. Social and cultural perceptions have perforce driven, the wide existence of the very personal handicap underground and unacceptable. Accidentally discovered during routine examination, during secondarily associated medical problems, the mullerian agenecies syndrome has been subject of a wide range of clinical and laboratory investigations. The oddity in the syndrome is that the patient appears absolutely normal and that it presents with no genetic marker. We herein report the palmar dermatoglyphic and doctylographic features of a patient with MRKH syndrome. However interpretation, show conclusively, at least in this single case that the MRKH syndrome can be diagnosed through its characteristic dermatography patterns. In our view, routine dermatographic study of all live females births may lead to not only an early but also a cost effective diagnostic method.

Pattern of bacillary clearance in multibacillary leprosy patients with multidrug therapy.

The bacteriological index (BI) of the skin smears is traditionally one of the important parameters of assessment of severity and of progress of leprosy under multidrug therapy. The present study reports on BI clearance among 578 multibacillary treated leprosy patients and the factors that influence this clearance. The patients were treated till smear negativity or for 2 years fixed duration and their skin smears periodically examined every 6 to 12 months till negativity (and even afterwards). We confirm that bacterial clearance is a slow process. The time taken for each log-unit decline in BI is between 13.6 to 24 months probably depending on initial BI level. The rate of smear negativity appears to be dependent on immune competence of the patients as reflected by a rapid BI decline in borderline BT-BB patients vis-à-vis BL-LL lepromatous patients both in the low and high BI group. Patients who had several episodes of ENL, took significantly longer time (63.7 months versus 53.5 months, p<0.0001) to become smear negative than those without ENL.

Blepharochalasis.

Two cases of blepharochalasis, underwent cosmetic blepharoplasty, follow-up for 5 years revealed no progression.

Some epidemiological observations on leprosy in India.

This population sample survey conducted in rural and urban areas of the Agra District in India showed an active leprosy caseload of 60.1/10,000 in the rural and 39.1/10,000 in the urban areas against a targeted prevalence of < 1/10,000. The disease appeared to be widespread since almost 65% of the villages or urban pockets surveyed had at least one prevalent case of leprosy. Significantly larger numbers of leprosy patients were found among males, agricultural/manual workers, persons with no formal schooling, individuals living in unkept households with dirty surroundings, and among those living in dark and poorly ventilated houses. The epidemiological significance of this study reveals the endemic nature of leprosy in Agra and suggests the need to intensify and widen case-detection activities to achieve leprosy control.

Relapses in multibacillary leprosy patients: effect of length of therapy.

Two groups of MB leprosy patients, one treated to the point of smear negativity (TSN) and the other given therapy for fixed duration (24 doses of WHO MB regimen) (FDT), were compared for relapse rates during treatment and in the post-treatment period. During the follow-up of 980.2 person years in 260 patients treated with FDT, 20 relapses (2.04/100 patient years) were observed. In the other group of 301 patients, who received therapy till smear negativity, 12 relapses in 1085.46 person years (1.10/100 patient years) occurred. Comparison of survival rates (without relapse) has shown that although there is no difference up to 4 years, the risk of relapse was significantly higher on longer follow-up in the FDT group. In addition, when patients were compared on the basis of initial bacterial load, it was found that the relapse rates in patients with BI > or = 4 was significantly higher (P < 0.01) in the FDT group as compared to those receiving treatment till the point of smear negativity (4.29 versus 1.27/100 patient years). All the relapsed patients responded to retreatment with the same drug combination, indicating that the exacerbation in their condition was because of insufficient treatment. It is suggested that to prevent or reduce relapses, treatment where feasible would be continued till smear negativity, at least in patients with high BI.

Skin peeling syndrome.

Peeling of the skin is an uncommonly encountered disorder. Occurrence of vesicles and bullae in peeling skin syndrome is very rare. We report a case of idiopathic peeling skin syndrome with vesicular lesions.