[Evaluation of the Senegal leprosy endemic in 2002]. / Evaluation de l'endémie lépreuse au Sénégal en 2002.

UNLABELLED: The authors had for aim to assess the epidemiology of leprosy in Senegal after 7 years of efficient prevention. METHODS: A retrospective study was made on epidemiologic data in Senegal collected between January 1 and December 31, 2002. The indicators of eradication (total number of new cases diagnosed in that year compared to the country's population, expressed in cases per 100,00 inhabitants), the coverage rate (number of cases treated compared to the number of patients recorded for treatment), as well as the cure rate (percentage of patients having complied to the duration of treatment) were all noted. RESULTS: The mean detection rate was 0.5 case per 100,000 inhabitants with 434 new cases reported. The prevalence rate was 0.99 per 10,000 with 981 cases recorded for total management. The coverage rate for total management was 100%. The observed cure rate was 89% and 8% of the patients were lost to follow-up.

Distinguishing features of anti-beta2 glycoprotein I antibodies between patients with leprosy and the antiphospholipid syndrome.

Anticardiolipin (ACA), anti-beta2 glycoprotein I (beta2GPI), and antiprothrombin antibodies of IgG and IgM classes were quantitated by enzyme-linked immunosorbent assays in 176 untreated leprosy patients across the histopathological spectrum. Positivity rates ranged from 21% (IgG ACA) to 30% (IgM anti-prothrombin) versus 4% in healthy controls (p <10(-2) to 10(-3)). Levels of IgM anti-beta2GPI and IgG ACA were significantly higher in lepromatous leprosy and multibacillary patient subgroups. IgG3 was the most common subclass reactive to both beta2GPI and prothrombin in selected high-titer leprosy sera, unlike antibodies from patients with the antiphospholipid syndrome (APS) largely restricted to IgG2. In leprosy patients, but not in the APS control group, there was no statistical correlation between ACA and anti-beta2GPI antibody levels. Likewise, a large fraction of anti-beta2GPI positive sera (36/45 and 28/44 for IgG and IgM, respectively) were unreactive in the standard ACA assay. Most assayed anti-beta2GPI antibodies from leprosy patients showed (i) ability to recognize both human and bovine beta2GPI immobilized on non-irradiated polystyrene plates, (ii) concentration-dependent inhibition of binding by cardiolipin, and (iii) relatively high avidity binding to fluid-phase beta2GPI, thereby differing from those found in APS. Finally, the location of the major epitopic region on the beta2GPI molecule targeted by autoantibodies was different in leprosy and APS, as assessed by direct binding to domain I- and V-deleted mutants and competition with the mouse monoclonal antibody 8C3, directed at domain I. Thus, leprosy-related antiphospholipid antibodies comprise persistent IgG and IgM anti-beta2GPI that differ from APS-related ones with respect to IgG subclass, avidity and epitope specificity, possibly reflecting distinct pathophysiological significance.

[Can plantar ulcers associated with leprosy be treated in the field. Results of experience in Senegal]. / Peut-on soigner les maux perforants plantaires des anciens malades de la lèpre sur le terrain? Résultats d'une expérience au Sénégal.

The introduction of a program for the treatment of plantar ulcers (PU) in field conditions in Senegal was studied. The program was complementary to the Health Education and Protective Footwear to Prevent Disability (POD) initiatives within the Senegalese anti-leprosy program. The wound care given in health centers was coded and simplified. Access to hospitals was made easier for those patients requiring surgery. More than 30% of patients with PU were treated each year, with a mean of 62% cured. An increasing number of leprosy patients have been admitted to regional hospitals for surgery. Never before have patients with signs of leprosy had access to general hospitals. This study emphasizes the need for regular supervision of the individuals treating wounds.

Field trial on efficacy of supervised monthly dose of 600 mg rifampin, 400 mg ofloxacin and 100 mg minocycline for the treatment of leprosy; first results.

In 1995, a field trial was implemented in Senegal in order to evaluate the efficacy of a regimen based on the monthly supervised intake of rifampin 600 mg, ofloxacin 400 mg and minocycline 100 mg to treat leprosy. During the first year of the trial, 220 patients with active leprosy (newly detected or relapsing after dapsone monotherapy) were recruited: 102 paucibacillary (PB) (60 males and 42 females) and 118 multibacillary (MB) (71 males and 47 females). All of them accepted the new treatment (none requested to be preferably put under standard WHO/MDT), no clinical sign which could be considered as a toxic effect of the drug was noted, and none of the patients refused to continue treatment because of any clinical trouble. The compliance was excellent: the 113 patients (PB and MB) detected during the first 6 months of the trial have taken six monthly doses in 6 months, as planned. The rate of clearance and the progressive decrease of cutaneous lesions was satisfactory. Although it is too soon to give comprehensive results, it should be noted that no treatment failure was observed in the 56 PB patients who have completed treatment and have been followed up for 6 months. The long-term efficacy of the new regimen is to be evaluated on the rate of relapse during the years following the cessation of treatment. If that relapse rate is acceptable (similar to that observed in patients after treatment with current standard WHO/ MDT), the new regimen could be a solution to treat, for instance, patients very irregular and/or living in remote or inaccessible areas since no selection of rifampin-resistant Mycobacterium leprae should be possible (a monthly dose of ofloxacin and minocycline being as effective as a dose of dapsone and clofazimine taken daily for 1 month). Nevertheless, until longer term results of this and other trials become available, there is no justification for any change in the treatment strategy, and all leprosy patients should be put under standard WHO/MDT.

[Should biopsy be done on the sensory branch of the radial nerve in leprosy patients? Apropos of 112 cases]. / Doit-on pratiquer des biopsies de la branche sensitive du nerf radial chez les malades lépreux? A propos de 112 cas.

Biopsies of the superficial sensory branch of the radial nerve are contested. Some authors mention it to be simple and without harm, but others are formally against this procedure. At ILAD, 274 biopsies were made between 1986 to 1992. We present a review of 112 leprosy patients for whom biopsy was done. On 112 reexamined patients, we observed 2 benign neuroma, hence 2%. The comparison of nerve function before biopsy and after, of 63 of the 112 patients, reexamination shows no significant modification of the functional score. Given even the occurrence of benign neuroma in only 2% of the cases, the authors do not recommend the biopsy of the superficial sensory branch of the radial nerve. For research purposes on neuritis in leprosy, as well as to assure diagnosis in primary neuritic leprosy, we propose the biopsy of the sensory branch of the musculo cutaneous nerve at elbow level.

[Simplification and codification of treatment for leprous plantar ulcers]. / Simplification et codification des soins aux maux perforants plantaires lépreux.

Practically leprous plantar ulcers (PU) are difficult to treat and heal under field condition. Considering the important number of patients showing a PU, the directors of national leprosy control programmes are determined, within the programmes on prevention of disabilities (POD), to treat the PU in the field. Therefore it appears to be essential to codify and simplify their treatment thus enabling it to be effective. The healing of PU being the only criteria of effectiveness of the technique. Four clinical stages were defined, each corresponding to a precise way of treatment using only essential and basic products at low cost. During the trainings about the treatment techniques and attitudes much emphasize is given on the discharge of the PU, on the trimming of the wound and on the products to use according to PU's evolutionary stage.

Pseudoepitheliomatous hyperplasia in trophic ulcers in leprosy patients. A 28-case study.

Between 1984 and 1993, pseudoepitheliomatous hyperplasia developing in chronic ulcers were observed in 28 former Senegalese leprosy patients, which amounts to an annual frequency of 1.9 per 1000 ulcers. Correct diagnosis could only be made by histopathological examination of specimens taken from the depth of the lesion. Amputation was carried out on 17 patients and local excision on the other 10. Recurrence of growth was observed in 8 of the 10 patients treated by excision; in all of these 8 cases below knee amputation had to be subsequently performed. From our experience, it may be assumed that local excision should be carried out only in the case of small tumours. Since the aim of surgical procedure is to allow the patient to have physical autonomy, below knee amputation, followed by adaptation of prosthesis, should be the procedure chosen in the other cases.

[Tumoral proliferations in chronic plantar ulcers: how to treat?]. / Proliférations tumorales développées sur maux perforants plantaires: quelle attitude thérapeutique?

Between 1983 and 1994, 66 Senegalese leprosy patients were seen for cauliflower growths developed in chronic plantar ulcer (CPU), (2 patients had each 2 tumors). 68 biopsies for pathological examination were taken: the diagnosis of squamous cell carcinoma was effectively made in 39 cases (38 patients) and that of pseudo-epitheliomatous hyperplasia in the remaining 29 cases (28 patients). The mean annual frequency of cauliflower growths was 0.45 per 100 CPU. Among these tumors, the percentage of carcinoma was 57%. Of the 38 patients with a carcinoma, 5 refused amputation and all of them died. The 33 others were amputated and of these 8 died as a direct result of their carcinoma (24%). In the case of the 28 patients with hyperplasia, amputation was carried out on 18 patients and local excision on 10. In the months following the operation 8 recurrences were observed in 10 of the patients on whom excision had been carried out. These recurrences were treated by amputation. This gives a total of 93% of amputations in the cases of hyperplasia. These facts lead as to conclude that at least in countries where pathological examination is not available below knee amputation is the most reasonable action to take in the proliferative tumors developed on a CPU.

Fibronectin-binding antigen 85 and the 10-kilodalton GroES-related heat shock protein are the predominant TH-1 response inducers in leprosy contacts.

Peripheral blood mononuclear cells from 27 healthy leprosy contacts were analyzed for lymphoproliferation and TH-1 cytokine secretion (interleukin-2 and gamma interferon) in response to heat shock proteins with molecular masses of 65, 18, and 10 kDa from Mycobacterium leprae and the 30-32-kDa antigen 85 (Ag 85) from Mycobacterium bovis BCG. Cells from 18 and 19 of 19 lepromin-positive contacts proliferated or produced TH-1 cytokines in response to the M. leprae 10-kDa protein and to Ag 85, respectively. Limiting-dilution analysis for two lepromin-positive contacts indicated that about one-third of M. leprae-reactive T cells displayed specificity to the M. leprae 10-kDa protein and Ag 85. The M. leprae 65- and 18-kDa proteins were less potent TH-1 response inducers: gamma interferon and interleukin-2 could be measured in 14 and 19 lepromin-positive contacts, respectively. In contrast, very low or undetectable proliferative and cytokine responses were found for 8 lepromin-negative contacts. Our data demonstrate that the fibronectin-binding Ag 85 and the 10-kDa GroES homolog are powerful mycobacterial TH-1 response inducers in the vast majority of lepromin-positive contacts and suggest that they might be valuable candidates for a future subunit vaccine.

[The frequency of the appearance of perforating foot ulcers in patients with Hansen's disease as a function of treatment with disulone alone or with polychemotherapy]. / Fréquence d'apparition de maux perforants plantaires chez des malades hanséniens en fonction du traitement par disulone seule ou polychimiothérapie.

Between 1986 and 1989, in 5 departments of Senegal, 436 new cases of leprosy were detected, of whom 225 were put under dapsone monotherapy and 211 under multidrug therapy (MDT). Of them, 190 could be followed-up during 2 years by means of annual bacteriological and clinical examination, including neurological assessment. In 2 years, the onset of 10 (5.3%) chronic plantar ulcers (CPU) was observed: 4 (4%) among the 99 patients under dapsone monotherapy and 6 (6.6%) among the 91 under MDT (no significant difference). Of the 10 CPU, 3 (2%) appeared among the 149 patients without any disability at detection while 7 (17%) were observed among the 41 others who presented a grade 1 disability at detection (p < 0.01). Of the 6 CPU appeared in the patients under MDT, 5 (22%) were observed among the 23 who presented a grade 1 disability at detection and 1 (1.5%) among the 68 who did not (p < 0.01). This difference was not noted in the patients under dapsone monotherapy. Our results need to be confirmed by other studies including a higher number of patients followed-up during a longer period of time. Nevertheless, they suggest that MDT could prevent the onset of CPU, but only in patients without any disability at detection. Therefore, they reemphasize the importance of early detection of the disease in leprosy control programmes.

[Results obtained by a mobile handicap-prevention unit at the Institut de Léprologie de Dakar]. / Résultats obtenus par une équipe mobile de prévention des invalidités à l'Institut de Léprologie de Dakar.

Of 584 leprosy patients known at the Institut de Léprologie Appliquée de Dakar because they suffered a nerve lesion with or without chronic plantar ulcer (CPU), 242 (41%) could be followed-up during a mean period of time of 8.2 years (range: 5 and 10 years) by the means of the mobile disability prevention team (health education, medical care and shoe workshop). Every two months a visit of the patients, at their home town, was organized, with the purpose to assess whether they could actually put into practice the foot and hand as having been trained for. At the same time, further advice and encouragement were given to the patients. Adapted footwear was brought to the patient, at reduced fee, the foot prints and special moulds having been taken during the previous visit. The local health worker were responsible for light surgical cares. Among the 242 followed-up patients: of 107 without CPU at beginning, 90 (84%) remained so, of 135 with CPU at beginning, 57 (42%) were cured, of 135 with CPU at beginning, 74 (55%) remained stable (no worsening), the last 21, of whom 17 showed severe foot deformities but without CPU, worsened (all presented one or more CPU at the last control). Of the 242 patients, 221 (91%) remained stable or showed substantial improvement. Therefore, it must be emphasized that careful follow-up of patients is essential to insure the improvement or care of CPU as well as to prevent the onset, worsening or reappearance of CPU. Such follow-up must consist of cares, health education and special shoe wearing.