Neural pathology in leprosy during treatment and surveillance.

The histological findings of 22 patients with neuritis, 14 developing pain, tenderness and swelling during treatment and 8 during surveillance are presented in this study. Seven patients' biopsies showed macrophage type and 14 had epithelioid cell type of granulomas. All biopsies showed evidence of active disease, except for two patients with macrophage granulomas where some regressive changes were evident. One biopsy showed fibrosis with lymphocytic infiltration. The histology of epithelioid cell granulomas had varied histopathological presentations ranging from non-reacting BT to those with severe type I reaction with caseation necrosis, liquefaction and calcification. Two macrophage granulomas showed partial regression though there was neuritis clinically and features of ENL in the biopsy sections. One biopsy showed histoid changes. All the biopsies showed similar histopathological features irrespective of whether neuritis appeared during treatment or surveillance. The features of reaction were severe in nerves, probably due to the adjuvant nature of lipid and myelin in the nerve tissue. The histopathological features of nerve biopsies from patients under surveillance appeared to be ongoing active disease rather than relapse.

Injuries and granuloma caused by water slider.

Bite of waters slider (Ranatra) producing granuloma, numbness of the arm followed by neurotoxicity in the form of acute abdomen is being reported.

Induction of lepromin positivity and immunoprophylaxis in household contacts of multibacillary leprosy patients: a pilot study with a candidate vaccine, Mycobacterium w.

We screened 487 household contacts of multibacillary (MB) patients for evidence of disease and their lepromin status. From the 444 results available, 302 (68.02%) were lepromin positive and 142 (31.98%) were lepromin negative on initial testing. The initial lepromin status as assessed in the group of 54 contacts having disease at the outset showed 24 out of 46 (52.2%) to be lepromin positive and 22 of 46 (47.8%) to be lepromin negative. In the same group, among 24 lepromin positives, 22 (91.7%) had paucibacillary (PB) and 2 (8.3%) had multibacillary (MB) disease; among the lepromin negatives, 12 (54.5%) had PB and 10 (45.5%) had MB disease. Out of 72 initially lepromin-negative contacts administered Mycobacterium w vaccine and followed up, the cumulative percentages show that 53 (73.6%) converted to positivity after a single dose, 10 (87.5%) after a second dose and 67 (93.1%) after the third dose. The incidence of new cases with leprosy was 8 out of 231 (3.46%) among lepromin-positive contacts and 5 out of 93 (5.38%) among lepromin-negative contacts administered Mycobacterium w vaccine. Among 231 lepromin-positive contacts, the new cases occurred in those with a 1+ and 2+ lepromin response only, and no case occurred among 51 contacts with a 3+ lepromin response. The incidence among lepromin-positive contacts in this study (3.46%) was similar to the observations in two other studies: 3.2% by Dharmendra, et al. and 6.9% by Chaudhary, et al. However, the incidence among lepromin-negative contacts administered Mycobacterium w vaccine was significantly lower than that observed among lepromin-negative contacts not administered any vaccination in the other two studies (14.1% by Dharmendra, et al. and 29.0% by Chaudhary, et al.). To conclude, although a study of small sample size, the preliminary evaluation indicates that administration of Mycobacterium w vaccine seems to have the potential to reduce the incidence of leprosy among household contacts of leprosy patients. More explicit results about the vaccine will be available from the ongoing field trials in Kanpur Dehat in the near future.

Reactional states and neuritis in multibacillary leprosy patients following MDT with/without immunotherapy with Mycobacterium w antileprosy vaccine.

A vaccine based on autoclaved Mycobacterium w was administered, in addition to standard multidrug therapy (MDT), to 157 untreated, bacteriologically positive, lepromin negative multibacillary leprosy patients, supported by a well matched control group of 147 patients with similar type of disease, who received a placebo injection in addition to MDT. The MDT was given for a minimum period of 2 years and continued until skin smear negativity, while the vaccine/placebo was given at 3-monthly intervals up to a maximum of eight doses. The incidence of type 2 reaction and neuritis during treatment and follow-up showed no statistically significant difference in the vaccine and placebo groups. The incidence of type 1 reaction (mild in most cases), however, was higher in the vaccine group (P = 0.041, relative risk ratio 1.79), considering LL, BL and BB leprosy types together, and considerably higher (P = 0.009) in LL type, probably because of confounding due to higher number of patients with previous history of reaction in this group. The occurrence of reactions and neuritis in terms of single or multiple episodes was similar in the vaccine and placebo groups. The association of neuritis and reactions, as well as their timing of occurrence (during MDT or follow-up), was also similar in the two groups, with more than 90% of occurrences taking place during MDT. The incidence of reversal reaction was significantly higher among the males in the vaccine group (34.5% versus 8.3%, P = 0.019). Patients with high initial BI (4.1-6.0) showed higher incidence of reactions (70.3%) as compared to those with medium (2.1-4.0) and low (0.3-2.0) BI where the reactions were observed with a frequency of 56.1% and 38.8%, respectively. However, unlike reactions, neuritis incidence did not seem to be affected by initial BI to the same extent in the vaccine group, with frequencies of 35.3%, 36.3% and 25.9% in the three mentioned BI ranges. Overall, the vaccine did not precipitate reactional states and neuritis over and above that observed with MDT alone.

Mycobacterium w vaccine, a useful adjuvant to multidrug therapy in multibacillary leprosy: a report on hospital based immunotherapeutic clinical trials with a follow-up of 1-7 years after treatment.

A vaccine based on autoclaved Mycobacterium w was administered, in addition to standard multidrug therapy (MDT), to 156 bacteriologically positive, lepromin negative multibacillary leprosy patients compared to a well matched control group of 145 patients with a similar type of disease who received a placebo injection in addition to MDT. The MDT was given for a minimum period of 2 years and continued until skin smear negativity, while the vaccine was given at 3-month intervals up to a maximum of eight doses. The fall in clinical scores and bacteriological indices was significantly more rapid in vaccinated patients, from 6 months onward until years 2 or 3 of therapy. However, no difference was observed in the fall in bacteriological index in the two groups from year 4 onwards. The number of LL and BL patients released from therapy (RFT) following attainment of skin smear negativity, after 24-29 months of treatment was 84/133 (63.1%) in vaccinated and 30/120 (25.0%) in the placebo group; the difference was highly statistically significant (P < 0.0001). In all, 90.2% patients (146/162) converted from lepromin negativity to positivity in the vaccine group, as against 37.9% (56/148) in the placebo group. The average duration of lepromin positivity maintained following eight doses of vaccine administered over 2 years was 3.016 years in the vaccine and 0.920 years in the placebo group. Histological upgrading after 2 years of treatment in the LL type was observed in 34/84 (40.5%) cases in the vaccine and 5/85 (5.9%) cases in the placebo group, the difference being statistically significant (P < 0.001). The incidence of type 1 reactions was significantly higher (30.5%) in the vaccine group than (19.7%) in the placebo group (P = 0.0413); the difference was mainly observed in LL type (P = 0.009). The incidence of type 2 reactions was similar (31.8 and 34.6%) in vaccine and placebo groups. The vaccine did not precipitate neuritis or impairments over and above that encountered with MDT alone. After 5 years of follow-up following RFT, no incidence of bacteriological or clinical relapses was observed in both groups.

Sporotrichoid presentations in leprosy.

Two adult patients of leprosy, one woman and one man, presented with a clinical picture simulating sporotrichosis. The skin and regional nerve trunk was affected in one, and in the other the disease was confined to the nerve. Both had features of an upgrading reaction following anti-leprosy therapy; this was seen as erosion and scarring of the plaque, and acute onset of abscesses along the easily palpable and thickened nerve that ruptured through the skin. The diagnosis was supported by histopathology. In the light of other infections that give rise to a sporotrichoid pattern of infection it is concluded that leprosy should also be included in this category so that early diagnosis and use of corticosteroids can be implemented quickly to prevent nerve destruction.

Disabilities in multibacillary leprosy following multidrug therapy with and without immunotherapy with Mycobacterium w antileprosy vaccine.

A vaccine based on autoclaved Mycobacterium w was administered, in addition to standard multidrug therapy (MDT), to 157 bacteriologically positive, lepromin-negative, multibacillary leprosy patients supported by a well-matched control group of 147 patients with similar type of disease who received a placebo injection in addition to MDT. The MDT was given for a minimum period of 2 years and continued until skin-smear negativity, while the vaccine/placebo was given at 3-month intervals up to a maximum of 8 doses in the initial 2 years. The overall incidence of type 1 and type 2 reactions and neuritis during treatment and follow up was nearly equal in the patients in the vaccine and placebo groups; the differences were not statistically significant. The occurrence of disabilities, such as anesthesia, trophic ulcers, claw hand and grade 3 deformities, were not different statistically in the vaccine and placebo groups, an observation valid both for deformities present at induction and for those which developed during the course of therapy and surveillance. A statistically significant difference was observed in the recovery of newly developed trophic ulcers; recovery was quicker in the vaccine group. The recovery rate for motor deformities was marginally higher in the vaccine group, although not significant (p = 0.068) statistically. There was a statistically significant reduction in the incidence of grade 3 deformities following MDT with and without immunotherapy. To conclude, the addition of vaccine to MDT did not precipitate neuritis or deformities over and above that encountered with MDT alone, although it did accelerate bacteriological clearance, histopathological upgrading, conversion to lepromin positivity, and clinical improvement.

Induction of lepromin positivity following immuno-chemotherapy with Mycobacterium w vaccine and multidrug therapy and its impact on bacteriological clearance in multibacillary leprosy: report on a hospital-based clinical trial with the candidate antileprosy vaccine.

A vaccine based on autoclaved Mycobacterium w was administered, in addition to standard multidrug therapy (MDT), to 157 bacteriologically positive, lepromin-negative, multibacillary (LL, BL and BB) leprosy patients. The vaccinees were supported by a well-matched control group of 147 patients with similar type of disease who received a placebo injection in addition to MDT. The MDT was given for a minimum period of 2 years and continued until skin-smear negativity, while the vaccine was given at 3-month intervals up to a maximum of 8 doses. The lepromin response evaluated in terms of percentage of subjects converting to positivity status, measurement in millimeters, and duration of lepromin positivity sustained, reflected a statistically significant better outcome in the vaccine group patients (especially LL and BL leprosy) in comparison to those in the placebo group. The data indicate that lepromin-positivity status seems to have an impact on accelerating the bacteriological clearance, as is evident by the statistically significant accelerated decline in the BI of those patients who converted to lepromin positivity as compared to those remaining lepromin negative throughout therapy and post-therapy follow up. To conclude, the addition of the Mycobacterium w vaccine to standard MDT induces a lepromin response of a statistically significant higher magnitude than that observed with MDT alone.

Why relapse occurs in PB leprosy patients after adequate MDT despite they are Mitsuda reactive: lessons form Convit's experiment on bacteria-clearing capacity of lepromin-induced granuloma.

It is amazing how after years of scientific research and therapeutic progress many simple and basic questions about protective immunity against Mycobacterium leprae remain unanswered. Although the World Health Organization (WHO) has recommended short-term multidrug therapy (WHO/MDT) for the treatment of paucibacillary (PB) leprosy patients, from time to time several workers from different parts of the globe have reported inadequate clinical responses in a few tuberculoid and indeterminate leprosy patients following adequate WHO/MDT despite the fact that they are Mitsuda responsive. A few borderline tuberculoid patients harbor acid-fast bacilli (AFB) in their nerves for many years even though they become clinically inactive following MDT, a fact which has been ignored by many leprosy field workers. Keeping these patients in mind, we have attempted to investigate the cause of the persistence of AFB in PB cases and have looked into the question of why Mitsuda positivity in tuberculoid and indeterminate leprosy patients, as well as in healthy contacts, is not invariably a guarantee for protectivity against the leprosy bacilli. We have: a) analyzed the histological features of lepromin-induced granulomas, b) studied the bacteria-clearing capacity of the macrophages within such granulomas, and c) studied the in vitro leukocyte migration inhibition factor released by the blood leukocytes of these subjects when M. leprae sonicates have been used as an elicitor. The results of these three tests in the three groups of subjects have been compared and led us to conclude that the bacteria-clearing capacity of the macrophages within lepromin-induced granuloma (positive CCB test) may be taken as an indicator of the capability of elimination of leprosy bacilli and protective immunity against the disease. This important macrophage function is not invariably present in all tuberculoid and indeterminate leprosy patients or in all contacts even though they are Mitsuda responsive and are able to show a positive leukocyte migration inhibition (LMI) test. It is likely but not certain that this deficit of the macrophage is genetically predetermined and persists after completion of short-term WHO/MDT. Thus, after discontinuation of treatment slow-growing, persisting M. leprae multiply within macrophages leading to relapse.

Tarantula bite leads to death and gangrene.

Chilobrachys hardwikii-giant black hairy spider bite produced two deaths, one case of gangrene of the foot and urticarial rashes in another person in a remote village of Churulia 30 km from Asansol.

Ultrastructure of normal armadillo epidermis.

In view of the importance of the nine-banded armadillo (Dasypus novemcinctus) in leprosy research, we studied the ultrastructure of the normal epidermis of this species. The three basic cell types of human epidermis were identified in armadillo skin: keratinocytes, melanocytes, and Langerhans' cells. The role of Langerhans' cells in the human cell-mediated immune system and the description of changes in the number and structure of Langerhans' cells in human leprosy make detailed observations of these cells in the armadillo highly relevant. Clear cells with ultrastructural features typical of Langerhans' cells were observed in normal armadillo epidermis in all areas of skin sampled (abdomen, chin, ear, and thigh), but are fewer than in human skin. These baseline findings are valuable for further studies on Langerhans' cells and the cell-mediated immune function in armadillos with naturally acquired or experimental leprosy.

Addition of immunotherapy with Mycobacterium w vaccine to multi-drug therapy benefits multibacillary leprosy patients.

Immunotherapy with a vaccine consisting of autoclaved Mycobacterium w, was given in addition to standard chemotherapy (multidrug therapy (MDT)) to 93 multibacillary (MB) leprosy patients. One hundred and seven patients with similar types of disease served as controls and received MDT + placebo injections. The study was a double-blind randomised trial. On opening the codes, results obtained were in concordance with those in a single-blind trial which has been extensively reported. Bacteriological clearances were significantly more rapid in vaccinated patients (p < 0.03). Thirty-five LL or BL patients with a high bacterial index (BI) of 6 were completely cleared of acid-fast bacilli (AFB) after eight doses of vaccine. Only 8 patients in the control group became bacteriologically negative in the same time period. They all had BIs < 4. Associated with decreasing BI was accelerated clinical regression of lesions after vaccination and lepromin conversion rates of 100% for BB, 71% for BL and 70% for LL. A significant number of immunised patients showed histological improvement (p < 0.004). Thirty-six showed a complete disappearance of dermal granulomas and a picture of non-specific infiltration. The vaccine did not precipitate neuritis or deformities; episodes were noted in vaccinated patients as were incidences of Type 2 reaction. The overall improvement was reflected by a shorter duration of treatment and faster release of vaccinated patients.

Biometals in skin and sera of leprosy patients and their correlation to trace element contents of M. leprae and histological types of the disease; a comparative study with cutaneous tuberculosis.

The present study has provided information on the biometal contents of killed and dried Mycobacterium leprae as well as dermal granulomas induced by the invading mycobacteria in various histological types of leprosy patients. For comparison, the biometal contents of the contralateral leprosy-unaffected skin of the same patients also were measured. The study also reports changes of serum levels of the biometals in these patients which were compared with those in healthy control subjects and patients with skin tuberculosis. These data show that M. leprae is rich in zinc. During the course of the evolution of the disease there is gross alteration of the dynamics of the inflammatory cell population that infiltrates into leprosy granulomas, resulting in the alterations of trace element contents of the disease-affected skin lesions. Interestingly, the changes of the biometal contents in the granulomas of the patients with skin tuberculosis are similar to those in leprosy patients. It is postulated that the significant decrease of the contents of copper, zinc, iron, calcium and magnesium in the disease-affected skin in comparison to that of the contralateral healthy skin is a local effect, perhaps due to erosion or influx of biometal-deficient inflammatory cells into the affected skin with eventual loss of connective tissue of skin and mobilization of tissue-bound microelements into the vascular compartment. On the contrary, the changes in biometal levels in the sera of leprosy patients appear to be a general effect perhaps due to the release of interleukin-1, a product of inflammatory cells, causing hypercupremic, hypozincemic and hypoferremic responses in the hosts. Moreover, growth and multiplication of M. leprae, especially in polar lepromatous leprosy patients with a high bacillary load, demand essential biometals which may be mobilized into the bacterial bodies from the hosts. This perhaps results in the change in the homeostasis of the essential biometals in the hosts.

Neuritic leprosy: further progression and significance.

Sixteen neuritic cases have been seen developing cutaneous lesions. These cutaneous lesions by and large appear within 4 months after the diagnosis of neuritic leprosy. Leprosy pathology in cutaneous lesions has been found ranging between indeterminate and borderline lepromatous group. Development of cutaneous lesions does not seem to be influenced by age, sex or number of nerves or lepromin status. Neither lesions seem to appear in any particular part of the body. Therapy, duration and type i.e. monodrug or multidrug, also does not seem to influence the development of cutaneous lesions in either way. It appears that neuritic cases with either very early (indeterminate) or with advanced multibacillary neural pathology may develop skin lesions. Skin lesion possibly appear following reversal reaction in skin. Cases with newly developed skin lesions well respond to standard therapy. Development of cutaneous lesions by neuritic cases possibly indicates towards the natural history of the disease, conforming to the hypothesis that leprosy is basically neural in inception and that all other forms emerge from it.

Membrane attack complex in thickened cutaneous sensory nerves of leprosy patients.

Membrane attack complex (MAC) is a terminal end product produced as a result of complement activation. The deposition of MAC, in tissues, is known to have a local tissue damaging effect in several clinical conditions. Therefore, an attempt was made to demonstrate MAC in peripheral nerve biopsies, collected from leprosy patients. Interestingly, we could demonstrate deposition of MAC in involved cutaneous sensory nerves from most of the lepromatous leprosy patients. Contrary to this, majority of nerve biopsies from tuberculoid leprosy patients did not stain for MAC. Though MAC positive sections showed reactivity for S-protein, our observations support the possibility that MAC, either acting directly or indirectly, may be implicated in nerve damage, at least, in lepromatous leprosy patients.

Evaluation of modified lepro-agglutination as screening test for leprosy.

One hundred thirty-three leprosy sera (83 multibacillary (MB) and 50 paucibacillary (PB) cases) were screened by lepro-agglutination (LA) and M.leprae particle agglutination (MLPA) tests. Larger number of MB sera were positive by LA (86.75%) than by MLPA (45.12%) test. Thirty-seven of the 45 MB sera negative by MLPA test were positive by LA test. The reverse was true in three out of 11 MB sera. PB sera showed positivity of 16% in LA test and 24% in MLPA test. All the 55 sera from normal healthy individuals and 18 VDRL positive sera from syphilis patients were found to be negative by LA test.

Anticardiolipin antibodies in leprosy.

Eighty-four leprosy patients were studied clinically and for IgG and IgM anticardiolipin (aCL) antibodies. Following WHO criteria, 41 patients could be classified as multibacillary (MB) and 43 as paucibacillary (PB). Baseline levels of IgG and IgM antibodies were 27 +/- 4.8 GPL and 20 +/- 3.4 MPL per ml respectively. Comparing with these, 60.9% of MB and 39.5% of PB cases showed rise in IgG and IgM anticardiolipin antibodies; 19.5% of MB and 4.6% of PB sera showed rise in only IgG antibodies, while 4.8% of MB and 13.9% of PB cases showed rise only in IgM antibodies. Rise in aCL antibodies had no correlation with cardiovascular involvement, bacteriological index, reactive state and duration or regularity of treatment.