Hansen's disease in a general hospital: uncommon presentations and delay in diagnosis.

BACKGROUND: The question was raised as to why 'obvious' signs of leprosy, Hansen's disease (HD), are often missed by medical doctors working in a HD endemic area. METHODS: This study describes a small sample of patients who were diagnosed with HD during their hospital admission and not before. The discussion is whether the typical early signs and symptoms of HD are just not recognized, or whether unusual presentations confuse the attending physician. RESULTS: A total of 23 HD patients were hospitalized during the study period, of which 6 (26%) were only diagnosed with HD during their admission. All were classified as lepromatous leprosy (LL) with a history of signs and symptoms of HD. In nearly all patients, a suspicion of HD might have been raised earlier if a careful history and dermato-neurological examination had been done. CONCLUSIONS: Multibacillary (MB) HD, especially close to the lepromatous end of the spectrum, may mimic other diseases, and the patient can not be diagnosed without a biopsy or a slit skin smear examination. Clinicians working in a HD endemic area (Rio de Janeiro) do not always include HD in their differential diagnosis, especially when the clinical presentation is unusual. HD should be considered in all patients with skin lesions not responding to treatment, especially when they have neurological deficits, and live or have lived in an HD endemic area. Due to the increase in global travel and immigration, doctors in low endemic areas need to consider HD as a possible diagnosis.

The occurrence of reactions and impairments in leprosy: experience in the leprosy control program of three provinces in northeastern Thailand, 1987-1995 [correction of 1978-1995]. I. Overview of the study.

AIM: This paper is the first in a series of three reports on the occurrence of reactions and impairments in leprosy in Thailand. This first paper gives a general overview about the methodology of the study, some epidemiological observations, delay in detection, multidrug therapy (MDT) completion rates and relapses. The other two papers report on: II. Reactions and III. Neural and Other Impairments. This study was carried out from 1987 until 1995 in three neighboring provinces in northeastern Thailand. STUDY DESIGN: A population-based, prospective cohort study. STUDY POPULATION: All 640 newly diagnosed leprosy patients in the three provinces, registered between October 1987 and September 1990, were included [420 paucibacillary (PB) and 220 multibacillary (MB)]. This group was followed up (actively and passively) until the end of 1995. METHODS: Patients were found by active and passive case finding. All new, untreated leprosy patients from the area were enrolled and started on the World Health Organization (WHO) MDT (WHO/MDT) regimen. A vertical control service was run by specialized leprosy workers. During treatment the patients received their monthly doses at home. During surveillance the patients were followed up once a year by a special team. Patients were questioned about delay in detection. Treatment completion rates were calculated. The occurrence of reactions and neural and other impairments at the beginning of, during and after treatment was ascertained. After treatment, the occurrence of late reactions and relapses was recorded. RESULTS: A higher frequency of leprosy was found among the male patients, especially in the MB group. However, in the PB group a higher female/male ratio was found in the age group 55 years and older. There was an increase in the detection rate from the youngest age group to the age group 55 years and older, which showed the highest detection rate. Treatment completion rates were high, 95% in both in the PB and MB treatment groups. About 50% of the new cases reported a delay between onset and registration of 1 year or more. By 1995, 93% of the original patient group was still available for follow up. By the end of 1995, 8 PB and 2 MB relapses were recorded.

The occurrence of reactions and impairments in leprosy: experience in the leprosy control program of three provinces in northeastern Thailand, 1987-1995 [correction of 1978-1995]. II. Reactions.

AIM: This is the second paper in a series of three papers on the occurrence of reactions and impairments in leprosy in Thailand, and focuses on the prevalence and incidence of reactions, including silent neuropathy. STUDY DESIGN: A population-based, prospective cohort study. STUDY POPULATION: All 640 newly diagnosed and registered leprosy patients in three neighboring provinces in northeastern Thailand registered between October 1987 and September 1990 were included [420 paucibacillary (PB) and 220 multibacillary (MB)]. This group was followed up (actively and passively) until the end of 1995. METHODS: Clinical data and data on the sensibility and motor function of the eyes, hands and feet were obtained when appropriate. The occurrence of reactions, including silent neuropathy, at the beginning of, during and after treatment was ascertained. During surveillance mild late reactions were also recorded. RESULTS: Severe reversal reactions (RR) at the start of and during treatment were seen in 2.6% [confidence interval (CI) 1.1-4.1] of the PB and 29% (CI 23-35) of the MB patients. In the PB group the majority (82%) of severe RR were found at the start of treatment. In the MB group 35% of the severe RR were found at the start of treatment and another 59% during the first year of treatment. It is shown that there is a statistically highly significant increasing proportion of patients with severe RR starting from tuberculoid and going toward borderline lepromatous. The incidence rate of severe RR during treatment was 1.4 (CI 0.46-4.5) per 100 person-years at risk (PYAR) for PB patients and 12 (CI 9.0-16) per 100 PYAR for MB patients. Late (mild and severe) RR were seen in 2.7% of the PB and 9% of the MB patients (35% of these reactions being considered severe). Late reactions were mainly seen in borderline tuberculoid (PB group) and in borderline lepromatous patients. Recent silent neuropathies were seen at first examination and during treatment in 1.4% of the pB and 4.1% of the MB patients. During surveillance only a few silent neuropathies were seen. If all severe RR, severe erythema nodosum leprosum and silent neuropathies at the start of, during and after treatment were added together, then 53% of the borderline lepromatous and 42% of the lepromatous patients had or developed one or another serious complication in need of steroid treatment.

The occurrence of reactions and impairments in leprosy: experience in the leprosy control program of three provinces in northeastern Thailand, 1987-1995 [correction of 1978-1995]. III. Neural and other impairments.

AIM: This the third paper in a series of three papers on the occurrence of reactions and impairments in leprosy in Thailand, and focuses on the prevalence and incidence of neural and other impairments in leprosy. STUDY DESIGN: A population-based, prospective cohort study. STUDY SUBJECT: All 640 newly diagnosed and registered leprosy patients in three provinces of northeastern Thailand between October 1987 and September 1990 were included [420 paucibacillary (PB) and 220 multibacillary (MB)]. This group of patients was followed up until the end of 1995. METHODS: Clinical data; data on the sensibility and motor function of eyes, hands and feet, and data on wounds and bone loss were obtained where appropriate. The occurrence of neural and other impairments at first examination, during treatment and during surveillance was ascertained. RESULTS: The relationship between impairment prevalence (grade 2 of the combined PB and MB groups and grades 1 and 2 together of the combined PB and MB groups) and duration of disease (before diagnosis) was found to be statistically significant. Increased delay in detection led to increased problems of impairments. Too many patients still develop new/additional impairments while on treatment and thereafter. The incidence of nerve function impairment (NFI) among patients without impairments at first examination while on treatment was 1.7 [ 95% confidence interval (CI) 0.45-4.4] per 100 person-years at risk (PYAR) for the PB group and 12 (CI 8.4-17) per 100 PYAR for the MB group. Additionally, 2% of the PB and 11% of the MB patients who already had impairments at first examination developed new NFI while on treatment. The outcome, comparing the first examination with the last examination during/after surveillance [changes in the voluntary muscle test (VMT), the sensory test (ST), wound count and bone loss], indicated that of the PB patients 3.7% improved, 3.7% got worse and 3.9% kept the same impairment; of the MB patients 19% improved, 18% got worse and 2.9% kept the same impairment. During treatment most of the new/additional impairments were due to new/increase in NFI; during surveillance slightly more than 50% were due to new/increase in NFI. Eighty-three percent of the MB patients without impairments at first examination who developed NFI during treatment improved (completely or partially) after receiving prednisolone. Only 62% of the MB patients with a grade 1 impairment at first examination and who developed a severe reaction or recent silent neuropathy improved after receiving prednisolone. There is a need for an indicator to measure new/additional impairments while on treatment and thereafter. It is proposed to measure changes in impairment by measuring changes in VMT, ST, wound count and bone loss.

A study on the effectiveness and safety of the WHO/MDT regimen in the northeast of Thailand; a prospective study, 1984-1996.

The aim of this prospective study was to determine the effectiveness and safety of the multidrug therapy as recommended by the World Health Organization (WHO/MDT) in 1982. One-hundred-eighty-eight newly diagnosed leprosy patients [130 paucibacillary (PB) and 58 multibacillary (MB) patients] from three provinces in northeastern Thailand were recruited into a study from April 1984 to March 1985. The study lasted until May 1996. The results showed that 182 patients finished their course of WHO/MDT, representing a treatment completion rate of 95%; 167 (122 PB and 45 MB) were released from surveillance (RFS); 82 PB patients were still available for follow up by the end of 1994 and 31 MB patients by May 1996. Two PB patients were diagnosed with a relapse, showing a relapse rate of 0.2 per 100 person-years at risk. After an average of 8 years of follow up, no MB relapses have been diagnosed. The proportion of patients with a WHO grade 2 disability among PB and MB patients increased from 4% and 8% at the start of treatment to 7% and 13% at last examination, respectively. It is concluded that the fixed-duration, 6-month WHO/MDT regimen for PB leprosy and the 24-month regimen for MB leprosy are effective, acceptable and safe, and that clinical activity, histopathological activity and/or a positive skin smear at release from treatment (RFT) have no bearing on the efficacy of the WHO/MDT regimens. The relapse rates are low and in accordance with most published data available to date. The importance of skin-smear services for a reliable classification (WHO PB/MB classification for control programs) is stressed.

Rapid village survey to determine the size of the leprosy problem in Khon Kaen Province, Thailand.

The rapid village survey (RVS) method has been developed as a simpler, less-expensive alternative to random sample surveys for determining the prevalence of leprosy and was compared with a total population survey (TVS). In the RVS, the cluster population receives clear information about the disease, and those with symptoms are invited to be examined by the survey team. A list of household contacts and suspects was made and those on the list were actively traced. The registered population was 20,815; 10 new patients were found among the 2034 people self-reporting in the RVS, 0 among the household contacts and suspects, and an additional 2 new patients in the TVS. There were 12 registered patients among the sample population. The prevalence rate found by the RVS was 1.06 per 1000(95% CI = 0.49-1.63) and in the TVS 1.16 per 1000 (95% CI = 0.5-1.77). The man-days and costs of an RVS are considerably less than those for a TVS. It was concluded that the RVS is a valid replacement for the TVS as conducted in Khon Kaen Province, Thailand. The RVS can be applied under low-endemic conditions and could be carried out by the general health staff.