Strongyloidiasis infection in a borderline lepromatous leprosy patient with adrenocorticoid insufficiency undergoing corticosteroid treatment: a case report.

BACKGROUND: Strongyloidiasis is a soil-transmitted helminthiasis mainly caused by Strongyloides stercoralis. It is endemic to the tropics and subtropics. Sri Lanka has a 0-1.6% prevalence rate. S. stercoralis infection was identified in a 33-year-old Sri Lankan male patient treated with corticosteroids for borderline lepromatous leprosy with adrenocortical dysfunction. CASE PRESENTATION: In March 2020, a 33-year-old Sri Lankan (Sinhalese) male patient presented with watery diarrhea, lower abdominal pain, and post-prandial abdominal fullness. Previously, he was diagnosed with borderline lepromatous leprosy and was treated with rifampicin, clofazimine, and prednisolone 60 mg daily since July 2019. After developing gastrointestinal symptoms, he had defaulted leprosy treatment including the prednisolone for 3 months. Duodenal biopsy revealed numerous intraepithelial nematodes within the lumina of glands in the duodenum whose appearance favored Strongyloides. Fecal wet smear revealed numerous Strongyloidis stercoralis L1 rhabditiform larvae. Larval tracks were seen in the agar plate culture. L3 filariform larvae of Strongyloidis stercoralis were seen in the Harada-Mori culture. In addition, the short synacthen test revealed adrenocortical insufficiency, and oral hydrocortisone and fludrocortisone were started with albendazole treatment against strongyloidiasis. Fecal wet smear and culture repeated after treatment with albendazole were negative for Strongyloidis stercoralis. The patient was discharged in July 2020 on oral hydrocortisone. One month later his condition was reviewed and the repeated fecal wet smear and agar plate culture was normal. He is being followed up every 3 months. CONCLUSION: This is the first case of strongyloidiasis diagnosed in a patient with borderline lepromatous leprosy from Sri Lanka. The patient manifested symptoms of strongyloidiasis while on high-dose steroid therapy for his lepromatous reaction. Subsequently, the patient not only discontinued his steroid therapy, but also developed adrenocortical insufficiency as a complication of leprosy. Therefore, although diagnosis of strongyloidiasis was delayed, his subsequent low steroid levels probably protected him from disseminated disease. This is an interesting case where symptomatic strongyloidiasis was diagnosed in a patient who was initially treated with high-dose steroids but subsequently developed adrenocortical insufficiency. We emphasize the need to screen all patients prior to the commencement of immunosuppressive therapy.

The long-term impact of the Leprosy Post-Exposure Prophylaxis (LPEP) program on leprosy incidence: A modelling study.

BACKGROUND: The Leprosy Post-Exposure Prophylaxis (LPEP) program explored the feasibility and impact of contact tracing and the provision of single dose rifampicin (SDR) to eligible contacts of newly diagnosed leprosy patients in Brazil, India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. As the impact of the programme is difficult to establish in the short term, we apply mathematical modelling to predict its long-term impact on the leprosy incidence. METHODOLOGY: The individual-based model SIMCOLEP was calibrated and validated to the historic leprosy incidence data in the study areas. For each area, we assessed two scenarios: 1) continuation of existing routine activities as in 2014; and 2) routine activities combined with LPEP starting in 2015. The number of contacts per index patient screened varied from 1 to 36 between areas. Projections were made until 2040. PRINCIPAL FINDINGS: In all areas, the LPEP program increased the number of detected cases in the first year(s) of the programme as compared to the routine programme, followed by a faster reduction afterwards with increasing benefit over time. LPEP could accelerate the reduction of the leprosy incidence by up to six years as compared to the routine programme. The impact of LPEP varied by area due to differences in the number of contacts per index patient included and differences in leprosy epidemiology and routine control programme. CONCLUSIONS: The LPEP program contributes significantly to the reduction of the leprosy incidence and could potentially accelerate the interruption of transmission. It would be advisable to include contact tracing/screening and SDR in routine leprosy programmes.

The interrelationship between meteorological parameters and leptospirosis incidence in Hambantota district, Sri Lanka 2008-2017 and practical implications.

BACKGROUND: Leptospirosis is a bacterial zoonosis. Leptospirosis incidence (LI) in Sri Lanka is high. Infected animals pass leptospires to the environment with their urine. Leprospires' survival in the environment to infect a new host depends on meteorological factors. El Nino Southern Oscillation (ENSO) and Indian Ocean Dipole (IOD) modulate the weather in Sri Lanka. OBJECTIVES: The determination of interrelationship between the LI in the Hambantota District, and local meteorological parameters, ENSO and IOD. METHODS: We acquired notified leptospirosis cases in the Hambantota District and population data. We calculated weekly leptospirosis incidences for 2008 to 2017.Weather data from two weather stations was obtained, averaged and converted into weekly data. We plotted time series graphs and observed the correlation between seven aggregated weather parameters and LI. We estimated cross-correlations between those weather parameters and LI. As our principal analysis we determined correlation between LI and seven local weather parameters, Nino 3.4, Nino4 and Dipole Mode Index (DMI) indices using wavelet analysis. RESULTS: Our wavelet analysis results showed troughs of minimum, maximum, mean temperatures, soil temperature, the evaporation rate, the duration of sunshine were followed by peaks in LI and peaks of rainfall followed by peaks of LI, all after lag periods. Our time series graphs and cross-correlation determination results are generally in agreement with these results. However there was no significant correlation between rainfall and LI in the cross-correlation analysis. There were peaks of LI following both peaks and troughs of DMI. There was no clear correlation between both Nino indices and LI. DISCUSSION: This may be the first long-term study demonstrating soil temperature, evaporation rate and IOD are correlating with LI. The correlation pattern of LI with temperature parameters differs from similar past studies and we explain the reasons. We propose ways to control high LI we observed after periods of weather favorable for transmission of leptospirosis.

The long-term impact of the leprosy post-exposure prophylaxis (LPEP) program on leprosy incidence: a modelling study

The Leprosy Post-Exposure Prophylaxis (LPEP) program explored the feasibility and impact of contact tracing and the provision of SDR to eligible contacts of newly diagnosed leprosy patients in states or districts of Brazil, India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. This study investigated the long-term impact of the LPEP program on the leprosy new case detection rate (NCDR). Our results show that LPEP could reduce the NCDR beyond the impact of the routine leprosy control programme and that many new cases could be prevented. The benefit of LPEP increases gradually over time. LPEP could accelerate the time of reaching predicted NCDR levels of 2040 under routine program by up to six years. Furthermore, we highlighted how the impact varies between countries due to differences in the number of contacts per index patient screened and differences in leprosy epidemiology and national control programme. Generally, including both household contacts and neighbours (> 20 contacts per index patient) would yield the highest impact.

Utilization of government healthcare services by adult leprosy patients in the Western Province, Sri Lanka.

BACKGROUND: The leprosy services utilization by the patients at the clinic and field level should be high to achieve the target of eliminating leprosy as a public health problem in Sri Lanka. Furthermore, assessing patient and health system delay of a diagnosis and patient knowledge on disease are of equal importance to reveal the accurate picture. METHODS AND FINDINGS: A descriptive cross-sectional study was conducted to assess the utilization of government healthcare services by 672 adult leprosy patients in Western Province (WP). Paucibacillary patients diagnosed at least six months and above, and Multibacillary patients diagnosed at least 12 months and above were selected by consecutive sampling method. An interviewer-administered questionnaire (IAQ) was used for data collection. Clinic utilization by leprosy patients was 87.8%. The mean patient-related delay (time taken from the onset of symptoms to the encounter of a doctor/health facility for the first time) was 16.8 months and health care system delay (time taken from the date of clinic registration to start of treatment) was 21.2 days. The overall delay was 17.5 months. Services provided by the Medical Officer of Health (MOH) office for families affected with leprosy was known by 53.8% (n = 298) of patients. Majority of family contacts were examined at the hospitals (n = 299, 44%), 30.8% (n = 207) by the Public Health Inspectors (PHI) and 7% (n = 46) at the MOH offices. PHIs had visited 56.7% (n = 401) of the patient's houses and 54% (n = 363) had received health education by PHI. Mean knowledge score was 50.7 (SD = 17.9). More than half (57.9%, n = 389) of the study sample had a good or very good knowledge level. CONCLUSIONS: Utilization of clinic services was satisfactory. However, a considerable patient-related delay was found. Half of the patients were aware of available field services and a majority of contact screening was conducted at hospitals. Patient knowledge on leprosy was satisfactory.

Coexistence of mycobacterial infections - Mycobacterium tuberculosis and Mycobacterium leprae - in Sri Lanka: a case series.

BACKGROUND: Leprosy is one of the oldest mycobacterial infections and tuberculosis is the most common mycobacterial infection with a higher degree of infectivity than leprosy. Although both diseases are prevalent in clusters in developing countries, simultaneous occurrence of them in an individual is a rare entity, even in an endemic setting. CASE PRESENTATION: We describe six cases of tuberculosis and leprosy coinfection: a 57-year-old Sinhalese woman, a 47-year-old Tamil woman, a 72-year-old Tamil man, a 59-year-old Sinhalese man, a 54-year-old Sinhalese man, and a 50-year-old Sinhalese man. In this case series, five patients had lepromatous leprosy and the majority of patients were men. Three patients were detected to have tuberculosis at the outset of treatment of leprosy, while two developed tuberculosis later and one had extrapulmonary tuberculosis 5 years before the diagnosis of leprosy. The latter developed pulmonary tuberculosis as a reactivation while on treatment for leprosy. A majority of our patients with pulmonary tuberculosis had positive Mantoux test, high erythrocyte sedimentation rate, radiological evidence, and acid-fast bacilli in sputum. Human immunodeficiency virus and diabetes were detected in one patient. One patient had rifampicin-resistant tuberculosis, while she was on monthly rifampicin therapy for leprosy. CONCLUSION: An immunocompromised status, such as human immunodeficiency virus infection, diabetes, and immunosuppressive drugs, are risk factors for tuberculosis infection. The use of steroids in the treatment of leprosy may increase the susceptibility to develop tuberculosis. Development of rifampicin resistance secondary to monthly rifampicin in leprosy is a major concern in treating patients coinfected with tuberculosis. Despite the paucity of reports of coinfection, it is advisable to screen for tuberculosis in patients with leprosy, especially if there are respiratory or constitutional symptoms, high erythrocyte sedimentation rate, and abnormal chest X-ray. The fact is that positive Mantoux and QuantiFERON Gold tests and presence of acid-fast bacilli in sputum are misleading, chest X-ray evidence of active tuberculosis and positive tuberculosis cultures are important diagnostic clues for active tuberculosis infection in a patient with leprosy. This is important to avoid monthly rifampicin in patients with suspected coinfections, which may lead to development of drug resistance to tuberculosis treatment. Whether prolonged steroid therapy in leprosy is a risk factor for development of tuberculosis is still controversial.

Disseminated Mycobacterium simiae infection in a patient with adult-onset immunodeficiency due to anti-interferon-gamma antibodies - a case report.

BACKGROUND: Mycobacterial species other than Mycobacterium tuberculosis and Mycobacterium leprae are generally free-living organisms and Mycobacterium simiae is one of the slowest growing Non-tuberculous mycobacteria. This is the first case report of Mycobacterium simiae infection in Sri Lanka and only very few cases with extrapulmonary manifestation reported in the literature. CASE PRESENTATION: A 24-year-old, previously healthy Sri Lankan male presented with generalized lymphadenopathy with discharging sinuses, evening pyrexia, weight loss, poor appetite and splenomegaly. Lymph node biopsies showed sheets of macrophages packed with organisms in the absence of granulomata. Ziehl Neelsen, Wade Fite and Giemsa stains revealed numerous red coloured acid-fast bacilli within foamy histiocytes. Slit skin smear for leprosy was negative and tuberculosis, fungal and bacterial cultures of the lymph node and bone marrow did not reveal any growth. Later he developed watery diarrhea and colonoscopy revealed multiple small polyps and ulcers throughout the colon extending up to the ileum, Which was confirmed to be due to cytomegalovirus confirmed by PCR and successfully treated with ganciclovir. Positron emission tomography scan guided biopsies of the gut and lymph nodes confirmed presence of mycobacterial spindle cell pseudo-tumours and PCR assays revealed positive HSP65. The culture grew Mycobacterium Simiae. Flow cytometry analysis on patient's blood showed extremely low T and B cell counts and immunofixation revealed low immunoglobulin levels. His condition was later diagnosed as adult onset immunodeficiency due to anti- interferon - gamma autoantibodies. He was initially commenced on empirical anti-TB treatment with atypical mycobacterial coverage. He is currently on a combination of daily clarithromycin, ciprofloxacin, linezolid with monthly 2 g/kg/intravenous immunoglobulin to which, he had a remarkable clinical response with complete resolution of lymphadenopathy and healing of sinuses. CONCLUSIONS: This infection is considered to be restricted to certain geographic areas such as mainly Iran, Cuba, Israel and Arizona and this is the first case report from Sri lanka. Even though the infection is mostly seen in the elderly patients, our patient was only 24 years old. In the literature pulmonary involvement was common presentation, but in this case the patient had generalized lymphadenopathy and colonic involvement without pulmonary involvement.

Knowledge, Attitudes and Practices relating to Leprosy among Public Health Care Providers in Colombo, Sri Lanka.

Introduction: Leprosy remains a serious public health problem due to its ability to cause disability. The prevention of leprosy ultimately lies in the early diagnosis and treatment of the individuals having leprosy, thereby preventing further transmission. In Sri Lanka, 46% of new cases identified in year 2013, were late presentations and this caused to 7-8% patients to present with deformities. It has been observed that lack of awareness among health staff has contributed to this late diagnosis. Objective: To describe knowledge, attitudes and practices towards leprosy amongst public health care workers in Colombo Municipal Council area, Sri Lanka. Material and Methods: A descriptive cross sectional survey was carried out in Colombo Municipal Council area by distributing self administered questionnaire among all public healthcare workers (n=178) from January to February, 2015. Results: Hundred and fifty three participants (86%) identified 'hypo pigmented patches', 64 (36%) identified 'skin nodules' and 36 (20%) identified 'thickened nerves' as suspicious sings of leprosy. More than one fifth of participants believed leprosy is easily transmitted by touch. Sixty one (34.3%) health care workers were scared of leprosy and 77 (43.3%) didn't want to reveal to a friend that if a family member gets leprosy. Another 49 (27.5%) didn't want to share materials with a patient. A significant minority (22.5%) believed that patients should be kept apart from others. Conclusion: Including leprosy in continuous medical education and refresher training is crucial in early diagnosis of leprosy as certain gap in knowledge was identified. An emphasis needs to be placed on education regarding transmission and low rate of infectivity of leprosy as study revealed certain misconceptions and prejudices still exist even among healthcare workers.

Leprosy Post-Exposure Prophylaxis (LPEP) programme: study protocol for evaluating the feasibility and impact on case detection rates of contact tracing and single dose rifampicin.

INTRODUCTION: The reported number of new leprosy patients has barely changed in recent years. Thus, additional approaches or modifications to the current standard of passive case detection are needed to interrupt leprosy transmission. Large-scale clinical trials with single dose rifampicin (SDR) given as post-exposure prophylaxis (PEP) to contacts of newly diagnosed patients with leprosy have shown a 50-60% reduction of the risk of developing leprosy over the following 2 years. To accelerate the uptake of this evidence and introduction of PEP into national leprosy programmes, data on the effectiveness, impact and feasibility of contact tracing and PEP for leprosy are required. The leprosy post-exposure prophylaxis (LPEP) programme was designed to obtain those data. METHODS AND ANALYSIS: The LPEP programme evaluates feasibility, effectiveness and impact of PEP with SDR in pilot areas situated in several leprosy endemic countries: India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. Complementary sites are located in Brazil and Cambodia. From 2015 to 2018, contact persons of patients with leprosy are traced, screened for symptoms and assessed for eligibility to receive SDR. The intervention is implemented by the national leprosy programmes, tailored to local conditions and capacities, and relying on available human and material resources. It is coordinated on the ground with the help of the in-country partners of the International Federation of Anti-Leprosy Associations (ILEP). A robust data collection and reporting system is established in the pilot areas with regular monitoring and quality control, contributing to the strengthening of the national surveillance systems to become more action-oriented. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the relevant ethics committees in the countries. Results and lessons learnt from the LPEP programme will be published in peer-reviewed journals and should provide important evidence and guidance for national and global policymakers to strengthen current leprosy elimination strategies.

Prevalence and Correlates of Leprosy in a High-Risk Community Setting in Sri Lanka.

Leprosy is caused by the Mycobacterium leprae bacillus. Pockets of high endemicity remain in a number of countries including Sri Lanka, in spite of the fact that elimination has been achieved at the national level. In 2012, in a village in the Puttlam district, dermatologists reported an increase in individuals with leprosy. This village had been established in the 1990s for people displaced from Northern Sri Lanka during a civil war. A comprehensive household survey was conducted by district health officials from June to July 2012, and all household members present during the survey period were examined for leprosy lesions. Patients with suspected leprosy were referred to a dermatology clinic for clinical or pathological confirmation. The prevalence of leprosy was high (511 per 10 000 population). Household contact with another patient with leprosy increased the risk of leprosy (odds ratio = 6.69; P < .001). Continued vigilance is needed to keep leprosy at bay in high-risk communities.

Polymerase chain reaction detection of Leishmania DNA in skin biopsy samples in Sri Lanka where the causative agent of cutaneous leishmaniasis is Leishmania donovani.

Leishmania donovani is the known causative agent of both cutaneous (CL) and visceral leishmaniasis in Sri Lanka. CL is considered to be under-reported partly due to relatively poor sensitivity and specificity of microscopic diagnosis. We compared robustness of three previously described polymerase chain reaction (PCR) based methods to detect Leishmania DNA in 38 punch biopsy samples from patients presented with suspected lesions in 2010. Both, Leishmania genus-specific JW11/JW12 KDNA and LITSR/L5.8S internal transcribed spacer (ITS)1 PCR assays detected 92% (35/38) of the samples whereas a KDNA assay specific forL. donovani (LdF/LdR) detected only 71% (27/38) of samples. All positive samples showed a L. donovani banding pattern upon HaeIII ITS1 PCR-restriction fragment length polymorphism analysis. PCR assay specificity was evaluated in samples containing Mycobacterium tuberculosis, Mycobacterium leprae, and human DNA, and there was no cross-amplification in JW11/JW12 and LITSR/L5.8S PCR assays. The LdF/LdR PCR assay did not amplify M. leprae or human DNA although 500 bp and 700 bp bands were observed in M. tuberculosis samples. In conclusion, it was successfully shown in this study that it is possible to diagnose Sri Lankan CL with high accuracy, to genus and species identification, using Leishmania DNA PCR assays.

Polymerase chain reaction detection of LeishmaniaDNA in skin biopsy samples in Sri Lanka where the causative agent of cutaneous leishmaniasis is Leishmania donovani

Leishmania donovani is the known causative agent of both cutaneous (CL) and visceral leishmaniasis in Sri Lanka. CL is considered to be under-reported partly due to relatively poor sensitivity and specificity of microscopic diagnosis. We compared robustness of three previously described polymerase chain reaction (PCR) based methods to detectLeishmania DNA in 38 punch biopsy samples from patients presented with suspected lesions in 2010. Both, Leishmaniagenus-specific JW11/JW12 KDNA and LITSR/L5.8S internal transcribed spacer (ITS)1 PCR assays detected 92% (35/38) of the samples whereas a KDNA assay specific forL. donovani (LdF/LdR) detected only 71% (27/38) of samples. All positive samples showed a L. donovani banding pattern upon HaeIII ITS1 PCR-restriction fragment length polymorphism analysis. PCR assay specificity was evaluated in samples containing Mycobacterium tuberculosis, Mycobacterium leprae, and human DNA, and there was no cross-amplification in JW11/JW12 and LITSR/L5.8S PCR assays. The LdF/LdR PCR assay did not amplify M. leprae or human DNA although 500 bp and 700 bp bands were observed in M. tuberculosis samples. In conclusion, it was successfully shown in this study that it is possible to diagnose Sri Lankan CL with high accuracy, to genus and species identification, using Leishmania DNA PCR assays.

Lucio's phenomenon, an uncommon occurrence among leprosy patients in Sri Lanka.

BACKGROUND: Lucio's phenomenon is a rare manifestation of untreated leprosy which is seen almost exclusively in regions surrounding the Gulf of Mexico. Its occurrence elsewhere though documented is considered uncommon. We present a case of Lucio's phenomenon in a previously undiagnosed leprosy patient who presented to us with its classical skin manifestations. CASE PRESENTATION: A 64 year old South Asian (Sri Lankan) male with a history of chronic obstructive airway disease presented to us with fever and cough. He had a generalized smooth and shiny skin with ulcerating skin lesions afflicting the digits of the fingers. The lesions progressed to involve the extremities of the body and healed with crusting. Based on the clinical and investigational findings Tuberculosis and common vasculitic conditions were suspected and excluded. The unusual skin manifestations prompted a biopsy, and wade fite stained revealed Mycobacterium bacilli. In context of the clinical picture and histological findings, Lucio's phenomenon was suspected. A clinical diagnosis of Lucio's phenomenon occurring in the backdrop of lepromatous leprosy was made. CONCLUSION: Though leprosy is still a prevalent disease, it has manifestations that are not easily recognized or fully appreciated. Regional patterns of atypical manifestations should not limit better understanding of rarer manifestations as it will aid in clinching an early diagnosis and instituting prompt treatment, thereby reducing morbidity and mortality.

Determinants of mortality and impact of therapy in patients with leptospirosis admitted for intensive care in a Sri Lankan hospital--a three year retrospective study.

INTRODUCTION: Leptospirosis is a disease of epidemic proportions in Sri Lanka. There is paucity of data on the determinants of mortality and impact of therapy in patients with leptospirosis admitted to critical care settings in endemic territories. METHODOLOGY: This retrospective cross-sectional study was performed in patients with serologically confirmed leptospirosis admitted to the intensive care unit of the General Hospital, Kalutara from January 2011 to April 2014. Associations between socio-epidemiological, clinical and laboratory parameters and patient mortality were examined. RESULTS: Forty-five patients were included. The mean age was 49.11(SD = 16.95) and majority (92%) were male. Percentage mortality was 44.4%. Patient mortality was associated with age > 40 (p = 0.012), symptoms of uremia (p = 0.017), evidence of CNS involvement (p = 0.039), presence of oliguria (p = 0.002) and anuria (p = 0.014), presence of multi-organ dysfunction syndrome (MODS) (p < 0.001), CRP > 96 (p = 0.036), platelet count < 20,000 (p = 0.045), Potassium > 5.0 (p = 0.05), metabolic acidosis with pH < 7.2 (p = 0.03), INR > 2 (p = 0.037) and requirement of mechanical ventilation (p < 0.001). Cox regression analysis revealed MODS and potassium > 5 to be independently associated with mortality. CONCLUSIONS: A high mortality rate is noted. The presence of MODS and serum potassium concentration > 5.0 was independently associated with mortality in this retrospective study of patients with confirmed leptospirosis in a critical care setting.

A study of household contacts of children with leprosy.

INTRODUCTION: The new case detection rate of leprosy and new cases among children remain high in Sri Lanka indicating ongoing transmission. Identification of the positive contacts and the source of infection would break this chain of transmission. Contact tracing is known to identify early disease and thus prevent disabilities. However, in the recent past little emphasis has been laid on contact tracing by the health care providers. OBJECTIVES: This study looked at the household contacts of children with leprosy to identify the-rate of positive contacts within the household. METHODS: The study was conducted at the Lady Ridgeway Hospital, Colombo, Sri Lanka, during a period of one year and nine months from January 2007. The index cases were defined as children of less than 12 years who were presently on anti leprosy treatment or who were newly diagnosed with leprosy. A total of 311 contacts of 100 index cases were examined for evidence of leprosy. RESULTS: The total of positive contacts was 51 per 100 index cases. 33% of the index cases had a positive contact within the household. 11% had more than one member affected. 83.2% of positive contacts were of tuberculoid type. 20.8% of the contacts were less than 15 years of age. When considering the relationship to the index case, most (33.3%) were siblings while 25.0% were parents and 20.8% were grandparents. Twenty five persons (8.0%) out of 311 household contacts were de novo cases. CONCLUSIONS: This study highlights the value of contact screening of leprosy patients.

A histopathological study of cutaneous leishmaniasis in Sri Lanka.

UNLABELLED: INTRODUCTION; Cutaneous leishmaniasis is endemic in Sri Lanka. The immunopathogenesis of these lesions in Sri Lankans has not been documented. OBJECTIVES: To classify skin lesions into histological groups, to assess parasitic load, density of each inflammatory cell type and necrosis and to characterise the lymphocytic reaction in cutaneous leishmaniasis in comparison to leprosy. METHODS: Skin biopsies from 31 patients with demonstrable amastigotes in smears or tissue sections were studied. The lesions were classified by two independent observers into four distinct histological groups based on different cell types in the inflammatory infiltrate and formation of granulomata. Parasitic load and the presence of necrosis were recorded. Immunohistochemical staining for CD45RO and CD20 for counting T and B cells respectively was done. RESULTS: Histological groups of cutaneous leishmaniasis ranging from group I-IV were similar to that of the spectrum in leprosy ranging from lepromatous to tuberculoid leprosy. The histological groups from I-IV showed a significant inverse relationship with the mean parasitic index. Necrosis was not a prominent feature. The mean percentage of T cells in the histological spectrum from group I-IV in leishmaniasis was similar to the spectrum from lepromatous to tuberculoid leprosy. Mean percentage of T cells were 20.1% in group I, 20.5% in group II, 33.8% in group III and 47.8% in group IV. Lepromatous, borderline tuberculoid and tuberculoid leprosy had 21.3%, 33.4% and 48.0% T cells respectively. CONCLUSION: Cutaneous leishmaniasis is a spectral disease similar to leprosy. The mean percentage T cells from group I-IV were similar to those in the spectrum of leprosy and mean percentage B cells varied in a narrow range.

Can social marketing approaches change community attitudes towards leprosy?

This essay explores how the concept of social marketing can be employed to change attitudes towards leprosy. Firstly, the concept of social marketing is discussed, then the attitudes that people have about leprosy, the stigma that people with leprosy and their families may face, and the detrimental effects that this can have on their lives. The effect of knowledge and education on attitudes towards leprosy is discussed, as this can be a key component of social marketing campaigns. Various methods of social marketing used to change attitudes and reduce stigma are examined, such as mass media campaigns, school based education, methods which involve community leaders, and the integration and improvement of leprosy services. Principles of social marketing which can lead to the success of campaigns such as incorporating local beliefs are emphasized. The success of the social marketing campaign in Sri Lanka is described, which aimed to remove the fear of leprosy, and to encourage patients to seek and comply with treatment. Finally, it is argued that social marketing, used correctly, can be highly effective at changing community attitudes towards leprosy, reducing stigma and improving the lives of patients, who become able to seek treatment sooner as they lose their fear of stigmatization.

An analysis of the pattern of detection of leprosy patients by institutions in the general health services in Sri Lanka after the integration of leprosy services into general health services.

Integration of leprosy services into the General Health Services was initiated in 2001 in Sri Lanka, and by the end of 2003 all services related to leprosy care were fully integrated. Against this background, routinely collected data available at the Anti-Leprosy Campaign for a 3-year period from 2000-2003 were analyzed to identify the pattern of the detection of cases by hierarchical institutions in the General Health Services. The analysis showed that more than 75% of leprosy patients had been detected at base, general and teaching hospitals and this trend was increasing proportionally during the period of concern (P < 0.001). Teaching hospitals had detected more than 50% of patients and this trend was also proportionally increasing. Nearly one-third of patients detected at teaching hospitals had been detected at the Central Leprosy Clinic (CLC) at the National Hospital. The trend for case detection at the CLC was decreasing proportionally and in absolute terms during the 3-year period after integration. More than 60% of leprosy patients had been detected at institutions where consultant dermatologists were available. The analysis concluded that centralized leprosy diagnostic and treatment services have been taken over by the institutions in the General Health Services but within districts these activities are predominantly concentrated on higher level institutions with consultant dermatological services. This suggests that similar to the existing general trend of by passing of lower level institutions by patients to seek treatment at higher-level institutions, which are perceived to provide a service of better quality, leprosy patients too prefer to seek treatment at these institutions.

"Tap sign" in tuberculoid and borderline tuberculoid leprosy.

Deep pain upon percussion of lesions over bone in tuberculoid leprosy, in spite of superficial sensory impairment, has been described as the "Tap Sign" (TS). This study was conducted to identify possible causes for this phenomenon and to determine the sensitivity and specificity of this sign in leprosy patients with lesions overlying bone. In 37/53 patients with lesions over bone, the sensitivity of the TS was 66.7% and the specificity was 100%. The positive predictive value was 100%, and the negative predictive value was 75%. The Tap Sign appears to be a useful clinical sign in diagnosis of tuberculoid and borderline tuberculoid leprosy where a lesion overlies a bone (sensitivity 66.7%). This test could be very useful to increase the clinical diagnostic yield, in the global perspective, in places where leprosy is diagnosed and treated by healthcare workers and primary care physicians without other laboratory facilities. Possible mechanisms responsible for the deep pain are discussed.