Neutrophil extracellular traps contribute to the pathogenesis of leprosy type 2 reactions.

Up to 50% of patients with the multibacillary form of leprosy are expected to develop acute systemic inflammatory episodes known as type 2 reactions (T2R), thus aggravating their clinical status. Thalidomide rapidly improves T2R symptoms. But, due to its restricted use worldwide, novel alternative therapies are urgently needed. The T2R triggering mechanisms and immune-inflammatory pathways involved in its pathology remain ill defined. In a recent report, we defined the recognition of nucleic acids by TLR9 as a major innate immunity pathway that is activated during T2R. DNA recognition has been described as a major inflammatory pathway in several autoimmune diseases, and neutrophil DNA extracellular traps (NETs) have been shown to be a prime source of endogenous DNA. Considering that neutrophil abundance is a marked characteristic of T2R lesions, the objective of this study was to investigate NETs production in T2R patients based on the hypothesis that the excessive NETs formation would play a major role in T2R pathogenesis. Abundant NETs were found in T2R skin lesions, and increased spontaneous NETs formation was observed in T2R peripheral neutrophils. Both the M. leprae whole-cell sonicate and the CpG-Hlp complex, mimicking a mycobacterial TLR9 ligand, were able to induce NETs production in vitro. Moreover, TLR9 expression was shown to be higher in T2R neutrophils, suggesting that DNA recognition via TLR9 may be one of the pathways triggering this process during T2R. Finally, treatment of T2R patients with thalidomide for 7 consecutive days resulted in a decrease in all of the evaluated in vivo and ex vivo NETosis parameters. Altogether, our findings shed light on the pathogenesis of T2R, which, it is hoped, will contribute to the emergence of novel alternative therapies and the identification of prognostic reactional markers in the near future.

[EXPERIMENTAL STUDY OF SPECIFIC ACTIVITY OF 1.3-DIAZINON-4 COM- POUND PYaTd1 DERIVATIVE IN VIVO].

AIM: Study anti-leprosy activity of.a 1.3-diazinon-4 compound derivative under the labora- tory code PYaTd1 on the model of intra-plantar infection of mice and evaluate the character of its antibacterial effect. MATERIALS AND METHODS: Study of specific activity was carried out in vivo on the experimental model of leprosy, proposed by Shepard C.C., that assumes execution of intraplantar infection of mice with a suspension of mycobacteria, produced from lepromas or autopsy tissue of a non-treated leprosy infected, or from tissues of experimental mice, previously infected with Mycobacterium leprae from non-treated patients. The study was carried out on 120 CBA line-mice infected with M.leprae (VIII passage) from patient M; Dapsone and PYaTdl compound were administered to animals next day after the infection with forage at a dose of 25 mg/kg for 4.5, 6, 9 and 11 months. The mice were split into 3 groups: control (infected.without treatment), com- parison (infected, receiving.dapsone), experimental (infected, receiving PYaTdl). After.the control term the mice were euthanized under chloroform anesthesia. Suspensions for quantification of mycobacteria were prepared from paw pads. Smears were stained by Ziehl-Nilsson. RESULTS: After 4.5 months the intensity of infect reproduction under, the effect of dapsone and PYaTd1 was reduced compared with control by 18 - 25 times. After a 6-mont course - by 50 - 75% and after 9 months - by 85 - 90%. After 11 months in mice that had received PYaTd1, an intensive suppression of microorganism reproduction as observed: the yield in paws was 70 times lower than in control. In the group that had received dapsone, a reduction of the number of mycobacteria by 20 - 25 times was detected, it was significantly less effective than under the conditions of PYaTd1 admnistration. CONCLUSION: A novel 1.3-diazinon- 4 derivative under the code PYaTd1 can actively supress reproduction of-M. leprae, that gives evidence regarding its specific anti-mycobacterial activity and determines perspectives of its further studies.

Non pitting edema, arthritis and ichthyosis; presenting manifestation of leprosy.

Leprosy is a chronic granulomatous infection caused by Mycobacterium leprae. Predominantly involving skin and nerves and having classic clinical description, the diagnosis may be clear-cut in majority of patients but may be challenging in others. Non-pitting edema, ichthyosis and arthritis are uncommon in leprosy and very rare in tuberculoid type where the diagnosis may be challenging unlike relatively clear-cut clinical picture in lepromatous type. Musculoskeletal manifestation is seen in 1-5% of cases and usually associated with reactional states where again the diagnosis sometimes becomes evident. High index of suspicion is therefore recommended in patients with unexplained systemic illness especially in endemic areas. Herein we report a young male with non pitting edema and symmetric peripheral arthritis involving all four limbs, and ichthyosis as presenting manifestation of borderline leprosy where the neuro-cutaneous manifestation developed two months after the said presenting features and in absence of a reactional state.

Metabonomics reveals drastic changes in anti-inflammatory/pro-resolving polyunsaturated fatty acids-derived lipid mediators in leprosy disease.

Despite considerable efforts over the last decades, our understanding of leprosy pathogenesis remains limited. The complex interplay between pathogens and hosts has profound effects on host metabolism. To explore the metabolic perturbations associated with leprosy, we analyzed the serum metabolome of leprosy patients. Samples collected from lepromatous and tuberculoid patients before and immediately after the conclusion of multidrug therapy (MDT) were subjected to high-throughput metabolic profiling. Our results show marked metabolic alterations during leprosy that subside at the conclusion of MDT. Pathways showing the highest modulation were related to polyunsaturated fatty acid (PUFA) metabolism, with emphasis on anti-inflammatory, pro-resolving omega-3 fatty acids. These results were confirmed by eicosanoid measurements through enzyme-linked immunoassays. Corroborating the repertoire of metabolites altered in sera, metabonomic analysis of skin specimens revealed alterations in the levels of lipids derived from lipase activity, including PUFAs, suggesting a high lipid turnover in highly-infected lesions. Our data suggest that omega-6 and omega-3, PUFA-derived, pro-resolving lipid mediators contribute to reduced tissue damage irrespectively of pathogen burden during leprosy disease. Our results demonstrate the utility of a comprehensive metabonomic approach for identifying potential contributors to disease pathology that may facilitate the development of more targeted treatments for leprosy and other inflammatory diseases.

Analysis of newly detected leprosy in Sohag Governorate, Upper Egypt, 2004-2008.

INTRODUCTION: Leprosy is a chronic and complex infectious illness; the new-case detection rate is better than prevalence as an indicator of disease trends. This study presents an analysis of pattern of new cases of leprosy detected annually from 2004 to 2008 in Sohag Governorate, Upper Egypt. PATIENTS AND METHODS: Data about patients with newly diagnosed leprosy were collected from Sohag leprosy hospital, the main referral centre in the governorate. Case detection rates (CDR) were calculated for each year by dividing the newly diagnosed cases by mid-year populations for the same year. RESULTS: 587 patients were newly diagnosed between 2004 and 2008. The mean age of patients at diagnosis was 34 years, 62% were males, and 11% were children below 15 years of age. The overall leprosy case detection rate was 3-1/100,000 population and it decreased from 3.4/100,000 population in 2004 to 2.8/100,000 population in 2008. Ninety three percent were classified as multibacillary, and 20.4% had Grade 2 disability at diagnosis. CONCLUSIONS: Leprosy remains a health problem in Sohag Governorate. It is possible that new cases are being detected late owing to inadequate community awareness of the disease. Leprosy control activities should be provided in primary health care units in order to detect new cases, and continued surveillance is required to detect relapses and to ensure good patient compliance with treatment.

Can the skin smear examination in NLEP be reconsidered?

Slit and skin smear examination is an important laboratory test which was made optional in the NLEP. In a laboratory managed by LEPRA Society, this test was provided to voluntary reporting cases and those referred by the general health service institutions of the area. Total cases tested were 1180, out of which 152 (12.9%) were positive. Of the 152 smear reports, 121 were from Koraput district and constitute the sample for this study. Regarding the spread of site wise highest BI, 56% cases had BI of 3.1+ to 6+. Of the 121 cases, 112 (92.6%) cases completed 12 doses of MDT. Seventy patients, from whom detailed information was collected by personal contact, responded well to MDT resulting in regression of lesions. Out of them, 46 cases had repeat smear showing negative smear in 39% and decline of 81 in the rest of cases. There are 16 contact cases with 2 family clusters. A rough block-wise mapping showed 4 strata with a dense clustering in the urban area where the laboratory facility is available. The probable reasons for uneven distribution of cases and causes for late diagnosis were discussed. The study reflects the leprosy problem in urban pockets which high infection pool. Together these two factors remain unexposed due to winding up of smear labs and pose a potential threat to elimination. The paper also emphasized on the reasons for past failure of the test along with suggestions to revive this facility with minor modifications.

Impact of integration on the profile of newly diagnosed leprosy patients attending a referral hospital in South India.

This article compares the clinical profile of new untreated leprosy patients attending a referral hospital (The Schieffelin Institute for Health Research & Leprosy Centre, formerly known as SLR&TC, Karigiri, South India, in post-integration period (2005-2007) with that during the pre-integration period (1995-1996). A total of 529 patients--259 in pre-integration and 270 in post-integration period--were seen at this hospital. The clinical data culled from records for the earlier period were compared with data gathered prospectively for the latter period and was analyzed using SPSS software. The results showed a significant increase in the mean age of registration, percent multibacillary (clinical criteria) and grade 2 diabilities in post-integration period. Increase in proportion of cases with grade 2 deformities is a matter of concern and suggests continued need for referral hospitals for their management and also population based overall assessment whether actual numbers with deformities have increased or it is peculiar to a tertiary care hospital where the cases with problems may be coming. As the proportion of bacteriological positive cases was not found to change, it is a positive sign of effective coverage in the post-integration scenario in this population.

Powerful bactericidal activity of moxifloxacin in human leprosy.

In a clinical trial of moxifloxacin in eight multibacillary leprosy patients, moxifloxacin proved highly effective. In all trial patients, a single 400-mg dose of moxifloxacin resulted in significant killing (P

Sustainable leprosy related disability care within integrated general health services: findings from Salem District, India.

The main focus of leprosy control has been case detection and treatment delivery with relative neglect of prevention of disability. Absence of reliable data and lack of research have added to the problem. This raised concerns about the capacity of the general health system to address the needs of people living with leprosy-related disabilities. In this prospective study appropriate services for people living with leprosy-related disabilities were introduced in the form of self-care training, guidance and monitoring by the general health staff facilitated by a non-governmental organisation leprosy centre in a district in south India with a population of 3.1 million (estimated in 2005). The staff identified 1232 people with leprosy-related disabilities and trained them in self-care. Follow-up assessments indicated that 86% were found to be practising self-care regularly and all the 239 general health workers were found to be actively involved. The most heartening outcome was the healing of plantar ulcers in 70% of people at the 1-year follow up. This intervention is sustainable because of the simplicity of the procedures and the involvement of all health staff including supervisors.

Inter-state variations in integration of leprosy services into general health system in low/ moderately endemic states of India.

The objective of the study was to analyse inter-state variations in integration of leprosy services into the general health system, covering broad categories of structure integration, training of health functionaries, availability of MDT services and record maintenance, in 24 low/moderately endemic states. Multi-stage random sampling technique was used to select 9 states, 86 health facilities (including district hospitals, community health centres, primary health centres) and 108 sub-centres. Information from each level was collected on a pre-tested form by officers of three leprosy institutions of the Government of India. The results showed wide inter-state variations on each aspect. Redeployment of vertical staff was complete (100%) in Tamil Nadu and Tripura. Assam reported a higher level of training (97%) of medical officers in leprosy. Training of health supervisors and multipurpose workers was better than that of medical officers in most of the states. Tripura reported negligible training of all the health functionaries because of specific local problems. In Assam, Maharashtra and Sikkim, all the urban and rural health facilities were providing MDT. Three months' stock of all types of MDT blister packs was available only in one health facility in Andhra Pradesh and in Goa. Assam and Haryana had lower availability of MDT stocks. In Assam and Maharashtra, medical officers in all health facilities were diagnosing and treating leprosy cases, as compared with Himachal Pradesh where the value was 30%. Involvement of sub-centres in MDT delivery was more at 92% and 100% in Tamil Nadu and Maharashtra respectively in comparison to none in Himachal Pradesh and Tripura. Use of the Simplified Information System (SIS) 2002 guidelines and formats was universal. However, lower involvement of GHS staff in recording and reporting was noted in Assam (0%), Andhra Pradesh (10% and 30%). The study emphasized the need for further tailor-made follow-up studies to suit local problems.

[Pathological diagnosis of leprosy in developing countries].

In the developing countries where leprosy is prevalent, diagnosis of leprosy is made from clinical signs and symptoms. However, when difficult and doubtful cases increase after the advance of leprosy control programs, definitive diagnosis of leprosy by histopathology become necessary. This report describes our experience of technical support to re-establish histopathology service and introduction of immunohistochemistry in the leprosy referral center of Myanmar, and we discuss the ideal way of international technical support. This activity was performed as a part of leprosy control and basic health services project of Japan International Cooperation Agency (JICA) since 2000 to 2005.

Leprosy and tuberculosis in Iron Age Southeast Asia?

The recent excavation of a sample of 120 human skeletons from an Iron Age site in the valley of the Mun River, a tributary of the Mekong River on the Khorat Plateau in northeast Thailand, has provided the largest sample from this period in the region to date. This paper reviews three individuals from the sample with pathological changes for which the differential diagnosis includes systemic infectious disease. In two of these, both males with lesions of the hands and feet, leprosy and psoriatic arthritis are discussed as differential diagnoses, with leprosy the most probable. In the third, a female with lesions of the spine, the differential diagnosis includes tuberculosis and nonspecific osteomyelitis. Tuberculosis is the most probable diagnosis. Although the focus of this paper is a presentation of the evidence for infectious disease at Noen U-Loke, the significance of probable diagnoses of mycobacterial diseases for the history of the diseases and for prehistory in mainland Southeast Asia is also briefly discussed.

Study on integration of the National Leprosy Eradication Programme into primary health care services: a pilot project.

The Central Leprosy Training and Research Institute, Chengalpattu, Tamil Nadu, undertook an interventional study, as a pilot project, on integration of the National Leprosy Eradication Programme (NLEP) vertical activities into the PHC system in two selected districts of Visakhapatnam and Krishna of Andhra Pradesh, between September 1997 and March 1999. The objective of the study was to assess the various operational aspects and implications of integrated implementation of the activities of the NLEP through the PHC system. 1,304,163 people (239,142 in the study group and 1,065,020 in the control group) were enrolled in the study. The methodology employed in carrying out the pilot project in the two selected districts is described. MDT was in operation for more than 5 years in these two districts through vertical approach. Prevalence has declined from >50/10000 at the start of MDT to about 3/10000 at the start of the project. During the implementation phase, 1459 new leprosy cases were detected (NCDR 5.39/10000 person-years) and 1458 cases were released from treatment (RFT rate: 93.04%) and towards the end of the project 450 cases were under treatment (PR 1.66/10000). Simple rates, ratios and proportions were used in the analysis of data and results were compared. The interventional study was designed to assess the implications and impact of implementation of NLEP activities through PHC staff. The study design, rationale, data collection, data processing, quality control methods employed in the study project and the results are discussed. The results of the study indicate that integrated implementation of the NLEP by PHC staff is feasible, if proper support is provided.

Knowledge and practice of eye-care among leprosy patients.

In one hundred and thirty leprosy patients attending the Schieffelin Leprosy Research and Training Center, Karigiri, Tamil Nadu, India, the knowledge, attitude and practice of eye-care were ascertained using a questionnaire developed by Mathews & Mangalam. 74.6% the patients surveyed were aware of the disease, 60% knew about the early signs of leprosy, 74.6% considered leprosy curable and 36.9% knew the duration of treatment with MDT. Less than half of the patients (40.8%) knew that blindness occurred in leprosy and was preventable. More males had this knowledge (46.5%) than females (22.6%) (P = 0.001). Knowledge on how to take care of the eyes (26.9%), that eyes become anaesthetic due to leprosy (27.7%), and that precautions should be taken if sensation is lost (27. 7%) was very poor. Knowledge on prevention of damage in eyes (57.7%) and the fact that rubbing eyes could cause damage (55.4%) was found in more than half the patients. More males (64.6%) had knowledge on the prevention of damage in eyes than females (35.5%) (P = 0.008). Only 25.4% of the patients tried some measures to prevent eye injury, 21.5% used home remedies and all had the help of family members in their eye-care. More males (26.3%) used home remedies than females (6.5%). The older age group had better knowledge on taking care of the eyes than those aged 40 and below (P = 0.026). Although more patients with existing complications knew to take care of their eyes than those who did not have complications, the knowledge and practice of eye-care in both these groups were poor. Knowledge of leprosy in illiterate patients was not different from those who had some formal schooling, but the practice of eye-care differed significantly (P = 0.02). Health education must be undertaken to increase the knowledge of eye-care among leprosy patients, especially among illiterate persons, women and younger patients.

Ulceraciones en la lepra. Tratamiento / Ulcerations in lepra. Management

Se estudian las úlceras en la lepra, su etiología, frecuencia y localización, la mayoría de carácter neurotrófico. Se describen diferentes tratamientos tópicos y quirúrgicos, resaltando las dificultades terapéuticas y la cronicidad (AU)

Factors influencing the in vitro growth of Mycobacterium leprae: effect of inoculum.

Factors responsible for the in vitro growth of Mycobacterium leprae in Dhople-Hanks (DH) medium, and also to improve the technique devised earlier, and the source of the M. leprae used as inoculum, were investigated. M. leprae were obtained from armadillos and nude mice, both inoculated earlier with human- or armadillo-derived M. leprae. The growth of M. leprae in DH medium was monitored using two biochemical indicators. Normal growth was obtained when inocula were from livers and spleens of M. leprae-infected armadillos. The M. leprae harvested from the footpads of nude mice failed to multiply in the same medium. Using inocula from livers and spleens of infected armadillos, a gradual decrease in inoculum size resulted in a proportionately slower multiplication of M. leprae. When the DH medium was supplemented with whole M. leprae, or cell-free extracts of M. leprae, from irradiated livers and spleens of infected armadillos, nude mouse-derived M. leprae exhibited growth in the DH medium in accord with that obtained using armadillo-derived M. leprae. Similar results were obtained with cell-free extracts of M. leprae harvested from non-irradiated livers and spleens of infected armadillos, but no growth was obtained when the medium was supplemented with extracts from livers or spleens of normal armadillos. These results indicate the possible existence of a growth factor in armadillo-derived M. leprae.