Ma. Bernadette V. Lopez-Dee Adrian B. Lorenzo Hansen’s Disease Ma. Bernadette V. Lopez-Dee Adrian B. Lorenzo

Epidemiology Global prevalence – 1.25 cases per 10,000 persons India – 80% worldwide Male to female ratio of occurrence – 1.5 : 1 Age of occurence – before 35 (endemic areas), age 50 (exposure to armadillos) Latency period – 5 years (paucibacillary), 20 years (multibacillary) Mode of transmission – armadillo exposure, other cases of Hansen’s disease Close contact – 28 % (household contacts) - 80 % (neighbors, social contacts)

Infectious agent Mycobacterium leprae Weakly acid-fast organism Grows best at 30 ̊C below human body core temperature Long generation time (12-14 days) Unable to be cultured in vitro

Diagnosis Identification of infectious organism in affected tissue Skin biopsies: from skin or nerve lesions – stained for bacillus with Fite-Faraco stain Slit smears: from lesions and cooler areas of skin – stained with Acid-fast stain organisms found – multibacillary 5 or few lesions/ negative – paucibacillary

Classification Early and Indeterminate leprosy Tuberculoid leprosy Borderline tuberculoid leprosy Borderline leprosy Borderline lepromatous leprosy Lepromatous leprosy Histoid leprosy

1. Early and Indeterminate Leprosy Insidious onset Numbness – first manifestation in 90% of patients Loss of senses of cold and light touch - earliest sensory changes Solitary, ill-defined hypopigmented macule- often the first lesion Erythematous macules (cheeks, upper arms, buttocks, thighs) –less often

1. Early and Indeterminate Leprosy Biopsy – usually no bacilli or only a few Few cases remain in this state Evolve to lepromatous, tuberculoid, or borderline types Good cell-mediated immunity – often resolve spontaneously or never develop other signs and symptoms of Leprosy

2. Tuberculoid Leprosy Solitary lesions or few in number (5 or less) Asymmetrical distribution Lesions – hypopigmented or erythematous, dry, scaly, hairless Typical lesion – large, erythematous plaque w/ a sharply defined & elevated border that slopes down to a flattened atrophic center – “a saucer right side up” Common locations – face, limbs, or trunk Lesion is anesthetic & anhidrotic

2. Tuberculoid Leprosy Nerve involvement – early & prominent Greater auricular nerve & Superficial peroneal nerve – visibly enlarged Atrophy of interosseous muscles of hand, w/ wasting of thenar & hypothenar eminences, contracture of fingers, facial muscle paralysis, foot drop Evolution generally slow Often, there is spontaneous remission in 3 years, or less if w/ treatment

2. Tuberculoid Leprosy

3. Borderline Tuberculoid Leprosy Similar to tuberculoid lesions, but smaller and more numerous Characteristic – satellite lesions around large macules or plaques

3. Borderline Tuberculoid Leprosy

4. Borderline Leprosy Lesions: Numerous but countable, consist of red, irregularly shaped plaques Small satellite lesions may surround larger plaques Generalized but asymmetrical Edges are not so well defined Nerves may be thickened and tender Anesthesia is only moderate

4. Borderline Leprosy

5. Borderline Lepromatous Leprosy Lesions are symmetrical, numerous (not countable), may include macules, papules, plaques, and nodules Small lepromatous lesions > larger borderline type lesions Nerve involvement -appears later, symmetrical Nerves - enlarged and/or tender Sensation & sweating over individual lesions are normal Usually no features of full-blown leprosy (madarosis, keratitis, nasal ulceration, leonine facies)

5. Borderline Lepromatous Leprosy Hyperpigmentation due to Clofazamine

6. Lepromatous Leprosy Cutaneous lesions – pale lepromatous macules / lepromatous infiltrations w/ numerous bacilli Becomes progressively worse w/o treatment Divided into polar form LLp & subpolar form LLs Macular lepromatous lesions- diffuse & symmetrical distribution, small, numerous, ill-defined, blend into surrounding skin No loss of sensation over lesions, nerve thickening, nor changes in sweating Slow, progressive hair loss – outer third of eyebrows, eyelashes, then body. Scalp hair remains unchanged.

6. Lepromatous Leprosy Lepromatous infiltrations divide into diffuse, plaque, and nodular types Diffuse type Diffuse infiltration of face (forehead), madarosis, waxy shiny appearance of skin – “varnished appearance” Diffuse leprosy of Lucio – 1/3 of lepromatous cases. Diffuse infiltration of skin. Localized lepromas do not form. Unique complication – Lucios’s phenomenon (erythema necroticans)

6. Lepromatous Leprosy Infiltrations- manifested by development of nodules called lepromas Early nodules – ill defined, occurs in acral parts (ears, brows, nose, chin, elbows, hands, buttocks, knees) Nerve involvement – variable, very slow Nerve disease – bilaterally symmetrical, stocking-glove pattern (misdiagnosed as diabetic neuropathy)

6. Lepromatous Leprosy Multiple papules and nodules Enlargement of the earlobe

7. Histoid Leprosy Uncommon form of multibacillary leprosy Skin lesions – yellow-red, shiny, large papules and nodules in dermis or subcutaneous tissue 1- 15 mm in diameter Appear anywhere, but favor the buttocks, lower back, face, and bony prominences This pattern may appear de novo, but mostly described in patients w/ resistance to long-acting dapsone resistance

7. Histoid Leprosy