Hansen’s Disease

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

2. 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)

3. 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

4. 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

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

6. 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 hypopigmentedmacule- often the first lesion • Erythematous macules (cheeks, upper arms, buttocks, thighs) –less often

7. 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

8. 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

9. 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

10. 2. Tuberculoid Leprosy

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

12. 3. Borderline Tuberculoid Leprosy

13. 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

14. 4. Borderline Leprosy

15. 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)

16. 5. Borderline Lepromatous Leprosy Hyperpigmentation due to Clofazamine

17. 6. Lepromatous Leprosy • Cutaneous lesions – pale lepromatousmacules / 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.

18. 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 (erythemanecroticans)

19. 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)

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

21. 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

22. 7. Histoid Leprosy