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Leprosy in Sukkur region: A series of 143 cases from 2001-2011 at leprosy centre Sukkur Sindh.

Byline: Irfan Shaikh Farooq Soomro Nuzhat Seema Bhatti and Abdul Manan Bhutto

Abstract Objective To document the clinical characteristics of newly diagnosed leprosy patients in Sukkur Region Sindh.

Methods A total of 143 new leprosy cases referred and registered in leprosy centre Sukkur from 2001-2011 were studied. Diagnosis was based on clinical grounds and supported by acid-fast bacilli on slit-skin smear.

Results Out of 143 new cases 73 (51%) were males and 70 (49%) females. The peak age of disease onset was second decade. The most common form of the disease was borderline tuberculoid (BT) seen in 76 (53%) cases. Ulnar nerve was the most frequently affected nerve seen in 30 (21%) cases.

Conclusion Although in urban cities the cases of leprosy are in decline but still it exists in rural areas of Sindh. It is important for the practitioners to be aware of its diagnosis and management to prevent the deformities

Key words

Leprosy lepromatous borderline tuberculoid ulnar nerve.

Introduction

Leprosy is a granulomatous disease affecting the skin and peripheral nerves caused by Mycobacterium leprae.1 There were 407791 new cases diagnosed and reported to World Health Organization in 2004. It is more prevalent in India Brazil Republic of Congo Pakistan and central African Republic.

The WHO recommends classifying leprosy according to the number of lesions and the presence of bacilli on a skin smear. Paucibacillary leprosy is characterized by 5 or fewer lesions with absence of organisms on smear and lesions are typically anesthetic and hypopigmented. It generally includes the tuberculoid and borderline tuberculoid categories from the Ridley-Jopling system. Multibacillary leprosy is marked by 6 or more lesions with possible visualization of bacilli on smear disseminated and minimally hypopigmented. Lepromatous leprosy borderline lepromatous leprosy and mid borderline leprosy are included in the multibacillary types.5 The 2 common types of leprosy reactions type 1 or reversal reaction is mediated by an upgrade in cellular immune response to the bacterium and type 2 is a type III hypersensitivity reaction characterized by erythema nodosum leprosum.67 Nerve damage may occur early in tuberculoid disease but tends to be more insidious in lepromatous leprosy. The present study aimed to document the clinical features of 143 newly diagnosed cases of disease presenting to Leprosy Center Sukkur Sindh.

Methods

This study comprised 143 patients who visited Leprosy Centre Sukkur from 2001 to 2011. Descriptive information was recorded which included patient's age gender and place of birth type of skin lesions (macule. papule nodules patches etc.) distribution of lesions ocular lesions cranial nerve involvement peripheral neuropathy eyebrow hair loss involvement of nose or pinna type of disease and histopathologic diagnosis of biopsy specimen. Diagnosis was made clinically by finding a cardinal sign of leprosy and supported by acid- fast bacilli in slit-skin smears or typical histology on skin biopsy. Results

Out of the 143 patients studied 73 were males and 70 females ( equal male to female ratio). Age of patients varied from 5 to 70 years and most of cases seen were of 15 to 24 year age group (Table 1). Amongst the clinical characteristics the patches were common presentation seen in 103 (76%) cases (Table 2). Borderline tuberculoid leprosy was the common type seen in 76 (53%) cases significantly higher prevalence in females 46 (32%) cases (Table 3). Bacterial index was positive in 31 (22%) cases. Out of 31 cases 22 (15%) had borderline lepromatous leprosy (Table 4). Most cases of peripheral nerve involvement were seen in borderline tuberculoid 31 (22%) cases (Table 5). Ulnar nerve was the most commonly involved peripheral nerve seen in 30 (21%) cases.

Table 1 Age and sex distribution of the study population (n=143).

Age group (years)###Male (n=73)###Female (n=70)###Total

1-14###08 (11.0%)###08 (11.4%)###16 (11.2%)

15-24###21 (28.8%)###16 (22.9%)###37 (25.9%)

25-34###18 (24.6%)###08 (11.4%)###26 18.2%)

35-44###09 (12.3%)###10 (14.3%)###19 (13.2%)

45-54###08 (11.0%)###12 (17.2%)###20 (14.0%)

55-64###06 (8.2%)###11 (15.7%)###17 (11.9%)

Above 65###03 (4.1%)###05 (7.1%)###08 (5.6%)

Table 2 Clinical characteristics of patients lesions and deformities (n=143).

Types of lesions/deformity###Male (n=73)###Female (n=70)###Total

Macules###08 (11.0%)###05 (7.1%)###13 (9.1%)

Papules###06 (8.2%)###05 (7.1%)###11 (7.7%)

Plaques###12 (16.4%)###13 (18.6%)###25 (17.5%)

Nodules###03 (4.1%)###02 (2.6%)###05 (3.5%)

Patches###39 (53.4%)###64 (91.4%)###103 (69.9%)

Ulcers###07 (16.3%)###04 (5.7%)###11 (7.7%)

Clawing of fingers###04 (5.5%)###05 (7.1%)###09 (6.3%)

Foot drop###01 (1.4%)###01 (1.4%)###02 (1.4%)

Gynecomastia###04 (5.5%)###-###04 (2.8%)

Hanging ear lobes###05 (6.8%)###03 (4.3%)###08 (5.6%)

Depressed nose###01 (1.4%###01 (1.4%)###02 (1.4%)

Madarosis###02 (2.7%)###02 (2.9%)###04 (2.8%)

Table 3 Types of leprosy seen in the study population (n=143).

Types###Male (N=73)###Female (N=70)###Total

Lepromatous leprosy (n=02###01 (1.4%)###01 (1.4%)###02 (1.4%)

Tuberculoid leprosy (n=29)###19 (26.0%)###10 (14.3%)###29 (20.3%

Borderline leprosy (2=09)###06 (8.2%)###03 (4.3%)###09 (6.3%)

Borderline tuberculoid leprosy (n=76)###30 (41.1%)###46 (65.7%)###76 (53.1%)

Borderline lepromatous leprosy (n=27)###17 (23.3%)###10 (14.3%)###27 (18.9%)

Table 4 Bacterial Index in the study population (n=143).

Types###Positive N (%)###Negative N (%)

Lepromatous leprosy (n=2)###02 (100%)###0

Tuberculoid leprosy (n=29)###0###29 (100%)

Borderline leprosy (n=09)###05 (55.5%)###04 (44.5%)

Borderline tuberculoid leprosy (n=76)###02 (2.6%)###74 (97.4%)

Borderline lepromatous leprosy (n=27)###22 (81.4%)###05 (18.6%)

Table 5 Peripheral nerve involvement in leprosy patients (n=143).

Peripheral nerve###LL (n=2)###TT (n=02) BB (n=11) BT (n=31) BL (n=15) Total (n=61)

enlarged###N (%)###N (%)###N (%)###N (%)###N (%)###N (%)

Ulnar###0###02 (100%)###03 (27.3%) 21 (67.7%) 04 (26.7%) 30 (49.2%)

Median###0###0###02 (18.2%) 02 (6.5%)###03 (20.0%) 07 (11.5%)

Radial nerve###0###0###03 (27.3%) 06 (19.3%) 03 (20.0%) 12 (19.7%)

Lateral poplitial###01 (50%)###0###02 (18.2%) 01 (6.5%)###03 (20.0%) 06 (9.8%)

Posterior tibial###01 (50%)###0###01 (9.0%)###0###02 (13.3%) 06 (9.8%)

Discussion

In our study most of cases were between 15 to 24 year of age and borderline tuberculoid leprosy was the most common type. It was more common in females than males which is consistent with studies by Chatervedi et al.8 Caldwell et al.9 and Soomro et al.10 This can be due to long incubation period of leprosy significant physical and emotional changes in puberty and possibly impending early marriages cause leprosy in adolescence especially in females. Our study differs from Golfurshan et al.11 done in Iran which found 131 out of 195 cases having lepromatous leprosy and most common presentation was eyebrow hair loss. In our study the ulnar nerve involvement was seen in 30 cases and 21 cases had borderline tuberculoid leprosy which is similar to the studies done by Mahajan et al.12 Soloman et al.13 and Reddy and Prabhudass14 showed that ulnar and posterior tibial were the most commonly affected nerves in borderline tuberculoid leprosy and during MDT therapy.

Similarly deformities rate was around 6% which shows the undesired delay in the diagnosis and management of leprosy patients.

Conclusion

New cases of leprosy are in decline in urban cities but still exist in rural areas of Sindh. It is important for general practitioners to exclude the leprosy in any cutaneous disease which presents with nerve involvement.

References

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2. Global leprosy situation. Wkly Epidemiol Rec. 2005;80: 289-95. 3. Boggild AK Keystone JS Kain KC. Leprosy: a primer for Canadian physicians. CMSJ. 2004;17:71-8.

4. Van Brakel WH Feenstra P Saunderson PR. Leprosy. In: Quan S Heggenhougon K eds. International Encyclopedia of Public Health. New York: Academic Press; 2008. P. 11-55.

5. Scolland DM Adams LB Gillis TP et al. The continuing challenges of leprosy. Clin Microbiol Rev. 2006;19:338-81.

6. Bryceson A Pfaltzgraff RE Leprosy. clinical pathology symptoms and signs. In: Hastings RC ed. Medicine in the Tropics. 3ed ed. Edinburgh: Churchill-Livingstone 1990.P. 11-55.

7. Croft RP Nicholls PG Steyerberg EW et al. A clinical prediction rule for nerve-function impairment in leprosy patients. Lancet 2000;355:6103-6

8. Chatervedi S Kapil U Gnanasekaran N et al. Nutrient intake among adolescent girls belonging to poor socioeconomic group of rural areas of Rajasthan. Indian J Pediatr. 1996;33:197-201.

9. Caldwell JC Caldwell P Caldwell BK et al. The construction of adolescence in a changing world; implications for sexuality reproduction and marriage studies in family planning 1998. 29:137-53.

10. Soomro FR Pathan GM Bhatti NS et al. Leprosy in Larkano region; an analysis of 102 cases from 2001-2011 at leprosy center Larkano. J Pak Assoc Dermatol. 2012;22:126-29.

11. Golfurshan F Sadaghi M Goldust M et al. Leprosy in Iran: an analysis of 195 cases from 1994-2009. J Pak Med Assoc. 2011;16:558-61.

12. Mahagan PM Jogaikar DG Mehta JM. A study of pure neuritic leprosy. Indian J Lepr. 1996;68:137-41. 13. Soloman S Kurian N Rmadas P et al. incidence of nerve damage in leprosy patients treated with MDT. Int J Lepr Mycobact Dis. 1998;66:451-6.

14. Reddy PK Prabhudass N. Nerve damage in tuberculoid leprosy. Indian J Lepr. 1982;54:283-6.
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Publication:Journal of Pakistan Association of Dermatologists
Article Type:Report
Geographic Code:9PAKI
Date:Dec 31, 2014
Words:1649
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