A Study on Reaction States in Leprosy

Bharathi, S (2012) A Study on Reaction States in Leprosy. Masters thesis, Madurai Medical College, Madurai.


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INTRODUCTION : Leprosy or Hansen's disease is a chronic actively progressive granulomatous disease caused by Mycobacterium leprae, infectious in some cases and affecting the peripheral nerves , the skin and certain other tissues including reticulo-endothelial system, bones and joints, mucous membranes, eyes, testes, muscles, adrenals, etc. Named after the Norway physician Gerhard Henrik Armauer Hansen, who discovered the bacilli first in 1873, Mycobacterium leprae is the first bacterium to be identified as a human pathogen and it is the only species of mycobacteria to infect peripheral nerves and specifically Schwann cells. Leprosy is an ancient disease, which has existed in our community for a longtime. Leprosy today is not the `Leprosy’ of yesterday – a far off, little understood disease, during its long course, there may occur acute bouts of exacerbation, generally called as ‘Reactions’. Reactions are defined as `acute episodes occurring in an otherwise chronic course of infection’. It does not apply to the general progression or increase in the manifestations of disease. Remissions and relapse are the hallmark of reactions and these may last for a few weeks to few months. Leprosy reactions are immunological phenomenon that occurs before, during or after the completion of multi-drug therapy (MDT). They contribute immensely to the burden of leprosy and need to be diagnosed and treated early to prevent nerve function impairment and permanent disability. Reactions in leprosy are classified into Type-1 reaction, Type-2 reaction and Lucio phenomenon or Type-3 reaction .This study has been undertaken to determine the incidence and to study the clinical and histopathological features of lepra reactions in detail. AIM OF THE STUDY : 1. To study the incidence of different types of lepra reactions in various spectrum of leprosy. 2. To study the clinical & histopathological features of lepra reactions in detail. MATERIALS AND METHODS : This study on lepra reaction was conducted among the patients attending skin outpatient department, in Department of Dermatology, Govt Rajaji hospital, Madurai medical college, Madurai, during the period from Oct 2009 to Sep 2011. Permission from ethical committee of the hospital was obtained for this study. The patients were recruited for study with fulfillment of following criteria. Inclusion criteria: 1. Patients with clinical features suggestive of lepra reaction of any age and sex including both, leprosy patients presenting with lepra reaction for the first time and already diagnosed cases of lepra reaction presenting with recurrent episodes. Exclusion criteria: 1. Patients not willing for the study. 2. Treated cases of lepra reaction presenting with no active lesions at the time of examination. METHODOLOGY : HISTORY: A detailed history was taken which includes exacerbation of existing skin lesions, appearance of new skin lesions with duration, constitutional symptoms, systemic complaints, recurrence , neural pain , sudden onset of sensory loss or motor paralysis, onset of symptoms in relation to initiation of antileprosy drugs, and precipitating factors if any. CLINICAL EXAMINATION: A detailed general examination and systemic examination was done. Detailed dermatological examination was done which included number, morphology, distribution, symmetry, tenderness and sensation of skin lesions. Nerve involvement with thickening and tenderness, sudden sensory impairment and motor paralysis were noted. The clinical type of leprosy was assessed. INVESTIGATION: Routine lab investigation like urine routine, complete blood count, LFT, RFT were done. Diagnosis of type of leprosy was confirmed by SSS. Skin biopsy for histopathology study done for all patient. SUMMARY : 63 patients with clinical features of lepra reaction were included in the study. • 38 cases of Type 1, 25 cases of Type 2, no case of Type 3 reaction were observed. • Overall incidence of lepra reaction was 0.06%. • Mean age for Type 1 was 37.8yrs and mean age for Type 2 was 43.8yrs. • Male preponderance was observed with sex ratio of 2.9:1. • More number of BT patients had Type-I reaction and more number of LL patients had type II reaction. • Anti-leprosy drugs were found to be the most common precipitating factor followed by physical stress and intercurrent infection. • Erythema and swelling of the skin lesions, neuritis and edema of hands and feet were common features of Type I reaction. • Neuritis was most commonly seen in Type 1 than inType 2 reaction. • Sensory and motor deformities were seen in 46% and 20.6% of cases. • Crops of tender evanescent nodules, fever, joint pain, neuritis and edema of hands and feet were common in Type 2 reaction. • Pustular and ulcerative type of ENL lesions were present in signicant number. • Classical histopathological features were present in three fourth of cases. • Steroids are effective in 89% of Type 1 and 68% of Type 2 reaction. • BI was <3+ in Type 1 and >4+ in Type 2 reaction. CONCLUSION : TYPE 1 REACTION: Type 1 reaction was the most common type of reaction seen. The majority of the patients with Type 1 had BT hansen. Most of the patients developed it after 6-12 months of starting MDT and significant proportion of cases developed de novo. Antileprosy drugs were found to be the commonest precipitating factor followed by physical stress and intercurrent infection. Neuritis was the predominant clinical feature observed followed by erythema/swelling of the skin lesion and edema of hands /feet. Motor paralysis in form of foot drop, claw hand and facial palsy were significantly observed. Dermal edema with dispersed epitheloid granuloma were the predominant histopathological features observed. Exacerbation of Type 1 reaction was commonly observed during tapering of steroids [< 12 weeks]. Interesting observation of shift from BT to BL was observed in one case. TYPE 2 REACTION: Type 2 reaction was observed predominantly in LL and rarely in BL. Most of the patients developed it after 1-2 years of antileprosy drugs. Seven cases presented with ENL at their first visit [de novo]. Erythematous tender nodules, fever, edema of hands / feet and neuritis were the predominant clinical features. Rare variants of pustular and ulcerative ENL were also observed. Iritis and epididymo-orchitis were seen in few cases. Neutrophilic infiltration of dermis with panniculitis and vasculitis were the predominant histopathological features observed. Exacerbation and recurrence of Type 2 reaction were commonly observed after withdrawal of steroids [> 12 weeks], which insists the need for prolongation of steroids. There was a linear relationship in the risk of ENL with an increasing BI. An interesting observation in our study was, 3 patients primarily diagnosed as Histoid Hansen developed Type 2 reaction, which has also been observed in some recent studies. Early diagnosis, adequate treatment and proper follow up are very essential to prevent the deformities and systemic complications associated with lepra reactions.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Leprosy ; Reaction States.
Subjects: MEDICAL > Dermatology Venereology and Leprosy
Depositing User: Subramani R
Date Deposited: 02 Mar 2018 03:49
Last Modified: 03 Mar 2018 02:51
URI: http://repository-tnmgrmu.ac.in/id/eprint/5974

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