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Lep > Leprosy > Flashcards

Leprosy Flashcards

1
Q

What are the organs not involved in leprosy?

A 
Uterus/Ovary
Lung 
urinary tract
prostate
CNS
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2
Q

Bacillary index?

A

Dead + Live bacilli

Cannot monitor response to treatment?

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3
Q

Is there a laboratory test used to diagnose leprosy?

A

No.

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4
Q

Once a patient completes multidrug therapy, the individual is usually removed from the registry and is no longer considered a case, even if disability and reactional episodes continue long after treatment.

A
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5
Q

Whoa has the highest number of leprosy cases in the world?

A

India

but brazil has the highest new case detection rate among all countries.

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6
Q

What are the 3 countries that collectively account for >80% of the global leprosy burden?

A

Brazil
India
Indonesia

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7
Q

There is an overall genetic resistance toward developing leprosy, with more than 90% of people having a natural immunity, with cell-mediated immunity being most important in preventing disease progression.

A
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8
Q

What has a strong immunologic response to prevent overt M. leprae infection?

A

Indeterminate leprosy

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9
Q

What kind of leprosy may last for months or years before moving to spontaneous cure or toward one of the poles or borderline forms of the clinical spectrum, depending mainly on the cell mediated immunity of the host against the bacilli?

A

Indeterminate leprosy.

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10
Q

Polar tuberculoid leprosy? (TT)

A

FITZ 9th:Well-defined plaques
usually a few in just one segment of the body
hypochromic and/or erythematous, sometimes atrophic, present with papules or tubercles that are mainly circinate on the periphery of the lesions

BOLOGNIA:
infiltrated plaques, often hypopigmented
one or few lesions (up to 5)
localized, ASYMMETRIC distribution
WELL DEFINED, sharp borders
ABSENT sensation
NO bacilli in lesions

FITZ 8th
immunity is strong as manifested by spontaneous cure
absence of downgrading to a posture of less host resistance
primary skin lesion: sharply marginated plaque, often annular secondary to peripheral propagation and central clearing
Typically, the lesion is firmly indurated, elevated, erythematous, scaly, dry, hairless and hypopigmented
a nearby sensory nerve may or may not be enlarged, but the lesion itself is characteristically anesthetic and anhidrotic
skin lesions are often solitary, particularly in those patients who are TT de novo, as contrasted to those who upgrade to TT from BT, where multiple lesions, usually no more than 3 may be found
Immunity is sufficient to affect cure, thus placing an upper limit of 10 cm on lesion size (<10 cm daw. confirm)

IM PLATINUM:
Strong cell mediated immunity, STABLE but does not downgrade
may undergo spontaneous cure in 3 years
less than or equal to 5 lesions, usually solitary, <10 cm in diameter
sharply marginated indurated erythematous plaque, often annular
scaly, dry, hairless, anhidrotic, anesthetic

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11
Q

What is a special self-healing type of tuberculoid leprosy?

A

Infantile nodular leprosy

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12
Q

Infantile nodular leprosy?

A

can be found as a single nodular lesion, but also as papules or plaques, usually on the face of the child

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13
Q

What are the five types of peripheral nerve abnormalities that are common in leprosy?

A
  1. Nerve enlargement
  2. sensory impairment
  3. nerve trunk palsies
  4. stocking glove pattern of sensory impairment (SGPSI) with a slow loss of type C fibers, involving heat and cold discrimination before loss of pain or light touch, beginning in acral areas (nose, ears, hands, feet, fingers and toes) and over time, extending centrally but initially sparing the palms
  5. anhidrosis on palms or soles
    - suggest sympathetic nerve involvement
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14
Q

What are the nerves that are enlarged in leprosy? (RUGS SPPT)

A
  1. Great auricular
  2. ulnar
  3. radial cutaneous
  4. superficial peroneal
  5. sural
  6. posterior tibial
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15
Q

What eliminates primary neural leprosy?

A

A positive acid fast bacilli result on slit skin smears eliminates primary neural leprosy.

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16
Q

Borderline tuberculoid (BT) leprosy?

A

FITZ 9th:
All borderline patients have skin infiltration, varying from a few to many lesions, in one or many areas of the body
Although tuberculoid leprosy patients have just papules or tubercles with no infiltration, borderline-tuberculoid leprosy presents a CLEAR INFILTRATIVE BAND around the periphery of the lesions, changing from a very sharp border in tuberculoid leprosy to a A MORE DIFFUSE INFILTRATED OUTER LAYER in borderline-tuberculoid leprosy

FITZ 8th:
immunologic resistance is strong enough to restrain the infection, in that the disease is limited
That the disease is limited and bacillary growth retarded, but the host response is INSUFFICIENT to self-cure
These patients are somewhat UNSTABLE– resistance may increase, upgrading to TT, or decrease, downgrading to BL
Primary skin lesions: Plaques and Papules

An annular configuration is common and both disorders are sharply marginated but annular lesions or plaques may have SHARPLY MARGINATED SATELLITE PAPULES

In contrast to TT: there is little or no scaling, less erythema, less induration, and less elevation, but lesions may become much larger, that is well over 10 cm in diameter, a single lesion sometimes involving an entire extremity over time

Multiple, asymmetric lesions are the rule, but solitary lesions are not rare

Impairment of sensation in skin lesions is the rule
and nerve trunk involvement,
enlargement or palsies, usually in no more than 2 and asymmetric, are common

nerve abscesses, when they occur, are most often seen in males with BT disease

BOLOGNIA:
type of lesions: infiltrated plaques
number of lesions: single, usually with satellite lesions, to more than 5
distribution: asymmetric
definition: well-defined sharp borders
sensation: ABSENT
bacilli in skin lesions: few (1+), if any, detected

IM plat:
-immunity strong enough to contain infection, unstable (upgrades or downgrades)
-multiple, asymmetric
annular plaque with sharply marginated borders and satellite papules in and outside the lesion
Compared to TT, lesions are larger, but less scaly, erythematous and indurated
Hypoesthetic skin lesions with 1 or 2 nerve trunk enlargement/palsies

17
Q

Borderline- borderline (BB)?

A

immunologic midpoint or midzone of the granulomatous spectrum, being its most unstable area, with patients quickly up or downgrading to a more stable granulomatous posture with or without a clinical reaction.

Characteristic skin changes: annular lesions with sharply marginated interior and exterior margins
large plaques with islands of clinically normal skin within the plaque (SWISS CHEESE) or the classic dimorphic lesion

because of instability, the BB posture is short lived and such patients are rarely seen.

CLASSIC FOVEOLAR LESIONS

BOLOGNIA

  • plaques and dome-shaped, punched-out lesions
  • number of lesions: many
  • distribution: evident asymmetry
  • less well defined borders
  • DIMINISHED sensation
  • many bacilli in skin lesions

IM platinum:

  • immunologic midzone, easily upgrades or downgrades, (+) lepra reactions
  • Large, well delineated annular plaques with islands of normal skin with the lesion or swiss cheese appearance
18
Q

Borderline lepromatous? (BL)

A
  • resistance is too low to significantly restrain bacillary proliferation, but still sufficient to induce tissue destructive inflammation, especially in nerves.
  • BL patients have the worst of both worlds.
  • the BL category is highly variable in its clinical expression.
  • Although seen in only a third of BL patients, the classic dimorphic lesion is the most characteristic, having an annular configuration with a poorly marginated outer border (lepromatous like) but a sharply marginated inner one (tuberculoid like), hence, having both morphologies thus “dimorphic leprosy”

variation may be considerable in one patient and even greater across the entire BL population

  • poorly or sharply marginated plaques with “punched out” or “swiss cheese” sharply marginated areas of normal skin in the interior of the plaque are also characteristic, and can be thought of as a variant of the classic dimorphic lesion
  • annular lesions with sharply marginated exterior and interior borders are not uncommon
  • lepromatous-like, poorly defined papules and nodules may be numerous, but are usually accompanied by sharply marginated lesions elsewhere
  • lesions range in number from solitary to numerous and widespread
  • generally, the annular and plaque lesions are asymmetrically distributed, but the lepromatous-like nodules, if numerous, are symmetric
  • skin lesions are often hypesthetic or anesthetic, but not necessarily so
  • NERVE TRUNK PALSIES have the highest prevalence in BL disease, but are variable in number (ranging from none to serious neurologic deficits, both motor and sensory, in all four extremities)
  • involvement of both median and ulnar nerves, not infrequently bilateral, is characteristic.
  • When disease is extensive, BL patients may also develop stocking and glove pattern of sensory impairment
  • untreated BL patients have slow relentless progression of skin and nerve changes
  • with or without treatment, this course may be altered by a reactional state, UPGRADING OR REVERSAL REACTIONS being more common than erythema nodosum leprosum (ENL)
  • also, BL patients may silently downgrade to an LLs granulomatous posture
BOLOGNIA:
type of lesions: Macules, papules, plaques, infiltration
Number of lesions: many
Distribution: tendency to symmetry
Definition: less well defined borders
Sensation: DIMINISHED
Bacilli in skin lesion: many

IM Plat:

  • low immunity to contain infection resulting in destructive inflammation
  • numerous widespread nodules and classic dimorphic lesions: annular plaques with a sharply marginated inner border and poorly marginated outer border or “inverted saucer”
  • hyper/hypoesthetic skin lesions
  • multiple nerve trunk palsies
  • stocking-glove pattern of sensory impairment
19
Q

Lepromatous leprosy (LL)

A

FITZPATRICK 8th

  • diminished CMI toward M.leprae
  • permits unrestricted bacillary replication and widely disseminated, multiorgan disease
  • DIFFUSE DERMAL INFILTRATION IS ALWAYS PRESENT subclinically and may be overtly manifested by
  • enlargement of ear lobes
  • widening of the nasal root
  • fusiform swelling of the fingers
  • skin being thrown into folds
  • poorly defined nodules: MSOT COMMON LESIONS
  • poorly defined nodules are usually up to 2 cm in diameter and are symmetrically distributed

LEONINE facies- conjunction of skin folding and nodule formation

HISTOID LEPROSY

  • dermatofibroma-like or histiocytoma-like lesions
  • usually multiple
  • sharplly marginated erythematous appules or nodules, sometimes confluent onto plaques
  • less common presenting skin lesions include digitate, barely indurated patches of erythema, which in light -skinned patients are sometimes followed by a mild hyperpigmentation, a veil of melanin concealing the erythema; in dark-skinned patients multiple hypopigmented macules may be seen. Also, rarely, a dense dermal infiltrate may mimic a nevoid lesion.
  • A clinical clue of LLs:
    • sharply marginated region in a lesion (perhaps the residual of a BL lesion in a patient who has downgraded to LLs, or the presence of DERMATOFIBROMA-like lesions
  • hair loss is most common in the eyebrows (Madarosis)- where it may progress medially to laterally or be patchy
  • hair loss may also occur on the eyelashes and extremities, and may be partially reversible if treated early.
  • scalp involvement is are.
  • loss of eccrine sweating from sympathetic nerve involvement is common, as manifested by dry palms or soles.
  • any given skin lesion may or may not be hypoesthetic but generally, in each patient, some are.
  • nerve trunk palsies occur, but are LESS COMMON than in BL
  • The stocking glove pattern of sensory impairment is common and may be so severe as to lead to debilitating trophic changes of the hands or feet

BOLOGNIA
Types of lesions: macules, papules, nodules, diffuse infiltration
Number of lesions: numerous
Distribution: symmetric
Definition: vague, difficult to distinguish normal versus affected skin
Sensation: not affected
Bacilli in skin lesions: may (globi)

20
Q

Untreated LL disease is relentlessly progressive, but this course may be altered by reactional states.
LLs and LLp subjects frequently develop erythema nodosum leprosum (ENL)

A

LLp patients do not develop reversal reactions, whereas LLs patients may

21
Q

Indeterminate leprosy

A

BOLOGNIA:
types of lesions: macules, often hypopigmented
number of lesions: one or few
Distribution: variable
Definition: not always defined
Sensation: impaired
Bacilli in skin lesions: usually none detected

Fitz 8th
- early lesion appearing before the host makes a definitive immunologic commitment to a curative or overt granulomatous response
Clinically: hypopigmented macule or patch
- with or without an associated sensory deficit in or near the defect and
- AFB if found are present in very small numbers. such lesions are rare
- the term is sometimes used, to describe lesions rich in bacilli but having neither typical tuberculoid nor lepromatous histoloigcal patterns.

22
Q

world leprosy day?

A

last sunday of january

23
Q

What is the sensation lost in leprosy?

A

Temperature, light touch, then pain

24
Q

Multibacillary leprosy treatment?

A

For adults the standard regimen is: Rifampicin: 600 mg once a month
Dapsone: 100 mg daily
Clofazimine: 300 mg once a month and 50 mg daily

Duration= 12 months.

25
Q

paucibacillary leprosy treatment?

A

For adults the standard regimen is: Rifampicin: 600 mg once a month Dapsone: 100 mg daily Duration= six months

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