Answer

Leprosy

            Leprosy is a chronic granulomatous infection of the skin and the peripheral nerves.  It is characterized by damage to the mucous membranes, peripheral nerves, skin, and eyes (Bayal et al. 1). Similarly, Sanchez et al. (2), state that leprosy has the potential of causing long-lasting nerve damage as well as physical disabilities. The World Health Organization [WHO] adds that the disease affects the peripheral nerves, the skin, eyes and the mucosa of the upper respiratory tract (para. 1).

Etiology

            Leprosy is a debilitating form of skin disease caused by bacteria known as Mycobacterium leprae or Mycobacterium lepromatosis (Bayal et al. 1). M. leprae and M. lepromatosis belong to the M. leprae complex. The two species are classified as different species due to variation in their DNA sequences; however, they are both obligate intra-cellular organisms and share common features that leads to causation of the same clinical disease (Bhandari et al. 3). M. leprae complex are acid-fast rod-shaped bacilli (WHO par. 1).

History of the Disease

            In 1873, G. A. Hansen discovered M. leprae as the causative agent of leprosy. Notably it was the first bacterium to be identified as causing disease in man. However, treatment of the disease was not developed until 1940s with introduction of dapsone (WHO₁ para. 4). Leprosy is an aged-old disease that has been described in ancient literature to have ostracized families and communities (WHO para. 2). Leprosy has afflicted humanity for ages and it once affected all continents. It has left behind terrifying memories and images of exclusion from society, rejection, and mutilation in human history (WHO₁ para. 1). Leprosy has caused fear to humans for thousands of years; particularly in oldest civilizations of India, Egypt, and China (WHO₁ para. 2).

Eradication of leprosy as public health issue (less than 1 case in a 10,000 population) was accomplished in worldwide in 2000. Over 16 million leprosy patients have be managed using multidrug therapy (rifampicin, dapsone, and clofazimine) over the past 20 years (WHO para. 6).

Method of Transmission

            Leprosy is a highly contagious disease (Bhandari et al. 3). Transmission of leprosy has not been completely described; however, it is believed to be spread via respiratory means (Bhandari et al. 7). M. leprae grows in nine-banded armadillos, which are primarily found in South-Central United States. Apart from armadillos, mangabey monkeys, chimpanzee, and cynomolgus macaque can also harbor M. leprae (Bhandari et al. 4). Risk factors for the transmission of leprosy include close contact, armadillo exposure, old age and the young (5 – 15 years), genetic predisposition, and immunosuppression (Bhandari et al. 9-10).

Signs and Symptoms

            Lepromatous leprosy is characterized by development of many symmetrically distributed papules and nodules may also be present on the skin. If untreated the skin on the face thickens due dermal infiltrations resulting in the “leonine facies” (Bayal et al. 1). In tuberculoid leprosy, the skin develops few or one plague or lesions, which have well-defined edges (Bayal et al. 1-2). Hypopigmentation predominates over erythema in people with dark skin whole copper-color is often seen in lighter skin people (Bayal et al. 2).  The disease causes disability of the feet, hands, and eyes (Bhandari et al. 3).

Diagnosis

1. leprae and M. lepromatosis cannot be cultured in artificial media (Bhandari et al. 4). Diagnosis is major via physical assessment. Physical features that are evident of leprosy include lumps on the earlobes, paresthesias with numbness in the extremities, reddish skin patches with sensory loss, painless burns in extremities, and enlarged sensitized peripheral nerves (Bhandari et al. 15). Tests include skin biopsies and polymerase chain reaction. Evaluations demonstrate decreased hemoglobin, elevated leukocyte, low hematocrit, presence of elevated serum C-reactive protein, and increased liver function tests (Bhandari et al. 25-26).

Treatment

            Leprosy is a curable disease and treatment in early stages is necessary to prevent disability (WHO para. 1). Breakthrough in treatment of leprosy occurred in the 1940s, when dapsone was developed as anti-leprosy medication. Dapsone use required life-time compliance, which was difficult to adhere to.  However, resistance to dapsone was observed as from the 1960s. In the 1960s, clofazimine and rifampicin were discovered and added onto the treatment regimen of the disease. Combined use of dapsone, clofazimine and rifampicin was later termed as multidrug therapy for leprosy (WHO para. 3). In 1981, the WHO recommended multidrug therapy that comprised of medicines such as rifampicin, dapsone, and clofazimine. The drug regimen is taken for 12 months for multi-bacillary and six months for pauci-bacillary cases. The combined therapy eliminates the pathogen and cures the patient (WHO para. 4).

Upon successful treatment, relapses are often rare; however, neuropathy damage is irreversible and may necessitate lifelong care (Bhandari et al. 3). Other potential drugs include ofloxacin, minocycline, moxifloxacin, clarithromycin, and levofloxacin (Bhandari et al. 32). Once treatment has been started, hardening of lesions and general erythema should dissipate after some months (Bhandari et al. 33). Prognosis is leprosy depends on various factors including early initiation of treatment, stage of disease at diagnosis, compliance with therapy, and patient’s access to treatment (Bhandari et al. 42).

Prevention

            Bacille Calmette-Guerin (BCG) vaccine is considered to have partial protective effect against leprosy. BCG vaccine is administered at birth. Prophylaxis therapy include use of a single dose rifampin for children (>2years) and adults in endemic areas. The cultural stigma of the disease should be alleviated. Patient education should focus on diagnosis, prognosis, treatment, and complications of leprosy (Bhandari et al. 46).