Download MBBS Dermatology PPT 15 Leprosy Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Dermatology PPT 15 Leprosy Lecture Notes

LEPROSY

Cardinal signs of Leprosy

? 1. Anaesthetic/hypoaeshetic skin lesion or lesions
? 2. Enlarged peripheral nerve\s with impairment of sensations in the

area supplied

? 3. Acid-fast bacilli in the slit skin smear

? Any one of these signs is sufficient for diagnosis of leprosy. Two of

them are clinical. Therefore clinical skill of the health care worker is

important for diagnosis of leprosy.
Exclusion criteria for diagnosis of leprosy

? White (de-pigmented), dark red or black in colour
? Scaly lesion (regressed type 1 lepra reaction lesion may show scaling)
? Present since birth
? Seasonal or appears and disappears suddenly
? Hurts (discomfort may be felt in leprosy reaction )/ itches
? Presence of sweating
Current WHO classification.

MB; Multi bacil ary. PB; Pauci bacil ary.



Criteria





MB

> 6 skin lesions, or



Positive bacterial

index

PB

5 skin lesions





and

Negative bacterial

index

Leprosy Spectrum

CMI+Ab-ve

CMI?ve, Ab+


? Il -defined patch of

indeterminate leprosy

RIDLEY-JOPLING

CLASSIFICATION
RIDLEY JOPLING CLASSIFICATION

Tuberculoid leprosy (plaque type)

-Single or 2 or 3
-Erythematous or coppery
-Dry surface, hairless
-Raised well defined edge with sharp outer

margin and sloping inside & tendency of

central flattening

-Sensation(touch, temp. pain) : absent
-Feeding nerve to the patch or solitary

peripheral nerve may be thickened

-AFB: negative
Lepromin: +++


TT

? WELL DEFINED RAISED OUTER

BORDER OF A TT LESION .

? ENLARGED GREATER AURICULAR

NERVE

? INVOLVEMENT OF EAR

BT

? Large patches of BT leprosy

? SATELLITE LESIONS
BB Leprosy (macular, plaque, inverted saucer

shaped)

? Several number, bilateral but

asymmetrical distribution

? Variable size, sloping outer edge &

central punched out area

? Sensation: slightly diminished
? Slightly shiny
? Asymmetrical many nerve thickening
? AFB: moderate 2+to3+
? Lepromin: negative

Inverted saucer-shaped lesion of BB


LL (Fine to course infiltration)


? BILATERAL LOSS OF EYEBROWS ,

MOUSTACHE & BEARD

? glove & stocking distribution of

neuropathy.


Pure neuritic leprosy

HISTORY TAKING

?

Primary goal of history taking is to establish the diagnosis by excluding

other conditions simulating leprosy. History should be taken

according to the fol owing steps, mostly like any other medical history;

? ? Personal identification and demographic data.

? ? Presenting complaints.

? ? History of present il ness.

? ? Past history.

? ? Family history.

? ? Personal history.
Various presenting features of leprosy



IN ABSENCE OF REACTION

1.Skin lesions:; hypopigmented / erythematous, hypoaesthetic patches, skin-coloured / erythematous



papules,plaques nodules, which may be waxy ? umbilication.



2. Hypoaesthesia along distribution of peripheral nerves / gloves and stockings hypoaesthesia
3. Spontaneous blisters and ulcers on the hands and/ or
feet

4.

Trophic changes ; dryness, ichthyosis, fissuring / trophic ulcer

5.

Diffuse swelling of hands and feet ( early sign of lepromatous leprosy / leprosy reactions)

6.

Nasal stuffiness, epistaxis (early sign of lepromatous leprosy)

7.

Irregular thickening of ear and nodules on face (lepromatous leprosy)



WH I LE IN REACTION

1. Tingling and numbness of hands and/ or feet



2. Sudden w eakness of hands and/ or feet / inability to close eyelids

3. Sudden redness, swelling and pain of existing lesions and / or appearance of new lesions with or without

constitutional symptoms (type 1 reaction)

4. Sudden appearance of crops of evanescent, erythematous, painful nodules on apparently normal looking skin

with or without constitutional symptoms (erythema nodosum leprosum / type 2 reaction) / type 2 reaction)

5. Painful swelling on the dorsal aspect of wrists (tenosynovitis)

6. Acute scrotal pain (epididymo-orchitis)


7. Pain in and around eyes, redness, photophobia or diminished vision (iridocyclitis)



IN PRESENCE OF DEFORMITY

1.

Inability to use hands for precision works; e.g., button a shirt, eating rice with hands, typing, etc;



2.

Inability to make a power-grip; e.g., holding a rod, carrying utensils.

3.

Inability to wear slipper.

(al these are indicative of peripheral anaesthesia and poor functioning of smal muscles of hands and feet).



Looking for other organ involvement in leprosy

Table 10.2: Looking for other organ involvement in l

ORGAN

SPECIFIC QUESTIONS TO BE ASKED

Eye

Difficulty in eye closure? (Lagophthalmos)




Red eye with pain, watering and sticky discharge? (Corneal ulceration)

Red eye with pain, photophobia and diminished vision? (Iridocyclitis)

Localized redness, severe radiating pain to temporal region, normal/ slightly reduced vision? (Scleritis)

Localized redness, mild pain, normal vision? (Episcleritis)



Upper respiratory tract

Unable to perceive smel of food and scented materials? (Anosmia)

Nose is blocked with occasional bleeding?

Change of voice, chronic cough, and occasional breathlessness? (Laryngeal involvement)

Any episode of acute respiratory distress? (Laryngeal oedema)



Cardiovascular system*

Palpitation?

Dyspnoea on exertion?

Swelling of feet?



Adrenal glands**

Features of adrenal insufficiency? e.g., hypotension, asthenia, prostration

Male reproductive system

Normal / diminished libido? (Testicular atrophy)

Enlarging male breasts? ( Testicular atrophy)

If married, whether having children? (Sterility)




*Cardiovascular involvement in leprosy is very rare and rarely gives rise to symptoms. Involvement of peripheral blood vessels, though frequent, is rarely symptomatic.

** Adrenal suppression is very rare in leprosy. However, it may occur rarely during an episode of T2R..




? RR in a case of BT leprosy,

(left), RR in a case of BB leprosy

(Right), note the shiny erythematous

and oedematous plaques.

? BT lesion with type 1 reaction


? ENL in a case of LL. Note the

shiny erythematous papules

and nodules (usual y tender)

over face and thighs. The

lesions are evanescent and

usual y associated with systemic

features like fever, malaise,

joint pain etc.

? NODULES OF ENL


? Spontaneous blister on finger

? Cal osity over lateral mal eolus

(pressure point)


? Trophic ulcer

? partial or ulnar clawhand


? Bilateral complete claw hands

with guttering of dorsal

? interosseous spaces and

cal osities on interphalangeal

joints.

? A case of Bell's palsy (right side).

The facial paralysis in leprosy

involves upper part of face (due to

selective involvement of

zygomatic branch of facial nerve

by a leprosy lesion in the vicinity).

In Bell's palsy the involvement of

facial nerve is higher up, due to

oedematous compression in facial

canal, affecting al branches,

leading to paralysis of both upper

& lower parts of face.


? Secondary ichthyosis in

lepromatous leprosy with

brownish discoloration of the

scales due to clofazimine.

? LAGOPHTHALMOS
Lagophthalmos- inability to close the eyes , is in direct

proportion to the extent of damage to facial nerve
If the eyes cannot be closed regularly by normal blinking, or if

the eyes are not closed while sleeping , then the eyes are at risk

of exposure keratitis

CLINICAL EXAMINATION

? Clinical examination involves the following steps:
? 1. General physical examination
? 2. Cutaneous and mucosal examination
? 3. Ocular examination
? 4 Palpation of peripheral nerves and testing for sensory impairment.
? 5. Examination of musculoskeletal system
? 6. Examination of external genitalia
? 7. Other systemic examination, wherever indicated.
Precautions for examination of skin lesion

?

Examine patient under good light (preferably natural light)

?

Provide privacy to the patient

?

Examine the whole skin from head to toe as much as possible.

?

Always use the same order of examination, so that you do not forget to

examine any part of the body.

?

Ensure presence of an assistant of the same sex as that of the patient to assist

you. Especially, if the patient is of the opposite sex.

? A quick general cutaneous survey should be done followed by

examination of individual skin lesions.

? Prior explanation to the patient along with gaining his / her

confidence is of immense importance in achieving patient

cooperation.


? DIFFUSE COARSE INFILTRATION OF THE SKIN- LL

? MORE SEVERE INFILTRATION

WITH NODULAR LESIONS

(LEONINE FACIES)


LL (Leonine face)

Lepromatous nodule on tongue and palate

(same pt.)


? Oedema of hands and feet in a

patient with

untreated LL


? Recommended sensory testing

sites (WHO) on palms and soles

OCULAR EXAMINATION

? Tested by-

- fine wisp of cotton

- lightly blowing a puff of air into each cornea (Hutchison's 21 ed)
- aesthesiometer (fine filament ?calibrated)
- observing infrequent blinking (because the stimulus for eye closure

is decreased)


? TESTING CORNEAL SENSATION

PALPATION OF PERIPHERAL NERVES

? Clinician should be well aware of the specific sites / bony land-marks

along which the peripheral nerves commonly involved in leprosy are

to be palpated, as well as the area of distribution of sensory nerves.

? Nerve palpation should be gentle (using pulps of fingers rather than

tips) to avoid causing pain to an inflamed nerve (neuritis).


Nerve

Site / bony landmark

Patient position

Method

Head & Neck
Supraorbital

Supraorbital notch at the junction of medial 1/3rd and

Sitting / standing with

Palpate with both thumbs on both sides (Fig 38)

lateral 2/3rd of supraorbital ridge

head kept straight.

Supratrochlear

Medial to the supraorbital nerve

Same as above

Same as above



Infra orbital foramen, just below the medial part of inferior Same as above

Same as above

orbital margin

Infraorbital

Branches of facial nerve:







Zygomaic & temporal.

Zygomatic arch

Same as above

Same as above











Great auricular

Lateral side of neck, crosses sternomastoid muscle, from

Sitting / standing with head turned completely to

Easily visible, crossing sternomastoid obliquely. May be palpated with 2 fingers

lateral side to infra-auricular area.

opposite side

Clavicular

Shaft of clavicle

Sitting / standing straight

Fingers rol ed along the shafts of both clavicles

(3 sets)

Upper extremity




Sitting / standing with elbow flexed at 90?.





Spiral groove on humerus, posterior to the deltoid

Examiner's right hand holds patient's right hand in Examiner's left fingers rol the nerve in the radial groove.

insertion.

shaking-hand manner (& vice versa).

Radial







Examiner's left little finger locate the nerve in the groove; other fingers palpate

the nerve upwards along medial aspect of arm (Fig 39).



Ulnar groove on medial epicondyle of humerus, medial to

Same as above.

the point of elbow.

Ulnar

(Both the nerves may be palpated simultaneously
for better comparison)



Lateral border of radius, just proximal to the wrist;

Same as above.

Examiner's left fingers rol the nerve against radius (Fig 40). It can be further

thereafter along the proximal part of extensor pollicis

traced and rol ed from side to side on extensor pol icis longus tendon &dorsum



longus tendon, which stands out prominently on ulnar side Patient is asked to extend the thumb to visualize of hand.

of the anatomical snuff box

the anatomical snuff box.

Radial cutaneous











Proximal to the flexor aspect of wrist joint (proximal to

Sitting / standing with elbow flexed at 90?, &

Examiner's right fingers palpate the nerve deep between the tendons.

flexor retinaculum), between the tendons of palmaris

wrist in supination. Examiner's left hand

Median

longus and flexor carpi radialis

stabilizes patient's right hand and vice versa

? Palpation of supraorbital nerve

with; fingers are used to

stabilize the head.


? Palpation of radial cutaneous

nerve.

? Palpation of ulnar nerve


? Palpation of lateral popliteal

nerve.

? Palpation of sural nerve.


? Palpation of posterior tibial

nerve.

? Sensory distribution of feet by

various nerves


? Sensory distribution of HANDS

by various nerves

? Terminal branches of facial

nerve


MUSKULOSKELETAL

SYSTEM EXAMINATION

? Z THUMB DEFORMITY


? Ochsner's clasping test with

pointing index.

? Pen test.


? Book test with positive

Froment's sign (right side

? Positive Wartberg's sign:

earliest evidence of

ulnar nerve palsy
Examination of External Genitalia

? genitalia of both male and female patients should be inspected for presence of skin

lesions

? in male patients, testicles should be palpated gently to see for:

? ? Size and consistency:

? Whether the testicles are firm, resilient and of appropriate size or smal and soft (sequel

of advanced disease and / or repeated type 2 reaction).

? ? Testicular sensation:

? If absent, indicates fibrosis resulting from repeated episodes of epididymo-orchitis

(type2 reaction).

? ? Tenderness:

? Acute testicular pain indicates epididymo-orchitis, a part of type2 reaction and this may

be the presenting feature of type2 reaction.

OTHER SYSTEM EXAMINATION

? Upper respiratory tract is the most common site of involvement.

Though several other organs are involved in lepromatous leprosy and

also during type 2 reaction, clinical manifestations of such

involvement are unusual

? A hoarse voice, dry, hacking cough and occasional breathlessness are

indicative of laryngeal involvement and or uvular dysfunction


LEPROSY (QUICK FACTS)
Pole Tuberculoid Lepromatous
Skin

Localized lesion,

Symmetric diffuse lesions,

hypopigmented, raised

papules/macules/nodules,

erythematous margins

massive tissue destruction

Nerves

Epitheloid granulomas

Poorly organised

granulomas, vacuolated

M, few T cells

M.Leprae

Rare

Abundant

Classification
WHO

Paucibacillary Multibacillary

RIDLEY-JOPLING
Immunology

TT

BT

Borderline

BL

LL

Adaptive

Th1, cell mediated, IL-2, IFN- TH2, Humoral mediated,
IL-4, IL-10

Innate

? ?
Thank you!