Comlication of leprosy

ESTHER NIMISHA

1) LEPROSY REACTION

2) ADVERSE EFFECT OF ANTI-LEPROTIC DRUGS

3) DISABILITIES & DEFORMITIES

4) PSYCHO-SOCIAL PROBLEMS

-acute episodic exacerbation & remission of symptoms and signs of inflammation during active stage of leprosy & directly related to leprosy.

-reactions are due to heightened immunological response of the host to M.lepre or its breakdown products.

-two types:a) type 1 b) type 2

-due to rapid change in CMI either for better or for worse.

-seen in BT,BB & BL.

-also called upgrading or reversal reaction due to rapid increase in CMI as better response to t/t.

-due to antigen-antibody reaction in presence of complment and not due to change in CMI

-it is seen in LLp & LLs and rarely in BL

-treat neuritis

-rest to the part affected

-analgesic

-if severe then steroid (anti inflammatory doses) can be given

-if tenderness and thickening of nerve persisting,perineural infiltration with triamcinolone.

-bed rest

-analgesics and antipyretics

-systemic steroid ,starting at 40 mg/day ,tapering at 2 wks interval

-oral thalidomide (300-400 mg/day),tapering after the lesion subsides

DRUGS MINOR MAJOR

1. RIFAMPICIN RED URINE JAUNDICE

GIT UPSET HEPATITIS

FLU LIKE SYNDROME SHOCK

2. DAPSONE GIT UPSET DAPSONE SYNDROME

DRUG RASH EARLY SJS

ANAEMIA HEMOLYTIC ANAEMIA

AGRANULOCYTOSIS

3. CLOFAZAMINE GIT UPSET ACUTE PAIN ABDOMEN

DISCOLOURATION OF SKIN

ICHTHYOSIS

Disabilities such as loss of sensation and deformities of hands/feet/eyes occur because:◦Late diagnosis and late treatment with

MDT◦Advanced disease (MB leprosy)

◦Leprosy reactions which involve nerves

◦Lack of information on how to protect insensitive parts

The affected person finds it difficult or impossible to perform some activities at home or at workplace b/c of some impairment.

Only about 10-15% of leprosy affected person develop significant deformities and disabilities.

1) Specific deformities: - b/c of local infection with M.Leprae

- seen most often in the face(loss of eyebrow,nasal deformity),less often in the hand and only occassionly in the feet.

2) Paralytic deformities: - result from damage to motor nerve.

-seen most often in the hand(claw finger),less often in the feet &occassionly in the face(lagopthalomos,facial palsy)

3)Anesthetic deformity :

- Occur as a consequence of neglected injuries in part rendered insensitive b/c of damage to sensory nerve.

- Found most often on the feet and hand(ulceration,scar contrature,shortening of digits,multilation &skeletal disorganization of foot)

GRADE HAND & FEET EYES

0 NO DISABILITY FOUND NO DISABILITY FOUND

1 NON VISIBLE DAMAGE (LOSS OF SENSATION)

NO GRADE 1 FOR EYE

2 VISIBLE DAMAGE(wounds,ulcer,deformity due to muscle weakness,loss of tissue such as foot drop,clawhand,loss or partial resorption of fingers/toes)

Inability to close,obvious redness,visual impairement,blindness.

1)STAGE OF PARASITIZATION- A few M.leprae found in the nerve,but no other damage2)STAGE OF TISSUE RESPONSE- Bacilli recognised, host tissue response present.range

from indeterminate through tuberculoid and borderline to lepromatous

3)STAGE OF CLINICAL INVOLVEMENT-Nerve clinically thickened with or without associated

pain or tenderness.-no nerve funtion deficit (NFD)detected clinically- -

4)STAGE OF NERVE DAMAGE-clinically detectable NFD present,Recovery

possible.

5)STAGE OF NERVE DESTRUCTION-conducting elements destroyed-irreversible NFD-long standing muscle paralysis with severe

wasting.

Refer to all the action taken to achieve the sole aim of preventing damage to nerve trunk of the limbs and the eyelids & thereby prevent permanent loss of sensibility and muscle paralysis involving these part.

M/n can be divided into;a)No neuritis and no NFDb)With neuritis but no NFDc)With no neuritis but with NFDd)With neuritis and NFD

a) NO NEURITIS,NO NFD

-Pt has no problem at present & so no active nerve care is necessary.

-but,if there is risk of developing neuritis(BB or BL leprosy with thickening of more than two nerve trunk and past history of reaction or neuritis),pt should be warned of that possibility & asked to report without delay.

b) NEURITIS PRESENT,NO NFD-In case of moderate neuritis,start with 30 mg

prednisolone daily and then reduce the dose by 5mg/wk.

-In severe cases,higher dose(40,60,even 80 mg per day depending on severity),bring the dosage to 30 mg in course of 2-3 wk & maintain the dose for 3 month before tapering the dose down.

-In BT cases,if there is no improvement within 24-72 hrs of starting t/t or if condition worsens,despite steroid,it suggest that drug is not reaching site of inflammation b/c of ischemia,immediate surgical decompression should be done.

-in BL& LL,where ENL is likely cause of neuritis,one can wait for 6wk &consider decompression,if there has been no significnt clinical improvement.

c) NO NEURITIS,NFD PRESENT-M/n depends on;1)Whether the NFD is capable of recovery.2)Depends on anti leprosy t/t status of the pt.

-Recovery will not be possible if nerve has been destroyed by inflammatory process.

-Recovery may be possible if NFD is of recent onset,incomplete&no obvious and severe muscle wasting.

a) No neuritis,NFD present &considered irreversible;

M/m:Ignore NFD .train the pt in disability prevention practice,provide physiotherapy & reconstructive surgery ,if possible.

b) No neuritis,NFD present but considered reversible,pt has had MDT

M/m:start with 30 mg of predinosolone daily for 90 days or as long as NFD shows improvement,tepered off over 30 days.

c)No neuritis,NFD present but considered reversible,pt has not had MDT

m/n:provide MDT and monitor NFD (In many cases nerve function improves with anti leprosy chemotherapy)

- If NFD has not improved in 3 month,start standard course of steroid.

- Continue with steroid as long as improvement continues,taper off steroid after 3 mnth or wen there is no further improvement.

d)NFD present,considered reversible,onset or worsening of NFD while under MDT

-start standard course of steroid.-monitor NFD monthly.-continue with the steroid as long as

improvement continues,taper off steroid after 3 mnth or when there is no further improvement which ever is later.

d)NFD present,neuritis presentm/n;start high dose of steroid(40-80 mg /day)-reduce to maintence dose (30 mg/day)over

2-4 wks or continue as long as there is improvement or for at least 3 mnth whichever is later,then taper off,

-surgicl decompression need to be done, if there is no significant improvement in neuritis with 3-7 days of starting steroid.

-Nerve trunk thickens in leprosy:a)Accumulation of granuloma cell within the

fascicle,b)Thickening of neural investment,

-Two consequence result from excessive enlargement of nerve:

a)External compression b)Internal compression

It is indicated:

- when medical &ancillary method are being used &found inadequate to control the inflammatory process,

- other indication is intractable nerve pain where continues steroid therapy has become neccessary just for relief of pain,

-In most cases,these are cold abscess with caseation and colliquative necrosis,

-’hot abscess’ occur in ENL related acute neuritis& are usually microscopic,

a)If nerve shows no NFD:w/w.Evacuate the abcess &excise only if overlying skin is likely to breakdown &form sinuses,

b)If nerve considered irrecoverable damaged:same t/t

c)If NFD considered likely to recover:evacuate &excise the abscess

impairment Direct consequence Late consequence

Damage to somatic sensory fibers

Loss of sensibility Anesthetic deformity(ulcer,hand deformity,shortening of digits)

Damage to motor nerve

Muscle paralysis and paralytic deformity

contrature

Damage to sudomotor autonomic fibers

Dry skin Deep cracks,hand infection

Lepra rkn Inflammatory edema,osteoporosis, pathological fracture

Severe fixed deformity(intrinsic plus finger,bizarre deformity)

1) LOSS OF SENSIBILITY-pt is deprived of an important source of

information-deprives the hand of its protective mechanism-motor activity becomes clumsy.2) DRYNESS OF PALMER SKIN-due to destruction of autonomic sudomotor

fibers;-dry skin crack frequently especially at digital

creases,

Cracks and fissures

Injury care

Soak in water Apply cooking

oil/Vaseline

-Precaution against burn- Against cut

&penetrating wound-covering with thick

towel.-using utensils with

insulated handle

c) PARALYTIC DEFORMITIES OF THE HAND-occur due to destruction of motor fibers in

the major nerve trunk.

ULNAR PALSY-occur when lumbrical &interossei muscles ,

which balance long extensor & flexor at the MCP and PIP jt are paralysed.

-when both ulnar and median nerve are paralysed, pt has total claw hand(intrinsic zero hand)

-it lies curled up beside the palm

-it doesnot lift off the palm to oppose the other digits

a) PHYSICAL MEASURES- best exercise to put all jt thr’ their range of

movement several times a day.

b) SPECIFIC EXERCISE- to hold his clawed finger with his thumb

and index finger in total flexion at MCP jt and move PIP jt up and down.

1) ADDUCTOR BAND SPLINT2) GUTTER SPLINT3) FINGER LOOP SPLINT

GRIP –AIDS- Epoxy resin grip applied on article of work

helps ,hold the object & increase efficiency in working environment.

1) LASSO INSERTION-attaching the motor tendon slip distally to

the fibrous flexor sheath provide correction by augmenting flexing force at MCP jt to counter extending force.

2) ZANCOLLI’S OPERATION-shortening anterior capsule of the jt and

flexor pulley advancement

1) PLANTER ULCERATION2) DROP FOOT3) FIXED DEFORMITY OF TOES & FEET4) TARSAL DISORGANIZATION PLANTER ULCER-found in 10% of leprosy pt.-80% cases occur in ball of foot at MTP jt

region-5-10% in the mid lateral part of sole.-5-10%in the heel.

1) INJURIES FROM WITHOUT2) INFECTION THROUGH A FISSURE IN THE SKIN3) BREAKDOWN OF TISSUE FROM WITHIN(DUE

TO WALKING) STAGES IN THE DEVELOPMENT OF ULCER:

1)STAGE OF THREATENED ULCERATION2)STAGE OF CONCEALED ULCERATION3)STAGE OF OPEN ULCERATION

1)STAGE OF THREATENED ULCERATION:-foot should be rested in a splint-no wt bearing on the affected foot2)STAGE OF NECROSIS BLISTER:-blister is padded well-if danger of breaking open,it is snipped & sealed

with adhesive plaster and a below knee POP.-cast removed after 3 wks & asked to use

protective footwear.

1)ACUTE ULCER:are frankly infected,purulent, covered with slough and are acutely inflammed.

2)CHRONIC ULCER:indolent ulcer with heaped up hyperkeratotic edge,serosanguineous discharge & covered with pale granulation tissue.

a)SIMPLEb)COMPLICATED

ACUTE ULCER: -absolute bed rest -elevate the foot -Eusol bath,irrigation,dressing -limit surgery to drinage proced -antibiotic if needed -treat as chronic ulcer after acu te phase subside.

1) SIMPLE : -Scraping floor of the ulcer -sticking plaster or vaseline gauze

dressing. -below knee POP cast or bulky dressing. -protective footwear+foot care trainig.

COMPLICATED: -Ulcer debribment -physiological rest by below knee POP cast -protective footwear on POP removal -corrective deformity,if necc. -identify other complication & treat accordingly -skin graft of large ulcer.

RECURRENT: - improve quality of scar(scar rev ision using exision and suture local flap,distant flap,free flap)

- reduce load on scar by footwear modification or corrective surg

-eradicate infection.

1) PROTECTIVE FOOTWEAR:-should have a tough outer sole that will

resist penetration by thorn,nails,glass,-itself doesnt have any nails,-upper/straps and buckle should not rub

against the toes or cause undue pressure,-MCR(microcellular rubber ) m/c used for

reducing the stress generated during walking.

Infected ulcer/Cracks

Wounds/injury

weakness/paralysis

Clean with soap & water Rest & apply antiseptic

dressing Apply cooking oil/Vaseline

Soak in water Clean and apply clean

bandage Protect when working/cooking

Oil massage Exercises

-about 1-2% of leprosy pt develop drop foot due to damage to common peroneal nerve.

-pt is unable to lift the foot up & it droops down when the leg is lifted.

-if paralysis is recent,good recovery with steroid.

-drop foot (>1yr), unlikely to recover with steroid therapy & require surgical correction.

SRINIVASAN OPERATION:-Two tailed transfer of tibialis posterior to the

tendon of extensor hallucis longus & extensor digitorum longus in the dorsum of foot.

-when surgical correction are C/I, a drop foot appliance can be used which hold the foot at rt angle with the help of strap,stops or springs.

-One or more tarsal bone are damaged & progressively destroyed.

- firstly,due to spread of sec infection from plantar ulcer,

-calcaneum and cuboid are commonly damaged.

-can be t/t with appropriate antiboitics & surgical clearance of infected tissue, healing takes place with bony fusion and stable foot.

-secondly, occur as a result of injury,weakened by osteoporosis from neighbouring infection or prolonged immobilisation.

-Talus and navicular are m/c affected

-broken bone is not allowed to heel,walking is continued leading to the breakdown in the skeletal architecture & soft tissue swelling.

-T/t: immobilization in a plaster cast & rest

1)LOSS OF EYEBROWS(MADAROSIS)-results from atrophy of hair follicle as a

result of lepromatous infiltration of forehead & eyebrow region.

-corrective surgery:a)Transplantation of hair follicle through free

grafting of scalp skin.b)Transfer of artery pedicled island of scalp.c)Long pedicled scalp flap.

2) PREMATURE SENILITY

-facial skin is over streatched by heavy LL -elastic fibres in the dermis and sub dermal

region are destroyed

-’FACE LIFT OPERATION’: here excess skin is excised, left overskin gets stretched & wrinkles flatten out.

3) MEGA LOBULES:-elongated ear lobe hangs down lose.-corrected by excising the infero-medial

segment of lobule using curved incision(cresent wedge resection)

4)NASAL DEFORMITY:-ant &antero-inferior part of nasal cavity is

commonly involved in LL

-Nose loses its mucosal lining and internal surface of the nose loses its skeletal support.

-nasal septum is destroyed.

-without skeletal support,nose falls back on the face.

-internal raw surface adheres to the facial skeleton leading to ‘SUNKEN NOSE’.

-regular irrigation of the nasal cavity.

-smearing the nostril with liquid paraffin,vaseline or vegetable oil to prevent formation of crust.

-’POST NASAL EPITHELIAL ONLAY GRAFTING OF GILLES’ ,done for sunken nose deformity.

-Due to direct invasion of ocular structure like conjunctiva,sclera,and choroid by M.leprae.

-deposition of immune complexes in the ciliary apparatus give rise to acute iridocyclitis.

-damage to upper branch of facial nerve give rise to weakness of eyelid & lagopthalmos.

-damage to peripheral branches of trigeminal nerve result in corneal anesthesia.

Redness and pain

Injury to cornea

Difficulty in closing eye

Aspirin or paracetamol Atropine and steroid

ointment Cover with eye pad Apply antibiotic ointment Refer

Tear substitute eye drops Exercises Dark glasses to protect Refer

-enlargement of breast in males.

-usually b/l.

-due to hormonal imbalance b/c of testicular and liver damage.

-simple mastectomy is t/t of choice(WEBSTER’S OPERATION)

-are related to widely held beliefs and prejudices concerning leprosy & its causes.

-they often develop self stigma,low self esteem & depression as a result of rejection and hostility,

-need to be referred for proper counselling.