Presented By Dr Raghunandan Khandelwal

1. CASE PRESENTATION ON
LEPROSY
GUIDE-
DR. DHARMESH SHARMA
Asst. Professor (PSM)
S.M.S MEDICAL COLLEGE,
JAIPUR
PRESENTED BY
DR. R.N. KHANDELWAL
M.B.B.S, D.P.H (1st year)
S.M.S MEDICAL COLLEGE,
JAIPUR

2. * NAME OF PATIENT: AMIR CHAND SAHA
* FATHER’S NAME: JANADHARAN SAHA
* AGE: 21 YRS
* SEX: MALE
* CAST: SAHA
* RELIGION: HINDU
* OCCUPATION: LABOUR (~5000 P.M.)
* MARITAL STATUS: MARRIED
* FAMILY MEMBERS: TOTAL 5 (3 CHILDREN = 2 F +1 M)
* ADDRESS: VILLAGE- BHAGWANPUR, V.P.O RAJPUR,
DIST. BAXAR, BIHAR (MOB. 07891222169)
* CHIEF COMPLAINTS:
* Reddish PATCH WITH NUMBNESS at rt. leg – 4 months
* HISTORY OF PRESENT ILLNESS:
* Patient was apparently asymptomatic about 4months back then reddish patch develop at Rt.
outer leg. Gradually it increased in size and numbness.
* HISTORY OF PAST ILLNESS:
* No history of any specific past illness and previous hospitalization.

3. *FAMILY HISTORY: Not significant.
*5 members in the family, one male i.e. patient himself 21 yrs old and one female
his WIFE 20 yrs old. 3 CHILDREN, one male & 2 female.
*PERSONAL HISTORY:
*Patient is purely vegetarian, Non Alcoholic
*Smoker 10~15 biddies per day, Tobacco chewer 5~7 packet per day,
*Bowel and bladder habit normal.
*DRUG HISTORY: No history of any drug allergy.
*IMMUNISATION HISTORY: Unknown
*SOCIO ECONOMIC STATUS:
*Patient is migratory from Bihar. Residing at Kachhi basti near Transport nagar;
Jaipur since 2 years.
*And lives in rented pucca house 2 rooms without latrine and bathroom facilities.
*Labour by occupation and earns a monthly income of Rs.5000.

4. *GENERAL PHYSICAL EXAMINATION:
 general condition fair.
Patient is well conscious and well oriented to time place and person
 VITALS:
Blood pressure: 120/70 mmHg, pulse rate: 84/min/regular
RR- 20/min/regular, temp- afebrile
No Pallor, Icterus, Cyanosis, Lymphadenopathy, Oedema.
LOCAL EXAMINATION:
Single Erythamatous skin patch is present over the Rt. Leg lower on
lateral side.
Well define margin; Size~ 5cm *2.5 cm
Decrease sensation of touch, temperature, pain
No other patch and thickened peripheral nerve seen.

5. SYSTEMIC EXAMINATION:
Respiratory system: bilateral symmetry of the chest is normal
bilateral chest sounds clear.
CVS: S1 S2 normal, no murmur sound heard.
CNS : Normal.
INVESTIGATION DONE:
HEMATOLOGICAL INVESTIGATION:
C.B.C ~ NAD
SKIN BIOPSY:
TUBERCULLOID LEPROSY
TREATMENT: started on 19.09.2014
MDT 6 BLISTER PACKS FOR P.B. STARTED FOR 6 MONTHS
ONCE A MONTH = 2 CAP. REFAMPICIN 300 MG + TAB. DAPSONE
100MG
ONCE A DAY = TAB. DAPSONE 100MG

9. INTRODUCTION
LEPROSY (HANSEN’S DISEASE)
Leprosy is the oldest disease afflicting mankind
In Vedic reference it is mentioned as Kushta
Rog.(In Sanskrit means eating away)

10. *OCCURRENCE & SPREAD
•CAUSE- MYCOBACTERIUM LEPRAE
•INFECTION- VERY SLOW GROWING (15-20 days for
multiplication)
•EARLY SIGNS ~ APPEAR 3-5 YEARS (LONG INCUBATION
PERIOD)
•SUSCEPTIBLES- ONLY 2-5% (95-98% population is immune to
disease )
•SPREAD- Only untreated infectious smear + MB pt. By
throwing out large no. of germs from URT while sneezing &
coughing.(only 10-15% of all leprosy pt.) ONLY HUMANBEING
• Close skin to skin contact , Breast milk & Tattoing needle.

11. *Indian classification of Leprosy
1. Indeterminate :- One o two vague hypo pigmented patch or
definite sensory impairment. Bacteriologically Negative.
2. Tuberculoid :- One or two well defined hypo pigmented or
erythematous and anesthetic patch may be flat or raised.
Bacteriologically positive.
3. Borderline Type : - 4 or more flat/ raised, well or ill defined,
hypo pigmented or erythematous patch with sensory
impairment or loss. Bacteriologically positive.
4. Lepomatous Type: Diffuse, Infiltrate or numerous flat or
raised, poorly defined shiny, smooth, symmetrically
distributed lesion. Bacteriologically positive.
5. Pure Neuritic type:Nerve involved but do not have any skin
lesion. Bacteriologically Negative.

12. *DIAGNOSIS OF LEPROSY….
BE CAREFUL…………..
*EXAMINE IN DAY LIGHT OR IN
WELL LIT ROOM.
*EXAMINE THE ENTIRE BODY
(DON’T SHY)
*A HAND SHAKE CREATES
CONFIDENCE AND ESTABILISHES
RAPPORT B/W PATIENT &
DOCTOR. IT INDUCES A SENSE OF
CO-OPERATION AND HELPS IN
THE HEALING PROCESS.
*IF YOU THINK ABOUT LEPROSY,
YOU CAN DIAGNOSE IT

13. o INCREASE SIZE & NO. OF LESION DURING
TREATMENT ….. SEND TO NEAR
REFFERAL CENTER
o INCREASE NO. DURING TREATMENT
…..REACTION
o INCREASE NO. DURING AFTER
TREATMENT ….REACTION OR RELAPSE
o *LESION OVER NERVE TRUNK OR ON
FACE…. RISK FOR DEVELOPING
SENSORY/MOTOR DEFICIT.
1. MARGIN – ILL DEFINE / WELL
DEFINE
2. COLOUR – HYPOPIGMENTED /
ERYTHEMATOUS
3. SIZE –
4. NUMBER – SINGLE / MULTIPAL
5. SITE -
*1.SKIN PATCH WITH LOSS OF SENSATION

14. *SIGN. THAT LOOK LIKE LEPROSY…
1. TINIA CIRCINATA,
2. PSORIASIS,
3. VITILIGO,
4. NAEVUS (BIRTH MARK)
5. DERMAL LESHMANIIASIS
6. NEUROFIBROMATOSIS
7. NUTRITIONAL DYSCHROMIA
8. LICHEN PLANUS
9. PITYRIASIS ROSEA
10. LUPUS VULGARIS
11. SCAR & KELOID
12. XANTHOMATOSIS
1. DIABETIC NEUROPATHY
2. ALCOHOLIC NEURITIS
3. SYRINGOMYELIA
4. TABES DORSALIS
SKIN CONDITION
NEROLOGICAL CONDITION
• LESION SHOULD NEVER HURT NEVER ITCH
• TAKEN PROPER HISTORY….

15. *2 .EXAMINE FOR THICKENED PERIFERAL
NERVES…
*Ulnar nerve,
*Lateral popliteal nerve
*Post. Tibial nerve
* Radial nerve,
* Median nerve
*Trigeminal nerve,
* Facial nerve
Facial n.

18. *CONSEQUENCES OF NERVE DAMAGE
*Examine hands for injuries, blisters and stiff joints.
*Examine feet for dryness, cracks, swelling, wounds.
*Recurrent ulceration with infection due to repeated injuries
may cause destruction of bones & joints and develops severe
functional handicap.
*Examine face for lagophthalmos & facial palsy.
*Risk for eye complications and eventually blindness.
*Patient with depressed nose will have difficulty in breathing
normally & social rejection due to gross deformity.
*In india 7% of leprosy is pure neuritic type.

19. *3.SUSPECTED CHANGES IN SKIN….
without sensory loss
*If doubt Refer for SKIN SMEAR examination to referral centre.
*SKIN SMEAR examination is not mandatory to start MDT
*NLEP no longer routinely advises skin smear.

20. *Sign. Of infectious leprosy
*Look for any infiltration (thickness) of the skin, oily and shiny skin. It
could be early sign of infectious type of leprosy.
*Look for nodules with normal skin or redish colour; may be soft or
hard & small or large.
*Lepromatous leprosy is usually a generalised disease.
*Multiple hypopigmented patches seen in lepromatous leprosy
typically do not show loss of sensation.
*Glove and Stocking type of anesthesia is a common feature of
lepromatous leprosy.
*Nose, Testes & eyes are frequentally affected in advanced leprosy.
*Look for loss of eye brows & eye lashes

21. *MDT Grouping & Treatment…..

24. *
PB LEPROSY
•1-5 SKIN PATCHES
WITH SENSORY LOSS
•ONLY ONE NERVE
TRUNK THICKENED
WITH SENSORY OR
MOTOR INVOLVEMENT
MB LEPROSY
•6 OR MORE PATCHES
WITH SENSORY LOSS
•5 SKIN LESIONS +
ONE NERVE TRUNK =
6
•2 OR MORE NERVE
TRUNKS THICKENED
•SKIN SMEAR + FOR
AFB

25. *MDT for P.B.~ 6 months (maximum
complete with in 9 months)

26. *MDT for MB~ 12 months (Maximum
complete with in 18 months)

27. *LEPRA REACTIONS….
*REACTIONS MAY OCCUR BEFORE, DURING, AFTER
TREATMENT.
*DO NOT STOP MDT….. NOT CAUSE BY MDT
TYPE -1 TYPE -2

28. *TYPE 1… Reversible reaction
*Ag from broken bacilli react with T-CELL (Delayed
hypersensitivity reaction).
*Usually in the first 6 months.
*Existing patches become raised, erythematous, and
oedematous.
*Neuritis is a common feature.
*reaction is severe if pain & tenderness is severe and
paralysis or anesthesia threatens to follow the neuritis.
*Rx~ Steroids/chloroquine/aspirin

29. *TYPE 2……. ENL Reaction
**Circulating Ab against m. leprae react with the m. leprae Ag. (Ag-Ab reaction)
**Usually 6 months after treatment
**New erythematous & tender nodules (ENL’s) appear in crops. B/l
symmetrical.
**ENL may rupture in severe case.
**swelling of joints with systemic complaints +nt.
**other organs may involve.
*Rx…… steroids /clofazimine/ thalidomide/Znso4/pentoxyphyllin

30. *
*Grading Of Disabilities
*Hands & Feet
*• Grade 0: No anaesthesia, over palm/sole no visible deformity or
*damage
*• Grade 1 : Anaesthesia present, over palm/sole but no visible
*deformity or damage
*• Grade 2 : Visible deformity or damage present
*Eyes
*• Grade 0 : No eye problem due to leprosy; no evidence of visual loss
*• Grade 2: Severe visual impairment (vision worse than 6/60;
inability
*to count fingers at six meters), lagophthalmos, iridocylitis and corneal
*opacities.

31. *
LOSS OF SWEAT
CRACK
ULCER
LOSS OF
SENSATION
INJURY/PRESSURE
ULCER
LOSS OF MOTOR
FUNCTION
WEAKNESS/PARALYSIS
CONTRACTURE
Nerve damage

32. *
*Early diagnosis of leprosy
and treatment with MDT.
* Adequate counseling and
follow high risk patient.
*Possible signs and
symptoms of reaction (loss
of nerve function , lapra
reaction , neuritis )and need
to report immediately in
case of unusual .
*Check muscle strength and
sensation .
*Management earlier ……….

33. NATIONAL LEPROSY
ERIDICATION PROGRAME

34. *Milestones of Leprosy eradication
*1898 – Leper Act, British India abolish later on
*1948 – Hind Kusht Nivaran Sangh
*1955 – National Leprosy Control Program
*1982 – MDT
*1983 – National Leprosy eradication Program MDT started)
*1991 – WHO resolution to eradicate leprosy by 2000 AD
* 1993 – World bank supported the MDT program Phase NLEP-1
*1998-2004 :- Modified Leprosy elimination campaign
*2001-2004 :- NLEP project phase II
*2005 :- National wide evaluation of project II
*2005, Dec: Prevalence rate 0.95/ 10,000 and govt. declared
achievement of elimination target.
*2005 : NRHM covers NLEP.
*2012 : Special action plan for 209 high endemic Districts in 16 States / UTS

35. *NLEP progress report year 2013-14
* 1.27 lakh new cases were detected, gives ANCDR of 9.98 per 1,00,000
population. from 2012-13 (10.78).
* A total of 0.86 lakh cases are on record as on 1st April 2014, giving a PR of
0.68 per 10,000 population. from 2012-13 (0.78).
* A total of 5256 Gr. II disability detected amongst the New Leprosy Cases
during 2013-14, gives Gr. II Disability Rate of 4.13 / million population.
*12043 child cases were recorded, gives Child Case rate of 0.95/1,00,000
population . Shows reduction in child case rate from the year 2012-13 (1.07)
by 11.21%
* 33 States/ UTs had already achieved the level of elimination (PR less than 1
case per 10,000).
* Chhattisgarh & Dadra & Nagar Haveli has PR between 2 and 4 per 10,000
population. Odisha, Chhattishgarh and Lakshadweep which achieved
elimination earlier have shown slight increase in P.R. (1-2), in the current
year..
*PB Child proportion was high in 4 States/UTs namely (i) Bihar 11.04% (ii)
D&N Haveli 21.88%, (iii) A&N Islands 12.50% and (iv) Pondicherry 10.53%

36. RAJASTHAN
PR . 17 per 10000 population. (~.68)
ANCDR 1.48 per 100000 population(~9,98)
child case rate .03 per 100000,(~.95)
new gd 2 disability rate0.55 per million(~4.13)
DPMR Services =Disability Prevention and Medical Rehabilitation
1. Total 111 (Govt.- 60 and NGO- 51) Institutions have been recognized for
conducting Reconstructive Surgery to correct the disability in Leprosy.
2. During the year 2013-14 a total of 2707 RCS (Govt. – 921 and NGO – 1786) were
conducted.
3. A total of 12901 Reaction/Neuritis episodes were recorded and treated at PHCs
and in Secondary level Institutions.
4. At the PHC level 486 Relapse Cases were suspected and referred to the District
Hospitals. A total of 433 Relapse were confirmed and treated at District Hospital.
5. MCR footwear were provided to 69331 Leprosy Affected Persons.
6. Self Care Kits were provided to 44412 Leprosy Affected Persons.

37. B. ASHA Involvement
During 2013-14, their participation has substantially improved.
C. Active case detection =Search activities for early detection of New
Leprosy cases were carried out during the year 2013-14 .
(i) Intensive Case Detection Drive ( ICDD ) was carried out in all the high
endemic blocks of low endemic districts, along with special action plan
activities in the remaining blocks of High endemic districts, that were left
out during 2012-13.. A total of 8398 New Leprosy cases were detected
during these search.
(ii) House to house visit were also carried out in low endemic areas during
the Anti leprosy fortnight from 30th January to 13th February 2014. A total of
3215 New Leprosy cases were detected during these search.
** a total of 11613 New cases were detected through active search in the year
2013-14. Amongst these cases MB 4846 (41.7%), Child 1093 (9.4%), Gr I
disability 651 (5.6%) and Gr. II disability 443 ( 3.8%) were detected.

38. *
*FOUR LEPROSY VACCINES ARE CURRENTLY IN
TRAIL
*1)BCG –34.1% PROTECTION
*2)BCG+KILLED M.LEPRAE – 64.0%
*3)M.W – 25.7%
*4)ICRC – 65.5%
*7 CONTROLLED TRAILS AND 9 CASE –CONTROL
STUDIES EVALUATING THE ROLE OF BCG IN
PREVENTION OF LEPROSY WERE CARRIED OUT
AROUND THE WORLD