How to Diagnose Leprosy

Dr Balu P.S.Reader – Dept Of Community Medicine –JJMMC.

How to Treat Leprosy

Dr Balu P.S.Reader – Dept Of Community Medicine –JJMMC.

Learning Objective

• Suspect and Diagnose leprosy.• Able to perform basic clinical examination.• Classify leprosy patients and start treatment.

Leprosy - one of the few diseases which can be eliminated

• Leprosy meets the demanding criteria for elimination– practical and simple diagnostic tools: can be

diagnosed on clinical signs alone; – the availability of an effective intervention to

interrupt its transmission: multidrug therapy – a single significant reservoir of infection: humans.

How to recognize Leprosy?

Talk to the Patient• How long has the skin patch been there? How did it start? Has it

changed? Leprosy patches usually appear slowly.

• Do the patches itch? Is there pain? Leprosy patches do not itch and

are not usually painful.

• Does the person have unusual sensations in their hands or feet, such

as numbness, tingling or a burning feeling? Unusual sensations in the

hands or feet can be a sign of leprosy.

• Does the person think that their hands or feet have become weaker?

Do they have problems with holding or lifting things and with

moving their hands and feet? Losing strength in hands or feet can be

a sign of leprosy.

• Has the person experienced any social problems? This may be more

likely if the person already has some disability due to leprosy

Examine their Skin

What To Look In Skin Patches ?

Test the feeling in the skin patches

Feel the Nerves

How to Feel for Ulnar Nerve

Hand Shake Method

From Outside to Inside

How to feel for Peroneal Nerve

• ask the person to sit in achair and then kneel down in front of patient.

• With your left hand , feel for the nerve on the outside of the right leg, just below the knee; the nerve comes from just behind the knee and curves around the head of the fibula.

Examine the hands and feet fornerve damage

Four Point Test

Four Point Test – Contd….

Are You Thinking About Skin Smear ?

Sites for taking skin smear

• 2 sites are enough , previously recommended was 4 or 6 sites.

• Take smear from the edge of the most active lesion (raised and reddish )

Importance of skin smear• A skin smear may be useful for diagnosis: when positive it

indicates leprosy but skin smears are used primarily for the surveillance of the patient's bacteriological status.

• Many leprosy patients will have a negative skin smear. This means that although they have leprosy bacilli in their body, there are too few to be seen in the smear. If the laboratory technician can see leprosy bacilli, it means that the patient is heavily infected.

Remember, if you see a skin condition that looks like leprosy,ALWAYS

• Test the feeling in the skin patch.

• Feel if the nerves are enlarged.

• Test the feeling in the palms ofthe hand and the soles of thefoot.

• If possible, arrange for a skinsmear.

If a person shows one or moreof the following three signs,they have leprosy

• Pale or reddish patches onthe skin, with definite loss of feeling.

• Involvement of the nerves,shown by enlargement andloss of feeling.

• The presence of leprosybacilli in the skin smear.

Conditions That May Mimic Leprosy

Pityriasis alba

Tinea faciei

Localized scleroderma

Tinea Versicolar

What to do after you have diagnosed a patient as leprosy ?

• Count the skin patches.

• Check for nerve damage.– check to see if the person has any weakness of

the muscles in the hands, feet and eyelids

• Test four muscles on each side– One muscle controlling the eyelids.– Two muscles in the hand.– One muscle controlling the foot.

• Write down the result of your tests –– S (strong) if the muscle strength seems normal,– W (weak) if there is some movement but the muscle

strength is reduced, or– P (paralysed) if the muscle has lost all strength and

cannot produce any movement.

Testing the eyelid muscles

Testing Movement of Little Finger• ask the patient to move

the finger sideways, away from the other fingers.

• Now try to push the little finger back.

• If you can push it back easily, there is muscle weakness.

• If the patient cannot move the little finger at all, there is paralysis

Testing the movement of the thumb

• ask the patient to hold their handflat, with the palm upwards, andpoint the thumb upwards.

• Now, support the patient's hand and try to push the thumb down to a flat position at the side of the palm.

• If the patient does not resist and you can move the thumb down easily, there is muscle weakness.

• If thepatient cannot point the thumb upwards at all, there is paralysis.

Testing the movement of the foot

• support the patient's lower leg with your hand. Ask them to lift their foot.

• Now try to push it down. If you can push the foot down easily, there is muscle weakness.

• If the patient cannot lift the foot at all, there is paralysis.

Look also for signs of complications ?

Disability Grading /Impairment Grading / EHF Score

TRY IT.

How to treat Leprosy Patient ?

Steps in MDT• Classify the lesion*          

• Inform the patient*

• Explain the MDT blister pack*           

• Show drugs to be taken once a month and every day

• Explain possible side effects and complications*

• Give enough MDT blister packs to last until the next visit.

• Fill out the patient treatment card .

How will you classify the patients in these pictures?

How to tell if someone has PB or MB leprosy ?

• Count the skin patches– If you find five patches or less, classify the patient

as PB.– If you find more than five patches, classify the

patient as MB.

• When a skin smear is taken– If the skin smear is negative and the patient has five

patches or less, classify the patient as PB.– If the skin smear is positive, classify the patient as

MB, whatever the number of skin patches

Explain the MDT Blister Pack

Duration of treatment is 6 months.

Duration of treatment is 12 months

Single lesion paucibacillary leprosy (adults)

• Single dose of: • Rifampicin: 600mg • Ofloxacin: 400mg • Minocycline: 100mg

What is Accompanied MDT (A-MDT)

A patient receives a full course of MDT at the outset receives information (verbal and printed materials) about the

disease, its treatment and when and where to come for follow up, and

someone close to or important to the patient assumes the responsibility of ensuring that the patient completes a full course of treatment.

• Note: In some areas (difficult to access, poor security etc) or for some patients (students,workers etc), this will ensure that all patients have adequate supply of MDT at home.

When To Re- Start Treatment

• Reddish and or raised skin lesions.• Appearance of new lesions.• New nerve involvement.• New deformities.• Lepramotus nodules.• Signs of ENL or reversal reaction.

How to Recognize and ManageLeprosy Reactions?

What is leprosy reaction?

• APPEARANCE OF SYMPTOMS AND SIGNS OF ACUTE INFLAMMATION IN LESIONS OF A PATIENT WITH LEPROSY

Swelling • Redness • Heat • Pain • Loss of function

Skin• Ask the person if there is

any pain and swelling in the skin patches.

• Examine the patches for signs of inflammation.

• Examine the hands and feet for loss of sweating.

Nerves

• To find out if there is new nerve damage, compare the results of this test with the last examination.

• Here are the signs of new nerve damage– There are places on the hands or feet where the patient could

feel before but cannot feel now.– Any muscle has lost strength compared with the previous

examination.– Any nerve has become more painful or tender to the touch.

Nerve damage must be treated quickly to stop further damage.

Eyes

• Ask if there is any pain or recent loss of vision.

• Look for signs of inflammation: redness or an irregularly shaped pupil.

• Look for new or worsening lagophthalmos.

Common Problems In leprosy

Type 1 leprosy reaction

TTS in Type 1 reaction (RR)

Type 2 reaction (ENL)

Type 2 reaction (ENL)

Type 2 Reaction in LL (ENL Necroticans)

How to prevent Disabilities?

Self-Care: What to Teach and How to Teach it

Eye Care

Hand Care

Does patient have any weakness or stiffness in the hands or fingers?

Active finger straightening exercises

If patients hands are weak and he can no longer grip things properly ?

Foot Care

SYMPTOMS

DIAGNOSIS &TREATMENT

MDT TREATMENT PERIOD

PB 6 MONTHS MB 12/24MONTHS

RELEASEDFROMTREATMENT

SURVEILLANCE

1yr 2yr 3yr 4yr 5+yrs

Reversal reactionswithin 1yr

RELAPSE AFTER 1YR USUALLY IN PB2-5YRS IN MB

RELEASEDFROM CONTROL

Further Reading

• Difference between Relapse & Reversal Reaction.

• SET Centers.• Lepromin test.• Case finding methods in leprosy.

We Are Here To Create Not Compete

Thank You

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