eMedicine Specialties > Neurology > Neurological Infections

Leprosy: Follow-up

Author: Ramaratnam Sridharan, MBBS, MD, Head, Department of Neurology, Professor of Neurology, Chennai Neurospeciality and Research Institute, India
Coauthor(s): Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants; Lakshmi Narasimhan Ranganathan, MD, Tutor, Institute Of Mental Health, Chennai, India; Senior Civil Assistant Surgeon, Tamil Nadu Medical Services; Srinivasaraman Govindarajan, DMRD, DNB, Fellow in Radiology, Barnard Institute of Radiology, India
Contributor Information and Disclosures

Updated: Feb 27, 2007

Follow-up

Deterrence/Prevention

• Periodic examination of the contacts of persons with MB leprosy is essential to detect the disease in the early stages and start therapy.
• Several studies of 1 or more antileprosy drugs (dapsone, long-acting injectable dapsone, acedapsone, rifampicin) as chemoprophylaxis against leprosy failed to demonstrate any significant protection against leprosy. Therefore, at present, the only practical method of prevention is early detection and MDT for all patients with leprosy.
• BCG or other antileprosy vaccines may increase the immunity to the disease and help in prevention.
• Isolation of patients (eg, in a leprosarium) is not necessary because the viability of bacteria in skin biopsy samples falls sharply within 3 weeks of therapy with dapsone and rifampin is begun. This rapid drop in infectivity and the fact that family members already have had prolonged exposure to the patient before diagnosis makes physical isolation of patients unnecessary.

Complications

• Deformities and trophic changes
  • Deformities may be due to direct effects of proliferation of M leprae. Examples are collapse of the nasal septum and, in rare cases, direct invasion of the phalanges with pathologic fractures of the fingers.
  • Deformities are most often due to neuropathy. The effects include crippling deformities of the hand, contractures due to paralysis, and recurrent injuries to the hands, feet, and eyes due to insensitivity, leading to progressive absorption of the extremities and blindness.
  • Common problems include ulcerations on the plantar surfaces and sides of the feet and toes and on the hands. Lacerations, burns, abrasions, and hematomas are common on the hands. Shortening of digits on feet and hands may occur as a result of destructive osteomyelitis, and fragments of bone may be discharged through ulcerated areas. Amputations may occur traumatically. Impairments are graded as follows (WHO, 1982):
    • Grade 0 - Normal, no impairment
    • Grade 1 - Peripheral anesthesia over the hands and/or feet
    • Grade 2 - Trophic ulcers over the hands and/or feet, mobile clawing of fingers or toes, minimal absorption of the fingers and/or toes and wrist and/or foot
    • Grade 3 - Fixed deformities of the fingers and/or toes, more than minimal absorption of the fingers and/or toes, and nasal collapse
• Lucio phenomenon
  • This phenomenon is seen in certain Latin American patients with diffuse infiltrative LL leprosy.
  • The condition characterized by thrombosis of the deep subcutaneous arteries resulting in necrosis of the skin and subcutaneous fat. The underlying tendons and muscles may be exposed.
  • The outcome is often fatal.
• Secondary amyloidosis is a complication of severe LL disease, especially in chronic ENL reactions.

Prognosis

• Progression of tissue and nerve damage can be limited, but recovery of lost sensory and motor function is variable and generally incomplete.
• Hyperpigmentation, hypopigmentation, and loss of skin organs persist.
• Intercurrent reactional states, poor compliance, and emergence of dapsone resistance all can lead to clinical exacerbations or relapses, necessitating close follow-up.
• Much of the chronic debility results from repeated trauma to anesthetic digits and limbs. Careful counseling and consultations with physical and occupational therapy services are essential for an optimal outcome.
• Rejection and isolation by community and even family members lead to social and economic dislocation. Even when the disease is controlled fully, the stigma and social isolation persist.

Patient Education

• All of the activities and advice listed below should be explained, and patient adherence should be monitored on follow-up visits.
• Education of the patient about the disease, its bacterial origin, low communicability, and possibilities for successful treatment improves their self-esteem and motivation to take medical treatment.
  • Educate the patients about the condition and the consequences of neuropathy.
  • Periodic screening is recommended to detect signs and symptoms of neuropathic feet.
  • Any change in status may require a change in treatment protocol (possibly a different style of shoe or orthotic).
  • If any new injury or redness, swelling, or temperature are noted, it should be brought to the attention of a healthcare professional.
• Patients should be educated about proper self-care techniques. The patient must be told the importance of taking responsibility for self-care to ensure healthy feet.
  • Patients should be advised to cut their toenails straight across. If the nails are large or irregular in shape, professional care may be necessary. Patients should not cut calluses or corns or use corn removers; these are problems that a healthcare professional should address.
  • For dry skin, use a lotion that does not contain alcohol.
  • Patients should never use heating pads or hot water bottles, and they should not stand too close to a heater or fireplace. Insensitive feet and lower legs may not detect when temperatures reach dangerous levels that can cause burns.
  • A person with insensitive feet must always wear shoes and not walk barefoot, but the shoes must be appropriate. The shape of the shoe must match the shape of the foot, and patients should always have the feet measured when buying shoes.
    • The space between the tip of the longest toe and the shoe should be at least 0.5 in. The person should be able to pinch a small area at the widest part of the shoe to determine sufficient width. The toe box (end of the shoe) should be roomy enough to accommodate the toes.
    • Leather uppers are preferred because they conforms to the shape of the foot over time.
    • Patients should purchase shoes with a wedge and soft rubber sole.
    • Shoes should have a closure system. Clogs, slip-ons or loose-fitting shoes may easily come off the foot or rub red areas.
    • Patients should gradually break in new shoes. They should begin by wearing new shoes for no more than 2 hours the first time and then gradually wear them longer if they have no problems.
  • Patients should always wear socks with shoes and inspect them daily. White cotton socks are preferred because they are most absorbent and because white easily shows evidence of skin breakdown and drainage.
  • Patients should inspect their shoes before and after wear to ensure that no objects have accidentally fallen into the shoe and that no sharp items have penetrated the soles. Patients should not wear high-heeled shoes, as they tend to put pressure on the forefoot.
  • Patients should inspect their feet daily for redness, warmth, swelling or any other new injury. They should use a mirror to check the bottom of their feet.
• Educating the patient's family, friends, and employers of the items listed above facilitates acceptance of the patient in his or her family and in society.

Miscellaneous

Medicolegal Pitfalls

• In areas in which the disease is not endemic, always confirm diagnosis by smears or biopsy; if possible, mouse footpad cultures also should be done.
• Consult local health authorities regarding treatment policies and seek help from referral centers in difficult situations such as differentiation of relapse from reactions, treatment during pregnancy, treatment of persons who cannot tolerate standard drugs, and patients with associated hepatic or renal disease or HIV infection.
• Special attention should be paid to prevent deformities, blindness, and injuries to insensitive parts.

Special Concerns

• Patients who do not tolerate MDT because of adverse reactions or contraindications
  • These patients pose a difficult clinical problem. Once adverse events are conclusively established to be due to antileprosy drugs, other new antileprosy drugs can be used under direct supervision in a referral center. For patients who refuse to take clofazimine, educate the patient about the advantages of the drug, particularly the reversible nature of the discoloration produced by the drug; this information should be sufficient to encourage the patient to continue with clofazimine. In exceptional cases, ofloxacin 400 mg or minocycline 100 mg/d may be used under supervision in place of clofazimine.
  • As an alternative, patients may be treated with the monthly administration of 600 mg rifampin, 400 mg ofloxacin, and 100 mg minocycline (ie, ROM therapy) for 24 months.
  • For adults with MB leprosy who do not tolerate rifampin, clofazimine 50 mg/d with ofloxacin 400 mg and minocycline 100 mg for 6 months is recommended; this is followed by clofazimine 50 mg/d with minocycline 100 mg or ofloxacin 400 mg for at least an additional 18 months is recommended.
  • If the toxic effects of dapsone are severe in patients with PB, dapsone may be substituted with clofazimine at the same dose as that used for patients with MB but for 6 months. In patients with MB, dapsone should be stopped, and treatment should be continued with rifampin and clofazimine at the standard doses.
• Patients who default during treatment
  • If for any reason a patient cannot complete the required number of doses in time, the treatment regimen should be resumed from the point at which the patient stopped, and the full course should be completed.
  • Adequate efforts should be made to trace and persuade the patient to return for assessment and treatment.
  • A patient who returns for treatment and who has new skin lesions, new nerve involvement, LL nodules, or signs of ENL reaction should be given a new course of MDT.
• Patients with no response to therapy
  • Nonresponse may be due to poor drug compliance or other concomitant and debilitating intercurrent infections (including that due to HIV).
  • When the patient does not improve despite supervised drug therapy, health education, and thorough investigation and management of intercurrent infections, seeking an expert opinion may be necessary.
• Patients who have a relapse
  • In MB leprosy, relapse is defined as the multiplication of M leprae, as suggested by the marked increase (at least 2+ over the previous value) in the bacillary index at any single site, usually with evidence of clinical deterioration (new skin patches or nodules and/or new nerve damage). In most cases, relapse can be confirmed by the growth of M leprae in the mouse footpad system.
  • Recognition of relapse in PB leprosy is somewhat difficult because it is hard to distinguish from a reversal reaction. In theory, a therapeutic test with corticosteroids may be able to distinguish the 2 phenomena; definite improvement within 4 weeks of corticosteroid therapy indicates a reversal reaction, whereas no response to corticosteroids within 4 weeks suggests clinical relapse.
• Steroid therapy and leprosy
  • Indications for steroid use in people with leprosy include neuritis, impending nerve palsies, iridocyclitis, epididymoorchitis, severe reversal reaction, ENL reaction, or systemic involvement. No evidence suggests that immunosuppressive drugs, such as corticosteroids, accelerate the multiplication of organisms located in dormant foci or cause reactivation of leprosy.
  • Whenever the duration of steroid therapy (eg, for a late reversal reaction or other medical conditions) is expected to exceed 4 months, clofazimine 50 mg/d can be started as a prophylactic measure. This treatment should be continued until the course of steroids is complete.
• HIV infection and leprosy
  • Unlike tuberculosis and atypical mycobacteriosis, leprosy is not significantly associated with HIV infection in any case-controlled studies. HIV serodiagnostic tests based on ELISA and/or Western blotting may have a significantly increased rate of false-positive results among sera from patients with LL leprosy. The treatment of patients with leprosy and HIV infection is the same as that of any other patient with leprosy, including the treatment of reactions.
  • HIV-associated neuropathy might be confused with or exacerbate leprosy neuritis. Neuropathy due to antiretroviral chemotherapy might be confused with leprosy. Nonleprosy mycobacterioses in HIV-positive people might be diagnostically confused with leprosy.
  • National policies on BCG vaccination might be amended because of endemic HIV infection.
  • Slit-skin smear taking could spread HIV infection if proper precautions are not taken.
  • Leprosy workers in countries where leprosy is endemic may become increasingly involved with problems of HIV counseling.
• Women, pregnancy, and leprosy
  • Hormonal changes in puberty and pregnancy cause nonspecific suppression of cell-mediated immunity with worsening of leprosy. Pregnancy also can be associated with reactions. Deterioration usually occurs in the second half of pregnancy or the first 3 months after delivery. Late nerve damage has been recorded even in women released from treatment with MDT in relation to childbirth. Therefore, WHO recommends that MDT be continued during pregnancy.
  • Dapsone is not known to have any adverse effects on mother or fetus. Clofazimine, prednisolone, and thalidomide may affect both mother and fetus. Rifampin is not recommended in the first trimester. A small quantity of antileprosy drugs are excreted through breast milk, but no adverse reactions have been reported as a result of this except for mild discoloration of infants due to clofazimine. Infants of mothers with leprosy have decreased birth weights and an increased risk of the disease.
• Tuberculosis and leprosy
  • MDT for leprosy is not adequate for treatment of tuberculosis. Therefore, an appropriate antitubercular regimen should be given, in addition to antileprosy MDT, to patients with both leprosy and tuberculosis.
  • Except where daily rifampin is part of antituberculosis treatment, administering monthly rifampin as part of leprosy MDT is not necessary. If a leprosy patient with tuberculosis is treated for tuberculosis with a rifampin-containing antitubercular regimen, the patient may run the risk of developing rifampin-resistant leprosy.
  • For the reasons just listed, both diseases must be treated simultaneously.
• Leprosy and human rights
  • Patients taking MDT and those cured of disease should not be subject to restrictions in areas of life such as employment, education, and travel.
  • Any special legal measures that might increase prejudice against patients with leprosy or prevent affected individuals from presenting for diagnosis and treatment early in the course of the disease should be abolished.

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