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Pediatric Leprosy Clinical Presentation

  • Author: Benjamin Estrada, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: Sep 30, 2013
 

History

Patients with leprosy are usually native to or have emigrated from endemic areas. Leprosy should be considered as a diagnostic possibility among internationally adopted children who develop clinical findings suggestive of associated to this infection and who are originally from areas of the world where the disease is endemic.[7]

Neuromuscular symptoms associated with this disease are occasionally the first to be observed. Patients may also present with a history of chronic nasal discharge, which is frequently observed in individuals with lepromatous leprosy who have upper airway compromise.

Because of the prolonged incubation period, which averages 5 years, most cases are not diagnosed until several years after initial exposure.

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Physical Examination

The hallmark clinical findings in leprosy are hypopigmented skin lesions with loss of sensation. These lesions are observed more frequently in the cooler areas of the body, such as the nose and earlobes (see the image below).

Infiltration of ear lobes in patient with lepromat Infiltration of ear lobes in patient with lepromatous leprosy.

Hypoesthesia is the clinical manifestation of peripheral nerve involvement and is present in as many as 70% of children with this condition.

Visible deformities in children with leprosy have been associated with increasing age at the time of diagnosis, multibacillary disease, lack of access to health care, and multiple nerve involvement.[8]

Depending on the number of lesions and the number of bacilli observed on the lesion’s smear, leprosy can be classified into the following 3 groups:

  • Paucibacillary (PB) or tuberculoid (TT) leprosy
  • Multibacillary (MB) or lepromatous (LL) leprosy
  • Borderline leprosy

Paucibacillary (tuberculoid) leprosy

TT leprosy presents with one or few (usually < 5) hypopigmented and hypoesthetic lesions. Sensory loss is frequently observed around the lesions. Patients with tuberculoid leprosy have a characteristic normal cell-mediated response to M leprae antigens.

Multibacillary (lepromatous) leprosy

LL disease usually presents with multiple (> 5) poorly defined, hypopigmented or erythematous lesions associated with hypoesthesia. It is also associated with the presence of papules, macules, and nodular lesions. Necrotizing erythema nodosum has occasionally been reported in children.

Patients with advanced LL leprosy may present with loss of eyelashes or eyebrows (see the image below) and nasal septum perforation. The constellation of disfiguring facial features associated with this disease is named leonine facies.

Man with advanced deformities caused by unmanaged Man with advanced deformities caused by unmanaged leprosy: keratitis, loss of eyebrow, thickened skin, and typical hand impairments. Ho Chi Minh City, Vietnam. Image courtesy of D. Scott Smith, MD.

The peripheral neuropathy observed in LL leprosy causes muscle weakness and atrophy and has been associated with clawhands and foot drops. Other clinical manifestations of LL leprosy include corneal opacifications, keratitis, iritis, testicular atrophy, and kidney disease resulting in renal failure. Patients with LL leprosy present with characteristically abnormal cell-mediated responses to M leprae antigens.[9]

Erythema nodosum leprosum (ENL) is a condition observed in patients with borderline and LL leprosy. It is usually associated with neuritis, fever, and arthralgias. The development of ENL has been suggested to be caused by the presence of immune complexes.[10]

The development of nonhealing ulcers in the lower extremities of patients with LL leprosy secondary to arthritis is known as the Lucio phenomenon. These ulcerations are more common in individuals of Latin American descent and are associated with a high mortality.

Neuropathic pain is a potential sequela of MB leprosy that can present more than 10 years after completion of therapy.[11]

Leprosy immune reconstitution disease can develop among patients coinfected with HIV who undergo treatment with highly active antiretroviral therapy.[12]

Borderline leprosy

TT disease and LL disease represent the 2 ends of the leprosy spectrum. Between these 2 ends lies a broad disease group designated as borderline. Borderline epilepsy is characterized by the presence of single or multiple skin lesions with a raised central area. It is often subclassified as borderline tuberculoid (BT), midborderline (BB), and borderline lepromatous (BL).

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Contributor Information and Disclosures
Author

Benjamin Estrada, MD Professor, Department of Pediatrics and Adolescent Medicine, Division of Pediatric Infectious Diseases, University of South Alabama College of Medicine, University of South Alabama Children's and Women's Hospital

Benjamin Estrada, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Larry I Lutwick, MD Professor of Medicine, State University of New York Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus

Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Gary J Noel, MD Professor, Department of Pediatrics, Weill Cornell Medical College; Attending Pediatrician, New York-Presbyterian Hospital

Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

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Infiltration of ear lobes in patient with lepromatous leprosy.
Man with advanced deformities caused by unmanaged leprosy: keratitis, loss of eyebrow, thickened skin, and typical hand impairments. Ho Chi Minh City, Vietnam. Image courtesy of D. Scott Smith, MD.
 
 
 
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