LML closes temporarily

Leprosy Mailing List – June 5^th, 2011

Ref.:   LML closes temporarily

From: S. Noto, Genoa, Italy

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Dear All,

The leprosy mailing list closes temporarily up to the end of next July.  Thanks a lot to all of you, writers and readers.

S. Noto

On NO account should the mother stop breast feeding

Leprosy Mailing List – June 5^th, 2011

Ref.:   On NO account should the mother stop breast feeding.

From: B Naafs, Munnekeburen, The Netherlands

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Dear Salvatore,

I fully support Lysbeth Duncan (LML June 5th).  I would like to add that Dr Al Aboud (LML June 3rd) must also continue the dapsone though many sites warn against it.  There is no conclusive evidence that it harms the baby when it does not harm the mother.

Thanks for this discussion.

Dr Ben Naafs

On NO account should the mother stop breast feeding

Leprosy Mailing List – June 5^th, 2011

Ref.:   On NO account should the mother stop breast feeding.

From: M E Duncan, Peebles, Scotland, UK

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Dear Dr Noto,

Thank you to Dr Al Aboud for is message (LML June 3^rd, 2011) inquiring about recommendations for breastfeeding in mothers with leprosy.  Herewith are a few brief comments.

In the pre-antibiotic era, Pedley [Nepal] published finding of M. leprae in breast milk.  For women on treatment, especially on clofazimine, clofazimine passes freely into breast milk.  Clofazimine is lipophillic.  The mother should be advised that if the babe regurgitates milk, the milk may be the colour of strawberry icecream!  This is normal and is evidence that the mother is taking her clofazimine and will protect the baby. The baby's skin may also become pigmented.  The pigmentation will fade after the baby is weaned.  On NO account should the mother stop breast feeding.  The baby is far more likely to die of gastroenteritis [D&V] if he is bottle fed which is a tragedy.

Lysbeth Duncan

Dr M E Duncan

Rehabilitation and prevention of disabilities course, Pokhara, Nepal 5-16 December, 2011

Leprosy Mailing List – June 3^rd, 2011

Ref.:    Rehabilitation and prevention of disabilities course, Pokhara, Nepal 5-16 December, 2011

From: Gopal G, Pokhara, Nepal

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Dear Dr. Noto,

Please send the attached training announcement to all LML readers.

Many thanks for your support,

Gopal

Gopal Gurung
Program Manager
BIKASH Nepal
Green Pastures Complex
PO Box: 28
Pokhara, Nepal

Phone: 00977 61 430562
Fax: 00977 61 430940
Web: www.bikashnepal.org.np

Are there recommendations about breastfeeding for mothers with leprosy?

Leprosy Mailing List – June 3^rd, 2011

Ref.:   Are there recommendations about breastfeeding for mothers with leprosy?

From: K Al Aboud, Makkah, Saudi Arabia

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Dear Dr Noto,

I think that babies should not be separated from mothers and it is sufficient that mothers with leprosy get the anti-leprosy treatment.  However, what is the risk of transmission of leprosy from untreated mother to baby?  I suppose that the leprosy bacilli can pass through the milk or via the intimate contact (and hence, respiratory route) from mother to baby.  Is there a scientific base for advising the mother with leprosy, not to breast fed their babies because of the risk of transmission of leprosy?

There are some aspects to be mentioned for example: secretion of leprosy medications in the breast, nutritional deficiency in the babies if not breast fed, precipitation of reaction in this physiological period.  I can find one reference in the MEDLINE documenting this.  Duncan ME, Melsom R, Pearson JM, Menzel S,Barnetson RS. A clinical and immunological study of four babies of mothers with lepromatous leprosy, two of whom developed leprosy in infancy.  Int J Lepr Other Mycobact Dis 1983 Mar 51(1):7-17.

However, I wish to hear from our LML Panel, if there is a current recommendation regarding this matter by scientific societies or organization like WHO.

With respect and regards,

Dr Khalid Al Aboud
Consultant Dermatologist, King Faisal Hospital, Makkah, Saudi Arabia.amoa65(at)hotmail.com
alaboudkhalid(at)yahoo.ca

ILA Regional Congress and Brazilian Leprosy Congress, Maceio, Brazil, 23-26 November, 2011

Leprosy Mailing List – June 2^nd, 2011

Ref.:   ILA Regional Congress and Brazilian Leprosy Congress, Maceio, Brazil, 23-26 November, 2011

From: Marcos Virmond, Bauru, SP, Brazil

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Dear All,
With great pleasure I forward to the leprosy mailing list the enclosed message from the President of the International Leprosy Association (ILA), Dr Marcos Virmond.

Best regards,

S. Noto

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ILA Regional Congress of the Americas

The International Leprosy Association is pleased to announce that the ILA Regional Congress of the Americas jointly with the 12th Brazilian Leprosy Congress will be held in Maceio, Brazil, from 23 to 26 November, 2011.  These events are organized by the International Leprosy Association and the Brazilian Leprosy Society with support from the Ministry of Health of Brazil.  It will be a unique opportunity to convey leprosy workers from the Americas and other Regions to share experiences and knowledge towards the common goal of controlling this ancient disease.  Conferences, round tables and oral presentations are being prepared to fulfill all expectations.  So far, guest speakers already confirmed include Prof Ralf Klötzer (Germany), Dr Herman Joseph Kawuma (Uganda), Dr Bernard Naafs (The Netherlands) and Dr David Scollard (USA).  The Congress venue is the Rizt Hotel Lagoa da Anta (http://www.ritzlagoadaanta.com.br/site/).  In a few weeks full details will be available at the ILA website (http://www.leprosy-ila.org/do.php/Home )

Marcos Virmond

Summer School on Disability & Development, Depok, Indonesia, 4-28 July 2011

Leprosy Mailing List – May 31^st, 2011

Ref:    Summer School on Disability & Development, Depok, Indonesia, 4-28 July 2011

From: W v Brakel, Amsterdam, The Netherlands

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Dear Salvatore,

The VU University Amsterdam and the University of Indonesia organise an international Summer School on Disability & Development in Depok (near Jakarta), Indonesia, from 4-28 July 2011. This is the second year that this course is being organised.  The Summer School focuses on CBR, project planning, management information systems related to disability, indicator development, monitoring and participatory evaluation.  Please find the information leaflet attached.

With best wishes,

Wim

For further information, please contact: Dr. Wim van Brakel (w.van.brakel(at)vu.nl).

Strain-typing of M. leprae

Leprosy Mailing List – May 31^st, 2011

Ref.:   Strain-typing of M. leprae

From: D M Scollard, T P Gillis, J L Krahenbuhl.  Baton Rouge, LA, USA

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Dear Salvatore,

We would like to thank Dr. Warren (LML May 16^th, 2011) for her interest in the strain-typing of M. leprae that was used in the study published about 3 weeks ago in the New England Journal of Medicine (abstract attached).  This has subsequently been reported in many newspapers around the world and, as she noted, different journalists had somewhat different ideas about this.  If you only read the news accounts it could be confusing. 

As Dr. Warren indicated, for many years it was not possible to identify different strains of M. leprae.  However, as a result of the sequencing of the entire genome ofM. leprae it has become possible, in the last 10 years or so, to identify a small number of differences in the genetic sequences of bacilli isolated from patients in different parts of the world.  This paper marks a major advance in this effort, combining two different molecular techniques to identify small differences in M. leprae DNA.  The result is that we now can, in fact, identify different strains of this organism. 

The investigators used these techniques to examine M. leprae DNA from wild-infected armadillos in the US and compared this with M. leprae DNA from human biopsies.  We found that almost all of the infected armadillos had the same strain ofM. leprae, and a majority of the US patients who had no foreign travel had the same ‘armadillo’ strain.  This indicates that humans and armadillos are sharing this infection, although the exact means of transmission is still unclear.  US patients with a history of foreign travel often had strains of M. leprae associated with other regions of the world. 

There are still many limitations to these strain-typing techniques, but it is clear that we are now at the beginning of an era in which we can use methods like this to ‘track’ different sources of infection with M. leprae, and this is a major advance for epidemiological studies of this disease.  However, determining “strains” by this technique in no way implies a functional difference in the groupings that would result in an altered pathogenic potential, i.e., all strains cause the same range of clinical types of leprosy. 

David M. Scollard, M.D., Ph.D.

Thomas P Gillis, PhD.

James L. Krahenbuhl, Ph.D.

National Hansen's Disease Programs

1770 Physicians Park Dr

Baton Rouge, LA 70816

http://www.hrsa.gov/hansens

Human Anaplasmosis and Leprosy. A case report

Leprosy Mailing List –   May 21^st, 2011

Ref:    Human Anaplasmosis and Leprosy.  A case report

From: M A Piras, Sassari, Italy

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Dear Dr. Noto,

Tick-borne infection caused by Anaplasma phagocytophilum (formerly known as Erlichia granulocytica), has recently been emerging in Sardinia, where it has been reported in dogs, horses, ticks of the genus Ripicephalus (R.sanguineus and R.turanicus) (1-3) and  in two human beings (4).  Human Anaplasmosis is usually a benign flu-like disease but can be very severe and lead to renal failure in immune-depressed patients (5).  We report the case of a Nigerian immigrant with a severe Anaplasmosis infection and a protracted acute renal failure, who turned out to be suffering from borderline lepromatous (BL) leprosy as well.

Case report

A  Nigerian 26 year old man was admitted in our hospital with a 5-day history of mild remittent fever, headache and peripheral symmetric oedema of his hands and feet.  A migrant, who has been living in Europe for one year, homeless, spent daytime in a town park and the nights in a hospice.  He denied any stay in the countryside and/or contact with domestic or wild animal.  In his medical history he reported Malaria but denied other relevant diseases, particularly Tuberculosis.

Physical examination was significant for cutaneous dyschromia with  the presence of diffuse circular, smooth, hypopigmented spots on his trunk and limbs, small and non tender lymph nodes in the laterocervical and axillary regions, moderate splenomegaly and peripheral symmetrical  oedema of his hands, wrists, feet and ankles with functional impairment; he was underweight. Chest X ray and pulmonary HRCT scan were normal.

On admission, remarkable laboratory findings were: absence of  acute phase reactants with low ESR and normal C reactive protein, alfa2 globulin and fibrinogen, presence of severe leucopenia with normal differential count, mild anemia, high hypergammaglobulinemia, moderate hypoalbuminemia.  Glucose, renal function and urine examination were normal.  Serological tests were negative for Malaria antigens, Streptolysin O antibodies, HIV screening and viremia, Syphilis and HCV; he was immune for past infection to HBV, CMV, EBV, Parvovirus and Measles. TB Quantiferon test resulted negative.

Pending the unrevealing results of blood and urine cultures, empiric  therapy was established  with two consecutive, both ineffective, courses of piperacilline/tazobactam and cyprofloxacin  while fever assumed an intermittent pattern with climax of 39.6 °C.  Successively, pending serological investigation for tickborne diseases, a course of doxicicline 100 mg bid po for 2 weeks achieved  that hectic fever subsided into a slight persistent fever of 37.2-37.4°C.  Eventually, serology proved to be significant for Anaplasma phagocytophylum with indirect immunofluorescence titres of IgM 1/160 and IgG 1/40 followed by seroconversion with IgG 1/320 and disappearance of IgM.

Early in the doxicicline course, clinical chemistry parameters got worse with increase of ALT (6x), AST (5x), GGT (6x), alkaline phosphatase (7x), LDH (3x), CPK (4x), myoglobin (8x), beta2 microglobulin (8x).  Acute renal failure was detected on day 12 of doxicicline treatment and persisted throughout with a progressive decline of creatinine clearance.  In the meantime there was a worsening of anaemia to HB 7.1 g/dl with inadequate reticolocyte response, lymphocytopenia to 300/l with normal neutrophil and platelet counts.  Moderate signs of rhabdomyolis and increase of ESR occurred while C reactive protein, alfa2globulins and fibrinogen persisted in the normal range.  Judging the first course of treatment insufficient a second 2 week course of doxicicline was established without significant results apart from a change of cutaneous dyschromic spots that became prominent, scaling and erythematous.

Diagnostic procedures were performed on kidney, bone marrow and skin.  Renal biopsyshowed at glomerular level a mild increase of the matrix and mesangial cellularity with deposits of IgM and IgA, the tubules had aspects of granular degeneration.  At interstitial level there was a marked lymphocytic infiltration with rare polymorphonucleated cell and a few plasmacells, mild thickening of the vessel walls.  Osteomedullary histology showed normal representation and maturation of the three lineages without increase of lymphoid cells, normal representation of B and T cells and polyclonal plasmacells with mild increase of the reticolinic network and CD34 positive cells in the normal range.  Skin biopsy, taken without any definite suspicion at the center of a dyschromic lesion in the anterior chest, revealed in the superficial and middle dermis histiocytic infiltration with epitelioid cells organized in perivascular granulomatous structures without evident aspects of necrosis.  Histochemical investigations (Pas, Giemsa, Grocott, Ziehl-Neelsen) were negative.  Fite staining was not available.

The latter report, although inconclusive on a possible microbiological etiology, pointed to a possible diagnosis of Leprosy.  Actually, on active search we found bilateral hypertrophy of the great auricular and ulnar nerves (see figures 1, 2).  After consulting a Leprosy expert (who became one of the authors), the diagnosis of borderline borderline (BB) leprosy in reversal reaction (RR), as evolution of borderline lepromatous (BL) leprosy was made.  We considered the RR a consequence of the anaplasmosis and doxicicline treatment.  On that moment the patient revealed he had been thinking of having leprosy because he was aware of a few cases in his Nigerian village, but he had never consulted a physician nor had he been treated for leprosy.  A five day course of metil-prednisolone 30 mg daily was started when the result of the kidney biopsy became known.  This resulted in an improvement of renal function, anemia, leucopenia and reduction of the extremity edema.  After three months the patient was transferred to the regional centre for Hansen, disease where the diagnosis was confirmed.

Discussion

This unique case of association of anaplasmosis with leprosy can be regarded as an interesting natural experiment of immunological perturbation that caused a prolonged and difficult to decipher disease presentation.  Let us examine separately the most interesting points of the two infections.

Anaplasmosis: on an epidemiological point of view, it was not immediately clear if our patient had been exposed to tick infested in rural areas or had been in contact with pets or wild animals. Nevertheless, his stay in town parks and night cohabitation with homeless people could well have exposed him to ticks. The absence of acute phase reactants in a highly febrile patient was another intriguing point.  Actually, Anaplasma phagocytophylum has as virulence factor the escape from neutrophil phagocytosis, through the inhibition of phagolysosome fusion.  Although it is a potent inducer of -- INF, at the same time it behaves as an inhibitor suppressing the expression of -- INF membrane receptors and inhibiting the proinflammatory action in favour of bacterial multiplication withi n neutrophils (5- 6).  The apparent failure of the appropriate treatment for anaplasmosis was another point of doubt since, despite the abatement of fever, the clinical course tended toward a greater severity.  Limited rabdomyolisis with increased levels of creatinphosphokinase and myoglobin did not seem high enough to justify the persistence of moderate renal failure in comparison with similar data reported in the literature (7).  Other findings like anaemia, ineffective reticulocyte response, leucopenia and hypergammaglobulinemia suggested an anergy inducing disease that was searched in vain among lymphoproliferative disorders or miliary tuberculosis.  Furthermore, while renal insufficiency persisted, the second doxicicline course produced a variation of the skin lesions that, together with renal failure and nerve hypertrophy, were later interpreted as reversal reaction in BL leprosy.

Leprosy:  autochthonous leprosy has not disappeared in Europe, even if no case has been reported in WHO weekly epidemiological records in recent years.  In Italy, between 1970 and 2006, local data report a decreasing (autochthonous) incidence but with increasing percentage of imported cases.  These were 16% of 102 new cases in 1970-79 and 80% of 61 new cases in 2000-06 (8). In 2010 only one case of autochthonous leprosy was reported in Italy.  Thus, with the great migration of people from endemic countries we are coping with in the last decades, we should expect more than one opportunity to encounter a leprosy patient than we used to think.  Among Africa countries, Nigeria is afflicted by high Leprosy burden that has remained grossly stable between 2003 and 2009 when 88% of 4219 new cases were multibacillary forms (9).

Although our patient had an impressive dyschromic skin with  several circular hypopigmented spots we didn’t think of leprosy and passively accepted a trivial dermatologic diagnosis until the change of their appearance prompted new diagnostic procedures.  Unfortunately, the skin biopsy was taken from the centre of the lesion instead of the periphery, as prescribed for leprosy, so diminishing the chance to find mycobacteria in the histologic smear in spite of the multibacillary form of the disease.  Yet, the finding of a granulomatous lesion was the key to the final diagnosis.  Reversal reaction occurs mainly in the instable forms of leprosy, very rarely in polar forms, and is characterized by an upgrading of cell mediated immunity toward the mycobacterial antigens.  It implies oedematous alterations of the limb extremities, increase of inflammation in skin lesions with dermis oedema, nerve alterations with hypertrophy, neuritis and functional impairment.  Type 2 leprosy reaction is most frequent in lepromatous leprosy and is characterized by deposition of immune complexes causing erythema nodosum and glomerulonephritis. RR is controlled by steroid treatment (10).

In our case we hypothesize that the extremity peripheral oedema, for long ascribed to anaplasmosis, was already giving shape to a reversal reaction.  It could be triggered bygamma INF induced by Anaplasma phagocytophylum infection, with doxicicline treatment (which has an antibacterial effect against M. Leprae), contributing to the evolution of BL leprosy towards BB leprosy.  The small enlargement of latero-cervical and axillary lymph nodes that remained unchanged through the disease in a very thin patient were not considered of clinical significance.  Complicated Anaplasmosis is the most likely explanation for renal insufficiency.  Renal disease is not a feature of RR in instable forms of leprosy.  Serendipitously, steroid treatment, aimed to control renal insufficiency, turned out to be useful for the RR in our patient.

Best regards,

Maria Adriana Piras

MD, Clinic of Infectious Diseases, University of Sassari, Italy

Coauthors: Are R, Figoni M, Salis MT, Caddeo A, Fiori ML, Manconi GG

Figures: (attached)

1. Skin lesions on the chest figure 1, figure 2
2. Great auricular nerves
3. Table

References

1. Alberti A, Addis MF, Sparagano O, Zobba R, Chessa B, Cubeddu T, Pinna Parpaglia ML, Ardu M, Pittau M. Anaplasma phagocytophylum, Sardinia, Italy. Emerg Infect Dis 2005;11:1322-24
2. Alberti A, Zobba R, Chessa B, Addis MF, Sparagano O, Pinna Parpaglia ML, Cubeddu T, Pintori G, Pittau M. Equine and canine Anaplasma phagocytophylum strains isolated on the island of Sardinia (Italy) are phylogenetically related to pathogenic strains from the United States. Appl Environ Microbiol 2005;71:6418-22
3. Satta G, Chisu V, Cabras P, Fois F, Masala G. Pathogens and symbionts in ticks: a survey on tick species distribution and presence of tick-transmitted micro-organisms in Sardinia, Italy. J Med Microbiol 2010 Sept 30 [Epub ahead of print]
4. Mastrandrea S, Mura MSA, Tola S, Patta C, Tanda A, Porcu R, Masala G. Two cases of human granulocytic Erlichiosis in Sardinia, Italy, confirmed by PCR. Ann N Y Ac Sci 2006;1078:548-551
5. Dumler JS, Choi KS, Garcia-Garcia JC, Barat NS, Scorpio DG, Garyu JW, Grab DJ, Bakken JS. Human granulocytic Anaplasmosis ND Anaplasma phagocytophylum. Emerg Infect Dis 2005;11:1828-34
6. Bussmeyer U, Sarkar A, Broszat K, Ludemann T,Moller S, van Zandbergen G, Bogdan C, Behnen M, Dumler JS, von Loewenich F, Solbach W, Laskay T. Impairment of gamma interferon signalling in human neutrophilsa infected with Anaplasma phagocytophylum. Infect Immun 2010;78:358-63
7. Boateng F, Ohene-adijei R, Amoateng-Adjepong Y.  Rhabdomyolysis and acute renal failure associated with human granulocytic Anaplasmosis. Mayo Clin Proc 2007;82:250-53
8. Deepak s, Voltolini G. La lebbra oggi in Italia: malattia dimenticata? Giorn It Mal Tor 2007;61:413-416
9. WHO. Global leprosy situation 2010.  WHO Week Epidem Rec 2010;85:337-348
10. Walker SL, Lockwood DNJ. Leprosy Tipe 1 (reversal) reactions and their management. Lepr Rev 2008;79:372-86

Summer School on Disability & Development, Depok, Indonesia, 4-28 July 2011

Leprosy Mailing List – May 21^st, 2011

Ref:    Summer School on Disability & Development, Depok, Indonesia, 4-28 July 2011 From: W van Brakel, Amsterdam, The Netherlands

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 Dear Salvatore,

The VU University Amsterdam and the University of Indonesia organise an international Summer School on Disability & Development in Depok (near Jakarta), Indonesia, from 4-28 July 2011.  This is the second year that this course is being organised.  The Summer School focuses on CBR, project planning, management information systems related to disability, indicator development, monitoring and participatory evaluation.  Please find the information leaflet attached.

With best wishes,

Wim

Wim van Brakel
For further information, please contact Dr. Wim van Brakel (w.van.brakel(at)vu.nl).

Treatment of reactions sometimes needs to be extended more than 6 months

Leprosy Mailing List – May 21^st, 2011

Ref:    Treatment of reactions sometimes needs to be extended more than 6 months.

From: W. J. Theuvenet, Apeldoorn, The Netherlands

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Dear Dr. Naafs,

Thank you for your valuable observation (LML May 18^th, 2011) that reactions often need treatment longer than 6 months.  This covers my personal experience.  In my last borderline leprosy (BL) patient the neuritis of several nerves frequently recurred in the first 24 months after putting her on MDT/ Prednisone and an increased dosage of clofazimine.  Most of the nerve(s) function responded very well on this regimen and over this period she could never really do without varying dosages of the prednisone/clofazimine, this modulating with the severity of the neuritis.  The right tibial nerve was decompressed (by the "selective meshing of the epineurium" method) at the tarsal tunnel as it did not respond within 4 months on this regimen and sensation was restored within 2 weeks after operation!  From Semmes Weinstein Monofilament (SWM) test 6.65 negative to 4.31 positive at the vulnerable Hallux andfirst metatarsophalangeal (MTP) -1 area.

Personally I feel that more research is needed as the present neuritis treatment even when applied with a longer duration, often gives some "improvement" of nerve function, but this "improvement" is hardly ever back to a functional level, be it to full restoration of nerve function.  In this situation it is sad that there is very little attention paid to the alternative of a nerve decompression.  To operate on a nerve ("nerve decompression") seems to frighten the ignorant but it is not "brain surgery" and provides often a simple alternative for the restoration of nerve function where medical treatment fails.

TENLEP may offer valuable information and any new research is welcome, as nowadays permanent nerve function loss is often too easily accepted as a consequence of leprosy.  Without this nerve function loss there would hardly be any need for stigma reduction, community based rehabilitation, empowerment etc etc.  We therefore urgently need better tools to properly treat leprosy neuritis!

With best regards,

Willem J. Theuvenet.

Treatment of reactions sometimes needs to be extended more than 6 months

Leprosy Mailing List – May 18^th, 2011 

Ref:    Treatment of reactions sometimes needs to be extended more than 6 months.

From: B Naafs, Munnekeburen, The Netherlands

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Dear Salvatore,

Concerning the remarks of Paul Saunderson in LML May 13^th 2011.  Research to understand reactions and nerve damage is essential, but should serve a purpose.  The purpose is in my opinion "to gain understanding in order to improve treatment".  Treatment has been well described in the past and many patients have benefited.  Among the earlier papers, based on the extensive experience of John Pearson there is:-

         

            B. Naafs, J.M.H. Pearson and H.W. Wheate

            Reversal Reaction: The prevention of permanent nerve damage. Compari­son of short and long term steroid treat­ment.

            Int. J. Lepr. 47 (1979) 7-12

Many however followed the notion, expressed in so called “evidence based medicine”, that observational studies do not provide strong evidence.  Leprosy experts pushed therefor to shorten treatment protocols.  The result was that in the management of Type 1 leprosy reactions patients were, for a long time, not getting adequate treatment.

Leprosy experts with no “hands on” experience have designed and inspired trials which were not adequately designed, not taking in account what was earlier written and which only could conclude that the treatment should be longer and further research has to be done.  For the benefit of whom?  Researchers from Bauru, Addis Ababa, Karigiri, Hyderabad and Chandrigar had already shown long before, that reaction treatment sometimes needs to be extended to more than 6 months.  May be those recent trials teach some of the clinicians who conducted the trial.  But it takes longer to reach the less experienced leprologists and programme managers who have not enough experience to follow their own observations and those of the older literature.

In desperation I wrote two papers which should be kept in mind judging future trials and advises of authorities.

B. Naafs

Treatment duration of reversal reaction: A reappraisal. Back to the past.

Lepr. Rev. 74 (2003) 328-336

B. Naafs

Treatment of leprosy: science or politics?

            TM&IH 11 (2006) 268- 278

I’m afraid that even the mentioned Tenlep trial does not take the duration of reactions in some, especially MB, patients in account. The conclusion will be again that: for some patients the longer treatment seems better and more research has to be done.

With kind regards,

Ben Naafs

Mycobacterium leprae

Leprosy Mailing List – May 16^th, 2011 

Ref.:   Mycobacterium leprae

From: Grace Warren, Sydney, Australia

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Dear Salvatore,

I have seen a number of newspaper articles recently regarding the leprosy bacillus.  It is stated that a new strain of M. leprae has been discovered in the armadillo. As you well know for years we were taught that there was only one strain of M. leprae.  So I write to you to ask that someone give us a summary of the true facts.  Articles in papers and on the web do not always give the practical truth.

One paper says it cannot be passed on to humans.  Another says it can and one article says that in “America some people have one strain and some the other” implying that the armadillo strain can affect humans.  Though another article states it does not.  One article says the two strains are in South America and imply that the armadillo strain is transmitted to humans in S America. 

 I would love to have a bit more true information.  Thank you very much.

Grace Warren

Previously adviser in Leprosy and reconstructive surgery for The Leprosy Mission in Asia (1975-1995)

Leprosy situation in the Democratic Republic of Congo

Leprosy Mailing List – May 16^th, 2011

Ref:    Leprosy situation in the Democratic Republic of Congo

From: J F Mukalay, Kinshasa/Gombe, Democratic Republic of Congo 

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 Dear Salvatore,

I am sending this few information summarizing the leprosy situation in Congo today (please see the enclosed paper, text and slides).  It shows just the trend of new cases 2000-2009.  I couldn't get in time the 2010 data, but I expect them to be similar to 2009.

With regards,

Jean Felly Mukalay.

The Leprosy Mission Congo

124, Avenue Mongala,

Kinshasa/Gombe,

P.O. BOX 14347  KIN 1

Democratic Republic of Congo

Management of Type I reaction (reversal reaction)

Leprosy Mailing List – May 13^th, 2011 

Ref:    Management of Type I reaction (reversal reaction)

From: P. Saunderson, Greenville, SC, USA

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Dear Salvatore,

In relation to the management of Type 1 reactions, I would like to make a few comments:

1.    There is general agreement that steroid treatment probably needs to be longer than 12 weeks, although 30-40 mg seems to be an adequate starting dose.  There is a need for better evidence from well-designed clinical trials, before we can state clearly what is the best routine treatment for Type 1 reactions.

2.    A good starting point for discussion at the moment is the paper by Rao PS, Sugamaran DS, Richard J, Smith WC: Multi-centre, double blind, randomized trial of three steroid regimens in the treatment of type-1 reactions in leprosy.  Lepr Rev. 2006 Mar;77(1):25-33.  The paper is attached.

3.    On the basis of this paper, The Leprosy Mission now advocates the 20 week regimen tested in the trial, namely: prednisolone 30mg for 2 weeks, 25mg for 2 weeks, 20mg for 8 weeks, 10 mg for 4 weeks, 5mg for 4 weeks.  The aim is to extend the length of the course, but keep the total dose of prednisolone as low as possible.

4.    A new randomized, controlled trial is just about to start under the name ‘TENLEP’ (Treatment of Early Neuritis in Leprosy), which is a multi-center study managed by the Royal Tropical Institute (KIT) in Amsterdam.  This study will compare a 20 week regimen with a 32 week regimen in the treatment of new nerve function impairment, which is closely related to the occurrence of a Type 1 reaction.

Paul Saunderson MD, MRCP

Medical Director

American Leprosy Missions

1 ALM Way, Greenville, SC 29601, USA

Leprosy Mailing List – May 11^th, 2011 

Ref:    Management of Type I reaction (reversal reaction)

From: W. S. Bhatki, Santacruze (E), Mumbai, India

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Dear Dr Noto,
Though the standard treatment for management of leprosy reactions is laid down, the same cannot be practiced in all the cases.  The clinicians who actually handle the cases with leprosy reactions have often to decide the line of treatment, based on the response in individual cases.  I report herewith about “Difficulties in management of Type I leprosy reaction with facial lesions”.

I came across three cases (photographs enclosed below) with solitary, medium sized, raised, erythematous, plaque-like anaesthetic facial lesions. The patients received paucibacillary multy-drug therapy (PB/MDT) for 6 months and steroid therapy in tapering doses.  All of them were skin smear negative.  No biopsies were done. The three photographs (enclosed) were taken after these patients were referred to us after completing their course of PB/ MDT, and because of suffering from 1-2 episodes of reaction without satisfactory result while on steroids as described below.

The initial response to prednisolone with daily dose of 40 mg was good as the lesions showed noticeable regression. The dose of prednisolone was tapered by 5-10 mg every 2 weeks.  The lesions recurred with erythema and oedema when the daily dose of prednisolone was brought down to around 15-20 mg; this forced the clinician to raise the daily dose to 30 mg or more.  This phenomenon occurred repeatedly in the cases under reference. 

In the context of fluctuating clinical response, the clinicians often face problems such as:

1.    The total duration of steroid therapy is much more extended beyond the usually advocated period of 12 weeks posing a threat of serious side effects.

2.    The clinicians are often inclined to extend the period of MDT beyond 6 months or sometimes even switch over to multibacillary (MB) MDT.

3.    Due to repeated recurrence of face lesions, the case holding becomes difficult as the patients tend to change the doctors.

Steroid treatment (prednisolone) is still considered the treatment of choice for Type I reaction with the starting daily dose of 30-40 mg.  However, the duration of treatment could be a matter of debate.  I would like to have the opinions and the advice from colleagues on this and the issues mentioned above especially with reference to face lesions which could cause severe psychological distress to the affected persons.

Regards,

Dr. W. S. Bhatki

Maharashtra Lokhita Seva Mandal

Santacruze (E), Mumbai, India

Check images on: http://www.aifo.it/english/resources/online/lml-archives/2011/110511.htm

Leprosy supervisors will be conducting dermatology clinic in rural areas

Leprosy Mailing List – May 7^th, 2011 

Ref:     Leprosy supervisors will be conducting dermatology clinic in rural areas

From: J Mukalay, Kinshasa, Democratic Republic of Congo

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Dear Salvatore,

I refer to prof. Ryan’s message (LML May 5^th, 2011).  The “Task Force for Skin Care for All” sounds very interesting to us today when leprosy is becoming less endemic and less motivation of field workers.

We have already planned a dermatology workshop for some key leprosy supervisors nurses who will be conducting dermatology clinic in rural areas.

How to get the CD? Any cost?

With regards,

Jean Mukalay

Mr. Jean Mukalay

Technical advisor for The Leprosy Mission Congo

Kinshasa

Democratic Republic of Congo

Task Force for Skin Care for All

Leprosy Mailing List – May 5^th, 2011 

Ref:  Task Force for Skin Care for All

From: Ryan T., Oxford, UK

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Dear Salvatore,

Readers will note the publication of a Task force Skin Care for All contains much relevant to Leprosy.  I have prepared a CD with 44 articles containing the evidence that Community Dermatology has the Capacity to Benefit obtainable from Cindy Froehlich at the HQ of The International Society of Dermatology

Email: info(at)intsocderm.org   Our next move is to ensure that there is a workforce sufficiently well-funded to carry out the mission of Skin Care for All.

Sincerely,

Terence Ryan

Leprosy indicators in Gabon, 1991-2010

Leprosy Mailing List – May 4^th, 2011 

Ref:     Leprosy indicators in Gabon, 1991-2010
From:  Mondjo A., Libreville, Gabon

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Dear Salvatore,

Herewith are enclosed the key indicators of the leprosy programme in Gabon during the last twenty years.

Last year we reported 17 patients with WHO grade 2 disability (our population estimated = 1 800 000).  Our rate of new cases with invalidity grade 2 per 100,000 inhabitants is very high (0.93) and Gabon has planned to reduce it by 50% by the year 2015 (that is to say less than 9 cases with disability).

Best regards,

Dr Annick MONDJO

Patiet with leprosy awaiting renal transplant

Leprosy Mailing List – May 4^th, 2011

Ref:     Patiet with leprosy awaiting renal transplant
From:  V. Jain,  V. Halwai, R Ganapati, Mumbay, India

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Dear Dr Noto,

Renal damage due to repeated Type 2 (erythema nodosum leprosum) reaction used to be seen during dapsone monotherapy period.  We (RG) have  observed irreversible nephropathy as the  the cause of death in some such patients in leprosy hospitals.  The science of nephrology was not so advanced in those days.  Since the advent of MDT and effective management of reactions, such morbidity has considerably reduced.

We have been reading with interest the correspondence on the above subject and are keen to know the follow up of the patient.  We may bring to the notice of your readers the abstrct of the article on "renal transplantation in leprosy patients"  reported from Brazil by

Roselino Am, de Almeidia Am, Foss NT, LimaVJ, Raspanti EO, Ferraz AS, in the Int  J. Lepr Other Mycobact Dis, 1993 Mar;61(1): 102-5

"We report four cases of leprosy in renal transplant recipients, two of whom had the disease before transplantation and no signs of relapse even in the presence of immunosuppressive drugs. The other two cases presented with lepromatous and borderline (dimorphous) leprosy 5 months and 5 years after transplantation, respectively. The disease of the last patient was controlled with sulfone even in the presence of immunosuppressive drugs, but the mechanism whereby the first patient rapidly developed lepromatous leprosy is unclear, even though he was a home contact of a patient with lepromatous leprosy (his wife).  In view of the data presented here, we do not contraindicate renal transplantation in patients with leprosy who frequently suffer changes in renal function. We believe that renal function should be periodically evaluated in patients with borderline and lepromatous leprosy".

Thanking you,

Vivika Jain,  Vikas Halwai and R Ganapati,

Bombay Leprosy Project,

Infoleps Choice of new (e) publications on leprosy

Leprosy Mailing List – May 5^th, 2011

Ref:  Infoleps Choice of new (e) publications on leprosy 2011 04 26

From: Jiske Erlings, Amsterdam, The Netherlands

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Greetings from Infolep!

Have you tried the new website www.leprosy-information.org yet?
This is a joint effort of ILEP & Infolep to support information needs in global leprosy control efforts by providing access to leprosy information resources on leprosy and related subjects.
The website already includes references of over 21.000 publications.  Please bear with us while we improve the site with smarter viewing, better search facilities and interactive tools.

Below you will find this weeks selection of new publications on leprosy.  Feel free to contact me for full text versions.  Do you have publications on leprosy to include in the new website?  Please let me know! 

With kind regards,

Jiske Erlings
Infolep Leprosy Information Services
Postbus / P.O. Box 95005
1090 HA Amsterdam
The Netherlands

Tel: +31 20 5950530
E-mail: J.Erlings(at)Leprastichting.NL
Web: www.leprosy-information.org

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Articles

1: Caroline C, Puspita CG, Widjaja FF, Sopandi SS.
Stigma towards leprosy among medical students. Maj Kedokt Indon. 2011;61(120).

Free full text online: http://www.leprosy-information.org/resource/stigma-towards-leprosy-among-medical-students

2: Kanthraj GR.
Newer insights in teledermatology practice. Indian J Dermatol Venereol Leprol.2011;77(3):276-87.

Free full text online: http://www.leprosy-information.org/resource/newer-insights-teledermatology-practice

3: Montenegro RM, Molina MD, Moreira M, Zandonade E.
[The nutritional and dieting profiles of patients diagnosed with leprosy treated in the primary healthcare units of Greater Vitória, State of Espírito Santo, Brazil.]. Revista da Sociedade Brasileira de Medicina Tropical. 2011.

Free full text online: http://www.leprosy-information.org/resource/nutritional-and-dieting-profiles-patients-diagnosed-leprosy-treated-primary-healthcare-unit

4: Ribeiro SL, Pereira HL, Silva NP, Souza AW, Sato EI. Anti-b2-glycoprotein I antibodies are highly prevalent in a large number of brazilian leprosy patients. Acta reumatologica portuguesa. 2011;(1):30-7.

Free full text online: http://www.leprosy-information.org/resource/anti-b2-glycoprotein-i-antibodies-are-highly-prevalent-large-number-brazilian-leprosy-patie

5: Sampaio L, Silva L, Terroso G, Pimenta S, Brandão F, Pinto J, et al. Hansen's disease mimicking a systemic vasculitis. Acta reumatologica portuguesa. 2011;(1):61-4.

Free full text online: http://www.leprosy-information.org/resource/hansens-disease-mimicking-systemic-vasculitis

6: Scollard DM, Chaduvula MV, Martinez A, Fowlkes N, Nath I, Stryjewska BM, et al.
Increased CXCL10 Levels and Gene Expression in Type 1 Leprosy Reactions.Clinical and vaccine immunology : CVI. 2011.

7: Schmidt-Borko KM.
[Leprosy - the neglected disease.]. Deutsche medizinische Wochenschrift (1946). 2011;136(15):p11. German.

8: Shanmugam A, Natarajan J.
Comparative modeling of UDP-N-acetylmuramoyl-glycyl-D-glutamate-2, 6-diaminopimelate ligase from Mycobacterium leprae and analysis of its binding features through molecular docking studies. Journal of molecular modeling. 2011.

9: Walker SL, Nicholls PG, Dhakal S, Hawksworth RA, Macdonald M, et al. 2011
A Phase Two Randomised Controlled Double Blind Trial of High Dose Intravenous Methylprednisolone and Oral Prednisolone versus Intravenous Normal Saline and Oral Prednisolone in Individuals with Leprosy Type 1 Reactions and/or Nerve Function Impairment. PLoS Negl Trop Dis 5(4): e1041.Free full text online:http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0001041

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Publications Task Force for Skin Care for All In Int J Dermatol. 2011;50(5).:

Ryan TJ.
The International Society of Dermatology's Task Force for Skin Care for All: Community Dermatology. Int J Dermatol. 2011;50(5):548-51.

Hay RJ, Fuller LC.
The assessment of dermatological needs in resource-poor regions. Int J Dermatol. 2011;50(5):552-7.

Hay R, Estrada R, Grossmann H. Managing skin disease in resource-poor environments - the role of community-oriented training and control programs. Int J Dermatol. 2011;50(5):558-63.

Ryan TJ, Hirt H-, Willcox M. Collaboration with traditional health practitioners in the provision of skin care for all in Africa. Int J Dermatol. 2011;50(5):564-70.

Waugh M. Bringing treatment and control programmes for sexually transmitted infections (STIs) through international development and cooperation: a commentary on the Task Force for Skin Care for All. Int J Dermatol. 2011;50(5):571-2.

Handog EB, Gabriel MT, Co CC. Leprosy in the Philippines: a review. Int J Dermatol. 2011;50(5):573-81.

Ersser SJ, Kaur V, Kelly P, Langøen A, Maguire SA, Nicol NH, et al. The contribution of the nursing service worldwide and its capacity to benefit within the dermatology field. Int J Dermatol. 2011;50(5):582-9.

Karelas GD. Social marketing self-esteem: a socio-medical approach to high-risk and skin tone alteration activities. Int J Dermatol. 2011;50(5):590-2.

Murrell DF, Ryan TJ, Bergfeld WF. Advancement of women in dermatology. Int J Dermatol. 2011;50(5):593-600.

Andersen LK. Global climate change and its dermatological diseases. Int J Dermatol. 2011;50(5):601-3.

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Journals online

Indian Journal of Dermatology, Venereology and Leprology: 2011;77(3) - Read online:http://www.ijdvl.com/currentissue.asp?sabs=n

Indian Journal of Leprosy: 2011;83(1) - Read online: http://www.ijl.org.in/index.html

Leprosy Review: 2011;82(1) - Read online: http://www.leprahealthinaction.org/volume-82-number-1-march-2011/