Leprosy Mailing List – November 18, 2015
Ref.: (LML) Draft WHO Leprosy Strategy 2016-2020
From: Jaison Barreto, Bauru, Brazil
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Dear Pieter
It is important to emphasize that leprosy is a chronic disease, and it has a natural history. In a normal distribution, the disease is transmitted by ancestors of the index case, usually father or mother, or more often grandfather / grandmother when the patient is a child with MB leprosy.
In my PhD thesis, made in a non-endemic area of Brazil, I found that attack rate for family members of lepromatous leprosy did not changed after introduction of MDT, and it is still the same as published by Doull in Philippines in 1940's: 0.7% per year. This means that you have a chance of almost 10% to find a case by the age of 15.
When we find a case, it must be remembered that there is a natural history: early or TT leprosy (true PB) have a mean time of restricted nerve (Schwann cells) disease, i.e., nerve branches or nerve endings, from 3 to 5 years. As the multiplication time for M.leprae is two weeks, when ones found a child with high bacterial load (MB), it was infected by a continuous, earlier and closer exposition to lepromatous patient, usually grandmother or grandfather, and often they were not diagnosed before, as non-pathognomonic symptoms like nasal obstruction or paraesthesia in lower limbs are common in the elderly.
Also, it is not uncommon the finding that relapsing and intractable reactions are associated with family members not previously evaluated. Last week I found a case like this, in Dominican Republic. It was a 30 years old woman with recurrent ENL, for 6 years, steroid dependant. I asked her: who had leprosy in your family? Only 3 persons and they are my uncles. I asked again: brothers of your father or your mother? She answered: mother. I asked if she lived with their uncles in close contact. She told me no. I asked her if the household contacts were evaluated, and she told me that only the people who lived with her in the same house in the last five years, i.e., husband and sons. When I asked why her mother was not evaluated, she told me that the reason was because she was too old, deficient and blind due to diabetes. I emphasized that the history of several mother's brothers with leprosy was highly suspect. After she was convinced, she brought her mother, and the 80 years old woman presented a high advanced lepromatous leprosy, and also diabetes.
Cases like this are also very common in Brazil: intractable reaction due to chronic re-exposition. This is the reason our Ministry of Health recommends evaluation of ALL family members, living or not with the index case.
Best regards
Jaison
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
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