Ref.: (LML) Smear positivity after one year course of MB MDT

 

Leprosy Mailing List – August 23,  2021

 

Ref.:  (LML) Smear positivity after one year course of MB MDT

From:  Jaison Barreto, Bauru, Brazil

 

Dear Pieter,

 

We evaluate and we have done histopathology and inoculation in mouse foot pads for all patients with no good response to MDT. As many as 40% of BL and LL patients have a positive inoculation in mouse foot pads, and almost all have well stained bacilli or viable bacilli, or bacilli inside endothelial cells, which means recent bacillaemia.

 

The mean time interval to see a relapse bacteriologically is 8 years for patients in lepromatous range after MDT 12 doses, and 13 years for those treated with MDT 24 doses. Almost all patients show an initial improvement after 12 doses, but most of them still had viable bacilli that continued to grow, sometimes with reaction, mostly type 2, and after a enough time, we showed that, unfortunately, the patient was not cured.

 

We also have the problem of reinfection, once household contacts are usually not evaluated or followed. As many as 50% of my patients with relapse have family members with active disease. In this case, I think that these relapses are resulting from a mix of reinfection plus not enough treatment.

 

Leprosy is an ancient and complex disease. Doull found in Philippines, and published in 1942, a 0.6% per year rate of attack of leprosy in family members. The M.leprae know how to stay dormant and alive in family members. Dr Opromolla always said that who keep the endemic is the lepromatous patient.

 

It is very difficult to diagnose them. Most young LL patients do not show signs or symptoms of peripheral neuropathy. Most have signs and symptoms of rheumatism, or vascular disease. The expertise to stain the M.leprae in slit skin smear or biopsy slides was lost. Every month I see patients with reports of misdiagnosis due to a mix of lack of suspicion or/and mistakes in laboratorial examination.

 

Most physician continues to believe that leprosy is a question of patches, like vitiligo. Leprosy is a primary disease of Schwann cells, with or WITHOUT patches, as well as syphilis is a primary disease of endothelial cells, with or WITHOUT patches. Of course, as there are thousands of Schwann cells and endothelial cells in skin, these diseases usually have visible skin inflammation, but not always.

 

We also have the question of number of lesions, the Apocalypses of Leprosy. If the patient has 1 single visible leproma, is this patient a PB? Or should we call LL leprosy only with 6 lepromas? At the same way, should we consider Primary Syphilis with 1 lesion, secondary with 2 lesions, and tertiary with 3 or more?

 

Chaterjee wrote a very good concept of leprosy - in potentially a malign and a benign group. And Ridley found that only 10% of patients will develop self-limited disease. In these more than 20 years of Leprosy, I saw less than 10 cases of TT or Indeterminate (initial) disease. Most TT are, indeed, BT, when is possible to follow up, and they relapse due to insufficient treatment (PB with reaction) after 7 years. And most adults with Indeterminate Leprosy are, indeed, macular borderline, developing neuritis during or after treatment and relapses bacteriologically visible after 8 years. 

 

Finally, let's try to understand better this disease, and teach health professionals about the concept of spectral leprosy. 

 

 

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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