Leprosy Scenario in Ahmedabad District (Gujarat).

BACKGROUND: In India, leprosy still continues to be one of the major public health problems and demands a continuous awareness for its eradication. The reduction of the load of infection is the cornerstone of leprosy control. AIMS: The aim of the present study was to enumerate the epidemiology of leprosy in the Ahmedabad district of Gujarat.
METHODS: Three hundred new cases of leprosy (multidrug therapy cases) and patients who had completed antileprosy treatment and developed new signs and symptoms after that during the period from June 2010 to December 2012 were included in the study. A detailed history, clinical examination, and relevant tests were done.
RESULTS: Out of a total of 300 patients, male-to-female ratio was 2.1:1. Family history was positive in 4.3% of patients. Lepromatous leprosy was seen in 27.3%, pure neuritic leprosy occurred in 12 (3.9%), and smear positivity was seen in (44.6%). Thirty (10%) patients developed type 1 reaction and 32 (10.6%) patients had type 2 reaction. Nearly 1.3% of the cases were relapsing cases. LIMITATIONS: The study had geographical limitation and the study did not cater the whole population but only the cases who reported to the hospital. Hence, the social stigma factor associated with leprosy could not be annulled.
CONCLUSIONS: Leprosy still prevails and adequate knowledge and clinical skills, sensitive diagnostic tools and proper supply of medicines from the medical end and early reporting of symptoms, compliance regarding medicine intake, and social awareness to null social stigma associated with it from the patient's end may bring the country as a whole to the target of leprosy elimination.

Introduction

Leprosy, one of the oldest diseases of mankind, is a disease worth discussing. Although lot has been said about its diagnosis and treatment, its sufferers and even the caretakers have been rejected by the society at times. Despite the fruitful yields of recent research, many enigmas remain and constitute a challenge to medicine.

Leprosy is thought to have first originated in India; however, today, it is recognized globally. The WHO has launched a 5-year “Global leprosy strategy 2016–2020” in April 2016 titled “accelerating towards a leprosy-free world”[1] and a “Global leprosy update,2016: accelerating reduction of disease burden” – although there has been a significant reduction in the prevalence of the disease worldwide since the mid-1980s to elimination level, new cases continue to arise indicating continued transmission.[2] The global prevalence at the end of 2016 was 171,948 with a registered prevalence rate of 0.23/10,000 population, a decrease from that in 2015.[3]

Leprosy still continues to be one of the major public health problems in many countries, including India. Although India has succeeded in bringing the national prevalence down to “elimination as a public health problem” of <1/10,000 in December 2005 and even further down to 0.66/10,000 in 2016, the states of Chhattisgarh and the UT of Dadra and Nagar Haveli are yet to achieve elimination.[3]

The reduction of the load of infection is the cornerstone of leprosy control. As for all diseases, reporting of cases without social stigma can help in early diagnosis and early adequate drug treatment which is very important to reduce the load. A diagnosis demands good clinical knowledge, experience, and judgment; slit-skin smear (SSS) examination and confirmation of diagnosis in doubtful cases of leprosy by histopathological examination. To categorize, according to the WHO classification into paucibacillary (PB) and multibacillary (MB) cases, clinicopathological correlation of leprosy is much needed. To address the problems such as resistance, relapse, and bacterial persistence, a proper follow-up of the patients must be done and accurate diagnosis and adequate treatment become very important for elimination of leprosy.

The present study was carried out to find the prevalence and clinical presentation of leprosy in Ahmedabad district of Gujarat, frequency of lepra reaction, frequency of relapse and deformities associated with leprosy, appropriate management of the disease with associated complications, and the effects of newer antileprosy treatment.

Materials and methods

This descriptive study was conducted on 300 cases of Hansen's disease seen in the Department of Dermatology, Venereology, and Leprology, B. J. Medical College and Civil Hospital, Ahmedabad, during the period from June 2010 to December 2012. New cases of leprosy and patients, who had completed antileprosy treatment but developed new signs and symptoms after completing antileprosy treatment (post-MDT cases), were included in the study.

All the patients were entered in detailed pro forma, which was prepared as a guideline to aid the study of the cases. A detailed history regarding the age, sex, marital status, occupation, and residence of the patient was taken. A detailed cutaneous, sensory, neurological examination was done. Any signs of lepra reaction, ulceration, or deformity were noted. Apart from routine investigations, SSS for acid-fast bacilli was done from skin lesions, earlobes, and eyebrows by slit and scrape method. SSS was graded as per Ridley's logarithmic scale. When required lesions were subjected to punch biopsy from active border of lesion to confirm the diagnosis. Those with pure neural leprosy (PNL) were sent for electromyogram (EMG) and nerve conduction velocity (NCV). No nerve biopsy was taken.

Based on all the above findings, a diagnosis was made. The patients were then classified as per the WHO guidelines into PB/MB cases for treatment purpose, and treatment was provided accordingly. Patient and the family were thoroughly counseled and were also examined for similar signs and symptoms. Basic facts about leprosy were explained, and the need for regular treatment was stressed to both the patient and the family members. Any misconceptions related to the disease were cleared. Regular hand, foot, and eye care was explained.

Any patient with Bacillary Index (BI) >3, or any patient who had any time in the past taken regular/irregular anti-leprosy treatment (ALT) were given tablet ofloxacin (400 mg) once a day along with ALT for 1–3 months. The patients were regularly followed up during the study period. The occurrence of lepra reactions was noted. The treatment of the same was done using nonsteroidal anti-inflammatory drugs (NSAIDs), clofazimine, zinc, corticosteroid (1–2 mg/kg and tapered every 2 weeks), and thalidomide (400 mg for 1 week and then 300 mg, 200 mg, and 100 mg subsequently tapered over a period of 1 month) either alone or in combination as per the patient's condition. Thalidomide was used for the patients with either recurrent reactions not controlled by other drugs or those who had become steroid dependent.

A written and informed consent was taken from every patient. Females were explained about the need of strict contraception and pregnancy test was done at the start of treatment. During follow-up, a 3 monthly SSS was done, any other significant events during the treatment were noted. The patients were released from treatment (RFT) after the completion of their fixed MDT and smear negativity as per the WHO guidelines. These patients were followed up during the study period for any relapse/late reactions.

Results

A total of 300 patients were included in the study. The male-to-female ratio was 2.1:1. Age-sex distribution has been depicted in Chart 1.

Chart 1

Age-wise sex distribution

In the present study, 4.3% of the patients had a positive family history, highest being that of sibling. Furthermore, in two patients, there was more than one affected person in the family. One hundred and eighty six patients in our study were residents of Gujarat. Among these, 108 belonged to Ahmedabad district [Table 1].

Table 1

Area of residence

	Number of patients
Area of residence
Gujarat (Ahmedabad district)	108
Gujarat (other districts)	78
Migrants	60
Other states	54
Districts (n=78), n (%)
Kheda	18 (23.08)
Panchmahal	16 (20.51)
Rajkot	14 (17.95)
Baroda, Mehsana, Nadiad and Junagarh, and Dahod	12 (15.38)
Valsad, Gandhinagar, Jamnagar, Viramgam, Amreli, and Surat	9 (11.54)
Anand, Bhavnagar, Vyara, Dehgam, Porbandar, Himmatnagar, Surendranagar, and Jetalpur	6 (7.69)
Patan, Kutch, Godhara, Navsari, Banaskantha, and Sabarkantha	3 (3.85)

The clinical profile of the patients is shown in Table 2. Lepromatous leprosy (LL) was the most common [Figure 1], followed by borderline lepromatous (BL) [Figure 2] and borderline tuberculoid and indeterminate leprosy accounted for the least number of patients.

Table 2

Clinical profile of patients

Clinical characteristics	Subgroups	Number of cases (%)
Primary cutaneous	TT	60 (20)
	BT	60 (20)
	BB	9 (3)
	BL	74 (24.6)
	LL	82 (27.3)
	IL	3 (1)
PNL	Mononeuritic	2 (0.6)
	Polyneuritic	10 (3.3)
Total		300 (100)

TT: Tuberculoid tuberculoid, BT: Borderline tuberculoid, BB: Borderline borderline, BL: Borderline lepromatous, LL: Lepromatous leprosy, IL: Indeterminate leprosy, PNL: Primary neuritic leprosy

Figure 1

Lepromatous leprosy: lesions on forehead, neck, buttocks and earlobe infiltration

Figure 2

Borderline lepromatous leprosy: lesions on back and buttocks

About 80% of our patients required three-drug MB treatment as maximum number of patients in our study had LL. Among the PNL cases, NCV and EMG studies were consistent with the clinical diagnosis.

Skin lesions were the most common presenting complaint in 94.3%, followed by sensory complaints such as tingling, numbness, paresthesia, and slippage of footwear unknowingly in 15.6% of patients. Other presenting features were trophic ulcer in 43 (14.3%), fever in 89 (29.6%), deformities in 55 (18.3%), epistaxis in 33 (11%), edema feet in 92 (30.6%) and joint pain in 90 (30%) patients. Several patients presented with more than one complaints. Thirty three (55%) patients of tuberculoid leprosy presented within 6 months of onset of problem while only 25% presented after 18 months; 44 (53.6%) patients with LL presented after 18 months while only 26.8% of LL patients reported within 6 months.

One hundred thirty four (44.6%) patients had their skin smear acid fast bacilli (AFB) positive. About 97.5% of LL patients had smears positive for AFB with globi visible in 13% of them [Table 3].

Table 3

Acid-fast bacilli status in slit-skin smear (bacteriological index)

Diagnosis	Smear-positive patients			Total (%)
	Up to 2+	2-4+	>4+
TT	0	0	0	0
BT	4	0	0	4 (6.6)
BB	6	3	0	9 (100)
BL	30	11	0	41 (55.4)
LL	45	32	3	80 (97.5)
IL	0	0	0	0
PNL	0	0	0	0
Total (%)	85 (28.3)	46 (15.3)	3 (1)	134 (44.6)

TT: Tuberculoid tuberculoid, BT: Borderline tuberculoid, BB: Borderline borderline, BL: Borderline lepromatous, LL: Lepromatous leprosy, IL: Indeterminate leprosy, PNL: Primary neuritic leprosy

Both type 1 and type 2 lepra reactions were seen almost equally in our study with 30 and 32 patients respectively. Nineteen patients were in reaction at presentation of which 6 were in type 1 and 13 in type 2 reaction. There were 33 episodes of reaction after initiation of therapy of which 22 were type 1 and 11 had type 2 reaction. In addition there were 10 cases of reaction after completion of antileprosy therapy of which two were type 1 and 8 were type 2.

Ocular involvement occurred in 32 (10.6%) patients. Eye complaints at presentation included watering from eyes in two patients and red eye in four patients. During the reaction episodes, six patients developed conjunctivitis, two patients had episcleritis, and four patients had lagophthalmos. Madarosis, seen in 10 patients, was the most common deformity.

Four (1.3%) patients in the group presented as relapse and all of them belonged to MB group. Three of the relapse cases reported were within 2 years of RFT, and one reported after 2 years but within 5 years of RFT.

Different deformities were reported and their grading was done [Tables 4 and 5]. Hand deformities were most commonly seen (45%), followed by foot deformities in 38% of patients and eye deformities were seen in 5% of patients. Most of the deformities belonged to Grade I.

Table 4

Distribution of deformities

Deformity	Number of patients
Leonine facies	6
Sagging face	3
Saddle nose	4
Madarosis	10
Megalobules	6
Eye deformities	4
Claw hand	23
Wrist drop	1
Foot drop	2
Trophic ulcer
Upper limb	11
Lower limb	21
Resorption of digits	16

Table 5

Grading of deformities

Grade	Hands	Feet	Eye
0	119	156	285
I	135	114	14
II	46	30	1

The ulnar nerve was the most commonly affected nerve [Table 6].

Table 6

Nerve involvement

Nerve	Bilateral	Unilateral
Supraorbital	8	12
Great auricular	11	49
Supraclavicular	18	10
Ulnar	231	22
Lateral popliteal	166	9
Others	70	9

Discussion

Leprosy, exhibits a spectrum of clinical characteristics and being a chronic infectious disease, is one of the major public health problem of the developing countries. Leprosy is primarily a granulomatous disease of the peripheral nerves which in its progressive course can cause permanent damage to the skin, nerves, limbs, and eyes. The standard research classification follows that of Ridley and Jopling, which is based on histopathological changes and the immunological status of the individual. The study of pathological changes in leprosy lesions has contributed a great deal to understand the disease and clinicopathological correlative studies have provided further insights into the disease, its varied manifestations, and complications.[4]

The male-to-female ratio in the present study was 2.1:1. Other studies showed a similar ratio of 1.7:1,[5] 2.5:1,[6] and 3.5:1,[4] thereby showing increased males as compared to females presenting with leprosy. The lower prevalence of females could be because of lower medical facility sought by the females due to gender bias and also because of the social stigma attached to the disease. Higher frequency among males indicates their more vulnerability because of greater mobility and increased opportunities for contact in big population, and some unknown hormonal or neurotransmitter may be involved for neural involvement.

The age of the patients ranged from as young as 8 years to as old as 85 years in our study. Age incidence was the highest (25.6%) among adults between 31 and 40 years of age. The reason for these observations could be due to a higher rate of age-specific migration in Ahmedabad city. In the present study, 4.3% of the patients had a positive family history, which was lower than in a study by Thakkar and Patel (8.3%)[5] and study of Salodkar and Kalla (9.5%).[7]

A total of 186 patients in our study were residents of Gujarat. Among these patients, 108 belonged to Ahmedabad district. Sixty patients were currently residing in Gujarat but were originally natives of other states. Majority of these patients belonged to endemic zones for leprosy. This could be accounted due to better employment facilities in the state leading to more migration of people from other states. Most of them were from neighboring states of M.P., Bihar, Rajasthan, U.P., and Chhattisgarh. Being a tertiary care center for healthcare and good treatment facilities, the patients from other states frequently come here for treatment.

There were 12 patients (4%) of pure neuritic leprosy in our study. The greater prevalence of PNL in the present study could be due to a hospital-based good referral service from the orthopedic department where most of these patients present with deformity. Thakkar and Patel also had a relatively higher occurrence of PNL (18%) in their study.[5]

Out of 300 patients, 2 (0.6%) patients presented with mononeuropathy and 10 (3.3%) patients with polyneuropathy with no skin lesions and SSS negativity. In the study carried out by Pannikar et al.,[8] out of 60 patients, 6 (10%) had mononeuritic and 7 (11.6%) had polyneuritic Hansen's disease. These figures were notably higher than those in the present study. Skin lesions were the most commonly presenting complaint in 94.3%, followed by sensory complaints such as tingling, numbness, paresthesia, and slippage of footwear unknowingly in 5.6% of patients. Early neural involvement in tuberculoid patients while late in that of lepromatous patients were seen in our study. The nerve involvement results in neuritic symptoms at the earliest which if followed shall ascertain other symptoms in those patients on long-term follow-up. In a study by Jacob and Arunthathi,[9] where 67% of primary neuritic leprosy patients developed skin lesions on long-term follow-up reconfirms the theory.

About 10% of patients developed type 1 reaction and 10.6% of patients had type 2 reaction during the study period mainly after initiation of therapy. Type 1 reactions were the most common in the borderline group of patients, whereas type 2 reactions were seen in 10.9% of patients with LL and 2.7% of patients with BL. Systemic manifestation such as fever and myalgia formed the most commonly presenting complaint. About 30% patients with type 1 reaction and 15.6% patients with type 2 reaction had significant neuritis. Thakkar and Patel showed 24 (9.6%) patients of lepra reactions which included 8 (3.2%) of type 1 and 16 (6.4%) of type 2 reactions.[5] Two out of eight cases belonged to the PB group and rest six of type 1 as well as all 16 cases of type 2 reactions belonged to the MB group.[5] Salodkar and Kalla showed 11.1% patients of lepra reactions among which 19.9% of type 1 and 80.1% of type 2 reactions.[7]

About 1.3% of the patients presented as relapse much less than found in the study done by Abdul[10] where the value was 3.88%.

All the relapsed cases had taken multibacillary treatment earlier. This was in contrast to the above study by Abdul where relapse rate was higher in patients with PB therapy.[10] Deformities were seen in 35.6% of cases. Trophic ulcers occurred in 32 (10.6%) patients and were more common on lower limbs. In a study done by Peters et al.,[11] 71.2% patients had deformities with affection of the upper and lower limbs with consequent functional disability.

Leprosy cases showed so many diversities clinically and the reactions, everything has to be diagnosed and treated individually and efficiently. Lepra reactions were treated mainly with NSAIDS and steroids/thalidomide. Complete course of MB/PB packs was monitored and given to the patients. All the patients with deformities and nerve function impairment (NFI) were referred to physiotherapy department for splints and exercises. Patients with trophic ulcer had undergone reconstructive surgery.

The strengths of the study are a good sample size and complete follow-up of the patient from the diagnosis till end of the treatment. The main limitations of the study were geographical limitation and the study did not cater the whole population but only the cases who reported to the hospital. Hence, the social stigma factor associated with leprosy could not be annulled.

Conclusions

Adequate knowledge and clinical skills, sensitive diagnostic tools, and proper supply of medicines from the medical end and early reporting of symptoms, compliant medicine intake, and social awareness to null social stigma associated with it from the patient's end can bring the country as a whole to the target of leprosy elimination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.