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All about Leprosy
PVS Prasad
ONE:
Historical Aspects
TWO:
Microbiology
INTRODUCTION
CHARACTERISTICS
ULTRASTRUCTURE
Capsule
Cell Wall
Cell Membrane
Cytoplasm
Genome
CLINICAL APPLICATION
BIOCHEMICAL PROPERTIES
INVESTIGATIONS
Skin Smears
Bacterial Index
Morphological Index or Solid Ratio
Cochrane Method
SFG Index
Simple Method
Biopsy Index
Nasal Smear
Bacillary Counts Per Gram of Tissue
Bacteremia
Lepromin Test
Dharmendra Antigen
Leprosin or Leprolin
Polymerase Chain Reaction (PCR)
PCR Technique
Fluorescent Leprosy Antibody Absorption Test (FLA-Abs)
Fluorescein Diacetate Ethidium Bromide Staining
Other Tests
Other Staining Reactions
Cultivable Organisms
CONCLUSION
THREE:
Immunology
INTRODUCTION
T LYMPHOCYTES
INTERLEUKINS
INTERFERON
IMMUNOLOGY OF LEPROSY (Fig. 3.2)
Cell Mediated Immunity
Tuberculoid Leprosy
Borderline Leprosy
Lepromatous Leprosy
Macrophage
Humoral Immunity
M. leprae and its Antigenic Structure
Genetic Influence
Genomic Library
Immunologic Diagnosis: Specific Serologic Assays
Antigen-Based Radioimmunoassay (RIA)
FLA-Abs
ELISA
Immunologic Complications
Antigen Derived
Erythema Nodosum Leprosum or Type-2 Reaction
Lucio Phenomenon (Erythema Necroticans)
Reversal and Downgrading Reactions
Amyloidosis
Vaccines in Leprosy
BCG Vaccination
ICRC Bacillus
M. ω Vaccine
Skin Test Antigens
Second Generation Vaccines
Immunotherapy
FOUR:
Pathology
INTRODUCTION
SPECTRUM
Natural History (Fig. 4.1)
Skin Biopsy
PATHOGENESIS
Antigen
Immune System
Sites of Predilection
Location
Activity of the Infection
Evolution of the Disease and Natural History
Entry of Bacilli
Pathogenesis in Nerve
NEUROPATHOLOGY OF LEPROSY
1. INTRAFASCICULAR
Myelinated and Unmyelinated Fibers
Lepromatous Neuropathy
Tuberculoid and Borderline Neuropathies
2. GENERAL INFLAMMATORY RESPONSE TO BACILLI
3. EXTRA NEURAL
HISTOLOGICAL DIAGNOSIS
Areas for Examination
Epidermis
Adnexal Elements
Nerves
Cell Types
Necrosis
Tuberculoid Spectrum
Pathology
Lepromatous Leprosy
Reactions
Type-1 Reaction
Pathogenesis of Reaction
Pathology
Type-2 Reaction
Pathogenesis of ENL Reaction
Reversal Reaction
Pathology
Types of ENL
Lucio Phenomenon or Type-3 Reaction
Indeterminate Leprosy
Pathology of Partially Treated Cases
Nerve Abscess
Polyneuritic Type
Specific Organ Involvement
Lymph Node
Respiratory System
FIVE:
Epidemiology
DEFINITION
INTRODUCTION
DISTRIBUTION OF THE DISEASE
FACTORS INVOLVED IN TRANSMISSION
Sources of Infection (Portal of Exit)
Oral Mucosa
Nasal Breathe
Female Genital Mucosa
Breast Milk
Skin
Risk of Infection
Portal of Entry
Skin
Respiratory Tract
Age Prevalence
Changes in the Population Pattern
Incubation Period
Contact with Index Cases
Genetic Factors
M. leprae in the Community
Association with HIV Infection
Other Factors
SIX:
Classification
INTRODUCTION
CLASSIFICATIONS
Dannielssen and Boeck (1848)
Hansen and Looft (1895)
Neisser (1903)
Jadassohn (1905)
Darier (1923)
Rogers and Muir (1925)
Cairo (1938)
Pan American (1946)
Havana (1948)
WHO (1952)
Madrid (1953)
Indian Association of Leprologists (1955)
Dharmendra (1960)
Revised IAL (1981)
Ridley and Jopling (1962)
Job and Chacko's (1981)
WHO Classification (1982)
SEVEN:
Clinical Manifestations
INTRODUCTION
EARLY SYMPTOMS
CARDINAL SIGNS
ANESTHETIC LESION
NERVE ENLARGEMENT
DEMONSTRATION OF AFB
EXAMINATION FOR OTHER FEATURES
Indeterminate Leprosy
Tuberculoid Leprosy
Borderline Tuberculoid Leprosy
Borderline Borderline Leprosy (BB)
Borderline Lepromatous Leprosy (BL)
Lepromatous Leprosy
Lepra Manchada
Pure Neuritic Leprosy
Histoid Leprosy
Histoid Habitus
Significance
EIGHT:
Reactions in Leprosy
INTRODUCTION
TYPE-1 REACTION
Pathogenesis
Pathology
TYPE-2 REACTION
Pathogenesis
Pathology
TYPE-3 REACTION (LUCIO PHENOMENON)
NINE:
Neuritis in Leprosy
INTRODUCTION
STRUCTURE OF A PERIPHERAL NERVE
DEFINITION OF NEURITIS
MODES OF ENTRY OF M. LEPRAE
SITE AND EXTENT OF INVOLVEMENT
Indeterminate Leprosy
Tuberculoid Leprosy
Borderline Leprosy
Lepromatous Leprosy
Causes for Nerve Involvement in Leprosy
NEURITIS IN DIFFERENT FORMS OF LEPROSY
TREATMENT OF NEURITIS
TEN:
Eye Manifestations
INTRODUCTION
DIRECT SPREAD OF LEPROSY LESIONS
EYE LESIONS SECONDARY TO 5TH OR 7TH CRANIAL NERVES
CRANIAL NERVE INVOLVEMENT
DIRECT INVASION OF THE EYE WITH M. LEPRAE
Conjunctiva and Episclera
Cornea
Sclera
Iris and Ciliary Body
LESIONS OF THE POSTERIOR SEGMENT
ELEVEN:
Ear, Nose and Throat Manifestations
INTRODUCTION
NASAL LESION
LESIONS OF THE LARYNX
LESIONS OF THE EAR
LESIONS OF THE ORAL MUCOSA AND TEETH
TWELVE:
Systemic Involvement
INTRODUCTION
Gonads
Testis
Ovary
Adrenals
Pituitary
Thyroid
GYNECOMASTIA
ANEMIA
KIDNEYS
THIRTEEN:
Bone Changes in Leprosy
INTRODUCTION
TYPE OF BONE CHANGES
TYPE OF BONE CHANGES
Specific Bone Changes
Minimal Changes
Moderate Changes
Healing Phase
Nonspecific Radiological Changes
Acute Osteitis
Osteomyelitis
Secondary Periosteitis
Concentric Absorption
Cupping of the Joint
Osteophyte Formation
Tuft Erosion
Osteoporosis
PATHOGENESIS OF BONE CHANGES IN LEPROSY
Specific Changes
Nonspecific Lesions
FOURTEEN:
Animal Experiments
INTRODUCTION
NEED FOR ANIMAL STUDIES
Rabbits
Syrian Hamsters
Rats and Mice
Monkeys
Chimpanzees
Guinea Pigs
Cold Blooded Animals
Other Methods
Leprosy like Disease
Slender Loris
White Handed Gibbon
Shepard's Experiments
Drug Screening
Indian Experiments
Nude Mice
Thymectomized Mice
Armadillo
VIABILITY OF M. LEPRAE OUTSIDE THE HUMAN BODY
FIFTEEN:
Deformities
INTRODUCTION
FACTORS INFLUENCING NERVE DAMAGE
Agent Factors
Host Factors
Other Factors
MECHANISMS OF NERVE DAMAGE
Silent Paralysis
Acute and Subacute Neuritis
Catastrophic Onset
Late Onset
CAUSES OF DEFORMITY
TYPES OF DEFORMITY
DEFORMITIES OF FACE
Specific Deformities
Paralytic Deformities
Lagophthalmos
Facial Palsy
DEFORMITIES OF HAND
Specific Deformities
Reaction Hand
Twisted Fingers
Intrinsic Plus Finger
Paralytic Deformities of Hand
Claw Hand
Median Claw Hand
Wrist Drop
Paralytic Thumb
ANESTHETIC DEFORMITIES OF HAND
PARALYTIC DEFORMITIES OF FOOT
ANESTHETIC DEFORMITIES OF FOOT
Trophic Ulcers
Sensory Loss
Muscular Paralysis
Autonomic Nerve Damage
Scar Tissue Formation
Primary Vascular Insufficiency
Direct Action of M. Leprae
Secondary Infection
Sites
SIXTEEN:
Differential Diagnosis
INTRODUCTION
CLINICAL DIAGNOSIS
DD of Hypopigmented Macules
Pityriasis Versicolor
Early Vitiligo
Post-inflammatory Lesion
Nevus Anemicus
Nevus Achromicus
Post-Kala-azar Dermal Leishmaniasis (PKDL)
Seborrheic Dermatitis
Pityriasis Alba (Simplex)
Yaws and Pinta
Leukoderma Coli
Polymorphic Light Eruption
Erythematous Macules
Secondary Syphilis
Pityriasis Rosea
Seborrheic Dermatitis
Tinea Incognito
Fixed Drug Eruption
Other Rare Causes
Papules
Secondary Syphilis
Granuloma Annulare
Sarcoidosis
Psoriasis
Lupus Vulgaris
Granuloma Multiforme (Leiker's Disease)
Nodules
Neurofibromatosis
Leishmaniasis
Kaposi's Sarcoma
Sarcoidosis
Nodules of Histoid Leprosy
Plaques
Lupus vulgaris
Secondary Syphilis
Necrobiosis Lipoidica
Cutaneous T Cell Lymphoma
Diffuse Infiltrations
Lymphomas
Other features
Madarosis
Ear
Nose
Nerve Involvement: Differential Diagnosis
Purely Motor
Purely Sensory
Mixed
Thickening of Peripheral Nerves
Others
Trophic Ulcers
Diabetes Mellitus
Syringomyelia
Moorvan's Syndrome
Tabes Dorsalis
Diastometamyelia
Thevanard Syndrome
Congenital Sensory Neuropathy
Systemic Amyloidosis
Other Considerations
SEVENTEEN:
Chemotherapy
INTRODUCTION
ANTILEPROSY DRUGS
Chaulmoogra Oil
Sulfones
Promin
Soluble Avlo Sulfone
Diasone
Aqueous Suspension of Dapsone
Solapsone
Dapsone
Pharmacokinetics
Mode of Action of Dapsone
Indications
Dose
Adverse Effects of Dapsone
Hemolytic Anemia
Methemoglobunemia
Anemia due to Other Causes
Agranulocytosis
Infectious Mononucleosis like Picture
Dapsone Syndrome
Psychosis
Peripheral Neuropathy
Pseudoleukemia like Picture
Base line Monitoring Tests for Dapsone
Urine Test for Dapsone
Duration of Treatment with Dapsone Monotherapy
Sulfone Poisoning
Dapsone Resistance
Types of Resistance
Clinical Types
Contraindications for Dapsone Therapy
Rifampicin
Antibacterial Activity
Pharmacokinetics
Dosage
Mode of Action
Drug Interactions
Side Effects
Indications of Rifampicin
Clofazimine
Pharmacokinetics
Mode of Action
Therapeutic Effects
Dose
Side Effects
Contraindications
Indications in Dermatology
Ethionamide
Prothionamide (Isoprodian)
Management of Reactions
Other Treatment
EIGHTEEN:
WHO–MDT in Leprosy
EVOLUTION OF LEPROSY TREATMENT AND ITS PROBLEMS
DIAGNOSIS OF DRUG RESISTANCE
Relapse
Reasons for Failure of Therapy
Dapsone
Rifampicin
Clofazimine
WHO-MDT Objectives (1981)
Principles of PB-MDT
Reasons for Recommending Rifampicin in PB Regimen
Principles of MB-MDT
Single Lesion PB Cases
Present Status of Short Course Treatment Regimens in Leprosy
Treatment of MB Patients
Treatment of PB Patients
Reactivation
ROM Therapy
Alternative MDT Regimens
NEW DRUGS IN THE CONTROL OF LEPROSY
Quinolines
Minocycline
Macrolides
Ansamycins
Cephalosporins
Dapsone Analogs
Amino Glycosides
Clofazimine Derivatives
Fusidic Acid
NEW CHALLENGES IN CHEMOTHERAPY
New Regimens of Shorter Duration
MOR
RMM
U-MDT
U-MDT with Fixed Duration Therapy
Fully Supervised Regimen
RMM Monthly Regimen
Clarithromycin and Minocycline (RCM)
Ampicillin/Sulbactum
Quadruple Regimen
Operational Aspects of MDT
Advantages of MDT
Requirements for MDT Implementation
Classification of Patients
Skin Smear Services
Monitoring
Duration of MDT
Surveillance After MDT
Diagnosis of Relapse
Training
Late Lepra Reactions
NINETEEN:
Surgical Aspects
INTRODUCTION
Preoperative Evaluation
During Operation (Intraoperative)
Postoperative Care
PERIPHERAL NEURITIS IN LEPROSY
Treatment of Neuritis
HAND DEFORMITY IN LEPROSY
Claw Hand
Surgery for Claw Hand
Active Intrinsic Replacement Procedures:
Passive Procedures for Restoration of Grasp
Restoration of Thumb Function
Opponens Replacement
Surgery for Other Deformities of the Thumb
Other Deformities of Fingers Needing Surgical Correction
TRIPLE NERVE LESION
FACIAL DEFORMITY
Facial N Paralysis
Surgery of Lagophthalmos
Temporalis Transfer (Gillies)
EYEBROWS
EARS
Lax Facial Skin
NOSE
Gynecomastia
Prepuce
External Meatal Stenosis
FOOT
Foot Drop
Treatment
Surgery for Foot Drop
Claw Toe Deformity
Treatment
Cocked up Toe
Treatment
Rosette Toes
Treatment
Ulcers of the Foot
Treatment
Stasis Ulcer
Treatment
Plantar Ulcer
Acute Neuropathic Disintegration of the Foot (Hot Foot syndrome)
Structural Deformities of the Foot
Rehabilitation
TWENTY:
Control Measures and Rehabilitation
NATIONAL LEPROSY ERADICATION PROGRAM (NLEP)
Structure of NLEP
Methods of Health Education
Objectives of Leprosy Surveys
Types of Surveys
Analysis of Surveys
Prevalence
Incidence
Leprosy Prevalence Rate
Interpretation of Facts
Signs of Activity of the Disease
Prevention of Disabilities
Components of Prevention of Impairment
Silent Neuropathy
Principles of Self-Care
Eye Care
Surgical Rehabilitation
Viva Questions and Answers
HISTORICAL ASPECTS
MICROBIOLOGY
IMMUNOLOGY
PATHOLOGY
EPIDEMIOLOGY
CLASSIFICATION
CLINICAL MANIFESTATIONS REACTIONS AND NEURITIS
EYE MANIFESTATIONS
EAR, NOSE AND THROAT MANIFESTATIONS
SYSTEMIC INVOLVEMENT
BONE CHANGES IN LEPROSY
ANIMAL EXPERIMENTS
DEFORMITIES IN LEPROSY
DIFFERENTIAL DIAGNOSIS
CHEMOTHERAPY AND WHO-MDT IN LEPROSY
SURGICAL ASPECTS AND REHABILITATION
CONTROL MEASURES IN LEPROSY
Important University Examination Questions in Leprosy
ESSAY TYPE QUESTIONS
SHORT NOTES
APPENDIX:
Technique of Slit and Scrape Method for Identification of Lepra Bacilli
Further Readings
TEXTBOOKS
MONOGRAMS
ARTICLES
JOURNAL ARTICLES
INDEX
TOC
Index
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