Title: Leprosy in the Southeast USA
1Leprosy in the Southeast USA
Carlos Franco-Paredes, MD, MPH
2Young D. Lancet 2002.
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4HD in the US 2006 NHDP (HRSA) June 2009
5Confounding our Understanding
- Incubation Period of 3-5 years
- Spontaneous Self-healing
- No Early Diagnostic Techniques
- In ability to Culture M. leprae
- Stigma for Reporting
Source Krahenbul J - NHDP
6Source of Infection
Human Non-human
or Environmental
- Few active cases (small reservoir)
- Male predilection in adults but gender neutral in
children - Lesions on exposed extremities
- Urban prevalence but rural incidence -farming
- Case clustering
- Some primates
- Armadillos
- Man is only known reservoir in most of the world
- More frequent among household contacts
- Limited extra-cellular survival of M. leprae
- Disease occurs in many environmental settings
and altitudes - Few susceptible animals
Source Krahenbul J - NHDP
7Portal of Entry Exit
- Large numbers of organisms are shed through the
skin, coughing sneezing - M. leprae not very robust
- Cant survive cooking or freezing
- immobile, lacks hyalulronidase or other invasive
mechanisms - Nasal involvement is apparent in many clinical
cases - Site of entry of filter
Source Krahenbul J - NHDP
8Source Krahenbul J - NHDP
9Leprosy in Wild Armadillos
- Discovered 1975, New Iberia, La
- DNA confirmed
- 4.5 infected
- CDC, little risk attributable from direct
contact - Potential Zoonosis
- Armadillo handlers
- Large Reservoir
Source Krahenbul J - NHDP
10Leprosy in Wild Armadillos
1
1985
1954
1914
1880
Mexico 1, Brazil 1, Argentina 2
Source Krahenbul J - NHDP
11Survey for Armadillo Leprosy
Lawton
Monroe
Tallulah
Palestine
Leesville
Woodville
College Station
Krotz Springs
Carville
St Marks
Lake Arthur
Prevalence 16 lt2 within 30 miles
Corpus Christi
Source Krahenbul J - NHDP
12Indigenous US Leprosy
Source Krahenbul J - NHDP
13Human Armadillo Leprosy
Source Krahenbul J - NHDP
14- Do armadillos transmit leprosy to humans?
- Suporting Evidence
- 30-40 endemic cases each year in TX LA
- Huge reservoir of leprosy bacilli in the US
- 12 25 prevalence in some areas
- Potentially 300,000 infected armadillos
- Leprosy prevalence coincides with human
- prevalence in TX Gulf coast and LA
- Gaps in our knowledge
- History of exposure to armadillos often
unreliable - Slow progression of disease
- Delayed diagnosis
- Epidemiological markers (DNA fingerprints)
- being developed from field isolates of M.
leprae - from armadillos
Source Krahenbul J - NHDP
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22PERIPHERAL NERVES
Median Nerve
Radial Nerve
23Demyelination the final common pathway of
neuropathy in leprosy
- Segmental demyelination
- Secondary to inflammation?
- Secondary to SC infection dysfunction?
- Teased nerve studies,
- Swift, 1974
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25TERMINOLOGY
- Reversal reaction (Type 1)
- Erythema Nodosum Leprosum (Type 2)
- Lucio Phenomenon Reaction
in Lucio leprosy
Franco-Paredes, et al PLoS Negl Trop Dis 2009 3
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31Type 2 Reactions (ENL)
TT BT BB
BL LL
32Results HD Overview
- 14/552 (2.5) patients with HD
- 10 males, 4 females
- Median age at presentation 45.1 (21.2-64.9)
- Median age at diagnosis 34.0 (21.8-64.4)
- 8 lepromatous or multibacillary disease
- 6 tuberculoid or paucibacillary disease
Jacob J, et al. Am J Trop Med Hyg 2008
33Results Leprosy
34Results
- All patients were treated with MDT
- Second-line therapy in 3 cases
- Reactions occurred in 10 (71) of patients
- 5 Type 1 reactions
- 5 Type 2 reactions
- Median time from initiation of treatment to onset
of reaction was 16.2 months (range 3.9-149.2)
35Results Leprosy Reactions
Jacob J, et al. Am J Trop Med Hyg 2008
36Conclusions
- HD is a reemerging infection in some parts of the
U.S. due to migration patterns - MDT is only part of the disease management
- Most patients require long-term follow-up and
aggressive management of sequelae - Reactions are common with HD
- Prior, during and after therapy
- Often require chronic antiinflammatory therapy
(steroids) - Further epidemiological, translational, and
clinical research is needed