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Leprosy in the Southeast USA

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Title: Leprosy in the Southeast USA


1
Leprosy in the Southeast USA
Carlos Franco-Paredes, MD, MPH
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Young D. Lancet 2002.
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HD in the US 2006 NHDP (HRSA) June 2009
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Confounding 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
6
Source 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
7
Portal 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
8
Source Krahenbul J - NHDP
9
Leprosy 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
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Leprosy in Wild Armadillos
1
1985
1954
1914
1880
Mexico 1, Brazil 1, Argentina 2
Source Krahenbul J - NHDP
11
Survey 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
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Indigenous US Leprosy
Source Krahenbul J - NHDP
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Human Armadillo Leprosy
Source Krahenbul J - NHDP
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  • 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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PERIPHERAL NERVES
Median Nerve
Radial Nerve
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Demyelination 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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TERMINOLOGY
  • 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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Type 2 Reactions (ENL)
TT BT BB
BL LL
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Results 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
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Results Leprosy
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Results
  • 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)

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Results Leprosy Reactions
Jacob J, et al. Am J Trop Med Hyg 2008
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Conclusions
  • 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
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