Leprosy in the Southeast USA

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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
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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
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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
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Source Krahenbul J - NHDP
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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
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1985
1954
1914
1880
Mexico 1, Brazil 1, Argentina 2
Source Krahenbul J - NHDP
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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