Background: Presence of physical deformities in patients with leprosy reflects the rate of disease transmission in the community; delay in detection of cases; and inadequacy or failure of treatment. Objectives: To determine the spectrum of physical deformities in patients with leprosy, to analyze the various sociodemographic factors affecting the study population, and to assess the treatment history of the selected number of patients. Materials and Methods: The study was an analytical study conducted on all leprosy patients who visited the dermatology out-patient department in a tertiary care hospital during the period of 1 year. Results: Males constituted 70.66% and females constituted 29.34%. It was found that a majority were in the age group of 21–60 years than in the extreme age groups (0–20 years and 61–80 years). Among the 92 patients studied, it was found that majority of the patients (60.86%) had WHO grade 0 or grade 1 deformity. Those with visible deformities (WHO grade 2 deformity) constituted 39.13% of the study population. Among those with visible deformities, the most common deformity was seen to be trophic ulcer (21.73%). This was followed by claw hand, foot drop, madarosis, claw toes, lagophthalmos, ear lobe deformity, facial palsy, and finally nose deformity. Conclusions: Our study found that more than one third of number of leprosy patients had deformities. It reflects the need for further efforts to curb this infectious disease and increase education among masses.
Keywords: Deformities, leprosy, trophic ulcer
In our study of spectrum of physical deformities in Hansens, we found that 60.8% had no visible deformity, whereas 39% had visible deformity. The most common visible deformity in our study was trophic ulcer (20 patients), followed by claw hand (12 patients) and foot drop (7 patients). The percentage of the new cases undergoing treatment was 73.9%. The percentage of those who had completed treatment and were in follow-up was 14.13%. Previously treated cases were 11.95% in whom multidrug therapy was reinitiated due to various reasons.
Leprosy, also known as Hansen disease, is a chronic disease caused by bacteria Mycobacterium leprae. Nerve damage is the most characteristic feature of the disease, and is also the cause of most of the disability that is suffered by the patient. Common clinical manifestations are sensory loss (most commonly reported symptom), followed by motor loss and lastly followed by autonomic function loss. The disease of leprosy is not directly responsible for most of the deformities that are attributed to it. It characteristically removes the sensation of pain, and so allows the patient to damage and to deform himself.
Secondary infections, in turn can cause tissue loss, resulting in fingers and toes to become shortened and deformed, as cartilage is absorbed into the body. Some of the impairments are not nerve related, for example, collapse of nose, hoarseness of voice, enlarged or eroded earlobes, and loss of eyebrows. Unlike nerve function impairment, they can always be prevented.
India has an estimated 6,45,000 leprosy patients with deformities. In an operational research conducted by Bombay Leprosy Project, it was found that about 33–56% of the newly registered leprosy patients already have clinically detectable nerve function impairment often no longer amenable to multidrug therapy (MDT). The pattern of visible deformity showed almost a constant trend in both national figures and the figures estimated in the study conducted. There was a declining trend from 2000 to 2004 and then again it started increasing gradually. In India, about 25–30% of leprosy cases develop deformities.
In spite of MDT and good surveillance, we still see good number of patients with deformities. So, early detection of leprosy cases is often not overemphasized. Those affected by the disease continue to face social stigma and discrimination.
This was an analytical study conducted at a tertiary care center in Mangalore, a city in South India. Patients visiting dermatology out-patient department during the year 2012–2013 who were diagnosed of leprosy (new and old cases) were included in the study. After Institutional Ethics Committee’s approval, the required information from the records of the Skin and VD department were collected using a pro forma. The observations were recorded by the faculty of department of Skin and Venereology. Data was analyzed by percentages and chi-square test.
The deformities were graded on the basis of updated WHO grading for deformities.
A total of 92 cases were included in the study. These cases included both newly diagnosed and old cases of Hansen disease. In the study population, males constituted 70.66% and females constituted 29.34%. Age distribution has been shown in [Table 1]. Most of them were in the age group of 41–50 years. Their place of origin has been elaborated in [Table 2].
In the study population, it is seen that about 74 % of the cases were either newly detected cases or cases which are currently undergoing treatment [Table 3]. Cases which have completed treatment previously constitute 14.13% of the study and the rest of the population were previously treated cases which had to restart treatment due to various reasons. In those undergoing treatment currently, majority were taking MBMDT (91.13%), the rest were taking PBMDT (8.87%).
In the study population, number of persons without visible deformities (61%) were found to be more than number of persons with visible deformities (39%). Among those with visible deformities, males (72.3%) were found to be more than females (27.7%) Their age distribution and regional distribution has been shown in [Table 4] and [Table 5]. Among those with deformities, majority were from Karnataka (83.33%).
No visible deformities were found in 56 of 92 patients. Most common lesion was hypopigmented patches (n = 45), followed by skin nodules and loss of sensations. Some of them also presented with erythematous patches [Table 6]. Among those with visible deformities, the most common deformity is seen to be trophic ulcer [Table 7]. None of the members of this group had wrist drop or ape hand. It was found that some patients had more than one type of deformities. There was no statistical association between gender and the type of deformity [Table 8].
This study was conducted to analyze the spectrum of deformities in a given population of leprosy patients. The study also aimed at assessing some sociodemographic and clinical factors of the study population.
The study included newly detected cases, cases already undergoing treatment, cases which have already completed treatment previously, and previously treated cases who had to restart therapy due to various reasons.
Among the study population, it was found that majority of the study population (60.86%) had WHO grade 0 or grade 1 deformity. Those with visible deformities (WHO grade 2 deformity) constituted 39.13% of the study population, which is comparable to a study conducted in New Delhi. In a study in Varanasi, the deformity rate was found to be as low as 3.73%, whereas a study in Pakistan found a higher incidence of visible deformities (55%) and 56.97% were found to have disabilities in a study conducted over 11 countries. In another study, it was found that in India, 25–30% of leprosy cases develop disabilities. This result is almost similar to the result obtained from our study.
In the study population, it was found that 70.65% were from Karnataka, 15.21% were from Kerala, and 14.13% were from other states including Jharkhand, Uttar Pradesh, Bihar, Calcutta, Orissa, and Chhattisgarh. This is probably because the study was conducted in a hospital in Mangalore which is at the border of Karnataka and Kerala. Population from other North Indian states include the migrants who are currently employed in Mangalore.
In the study population, it is seen that about 74% of the cases were either newly detected cases nor cases which are currently undergoing treatment. Cases which have completed treatment previously constitute 14.13% of the study and the rest of the population were previously treated cases which had to restart treatment due to various reasons. Among those taking treatment currently, majority were taking MBMDT treatment (91.13%) and the rest of them were taking PBMDT treatment (8.87%). Majority of the patients are given MBMDT treatment irrespective of whether they have visible deformities or not, probably, for providing some prophylaxis against development of deformities. In a previous study conducted in an urban leprosy center in Delhi, it was seen that 80.57% were in the MB group and treated with MBMDT and 19.43% were paucibacillary treated with PBMDT.
Among those with visible deformities, it was found that majority were males (72.3%) and females constituted 27.7%. Thus, among those with deformities also, males are more than females. A similar result was obtained in a previous study where increased proportion of disabilities were found in male sex.
Among those with visible deformities also, majority were in the age group of 41–50 years (27.2%). This was followed by those in 51–60 years age group and 21–30 years age group (19.44%). Among those with visible deformities, there was no person in the age group of 1–20 years. In a previous study, it was found that proportion of disability increased with age. In our study, majority of people with deformities were in the age group of 21–70 years.
Among those with visible deformities, majority were from Karnataka (83.33%). Migrants from states of Jharkhand, Uttar Pradesh, and Calcutta constituted 11.1% and the rest of the patients were from Kerala (5.55%). Most of them are from Karnataka, probably because the study was done in the state of Karnataka. It is found that among those with visible deformities, patients from north Indian states were more than number of patients from Kerala.
Among those with visible deformities, the most common deformity was seen to be trophic ulcer (20 patients). This was followed by claw hand, foot drop, madarosis, claw toes and lagophthalmos, ear lobe deformity, facial palsy, and finally nose deformity. None of the members of this group had ape hand or wrist drop. It was noted that some patients had more than one type of visible deformity. In a previous study done in west Bengal, it was found that feet were the commonly involved site of disability, followed by hands, whereas studies done in North India found claw hand to be the most common deformity.,
Among the deformities in the face, males suffered more than females. In a study in Nigeria, women were found to have more deformities than did men, probably due to the time taken for presentation to health-care facilities. In the deformities of the feet, again males suffered more than females. Among those with claw hand deformity number of males (10) were found to be more than females (2) According to chi-square test, these values were not found to be statistically significant.
Among those without any visible deformities, most of the patients presented with hypopigmented patches (45). This was followed by skin nodules, and loss of sensations. Some of them also presented with erythematous patches. It was seen that some patients had more than one type of lesion.
It was seen that among those with deformities, three patients developed recurrent type 2 lepra reactions. All three were males. They were 24, 40, and 47 years old. It was probably due to varied immune response to the antigen in these patients.
This study throws light on the much needed improvement in the field of leprosy elimination in India. It reveals that even now, a significant number of leprosy patients have visible deformities. This indicates the lack of awareness among patients, the possible symptoms of leprosy, and so delay in treatment resulting in deformities. Also early detection and aggressive treatment of type 1 reaction to prevent nerve damage and subsequent deformities has to be the priority.
What is new?
In our study, contrary to the popular perception that leprosy is in elimination phase, we found that, good number of new cases with severe manifestations were being reported. Also migrants from north and north-eastern regions were being diagnosed with Hansen disease in a large number. So the surveillance has to be more aggressive so as to halt the spread of Hansen disease in society.
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Conflicts of interest
There are no conflicts of interest.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]