ASTUDYON

LEPROCYPATIENT
OF
THELEPROCYMISSION
ASTUDYREPORTSUBMITTEDFORPARTIALFULFILLMENTOF
DR.RAMMANOHARLOHIAAVADHUNIVERSITY,ALLAHABADROAD,FAIZABAD
Acknowledgement
Inmymodestattempttoworkforasummertrainingproject,itmaynothave
beentotheexpectationyetIoweallmyachievementstoallwhowentoutof
thewaytohelpmyendeavor.
Ialsothank,Supritendent Dr.Trimothi Maximus,MedicalOfficerDr.Neeta
Maximus&Concellor Mr.Ashish Samson, forhisablesupportandguidance.
Iamheartilythankfultoallteachers fortheirguidance,regularattentionand
encouragement.
INTRODUCTIONOFLEPROSYMISSIONHOSPITALS
The leprosy mission is a charitable organization has been working for
more then 135 years internationally and as register a society in India from
1973 having registered office at no.5 amrita shegil marg. New Delhi T.L.M.
India mission statement is.
TLM Trust India works through 14 hospitals Barabanki, Belgaum,
Champa, Chandkhuri, Faizabad, Kolkata, Kothara, Muzaffarpur, Naini,
Poladpur, Purulia, Ramachandrapuram, Saldoha, Salur, Shahadra and
Vadathorasalur.,. Projects range from health and development to
advocacy and community empowerment. It works hand in hand with
governments, local communities, WHO, other NGOs, local Churches and
others to achieve our vision of a world without leprosy.
TLM Hospitals provide a wide range of services from specialist leprosy
treatment and care to reconstructive surgery for hands, feet and eyes.
Through provision of medical and surgical care for nonleprosy patients,
the hospitals help break down the stigma between leprosy and general
patients. Based in areas of great poverty and rural deprivation, TLM
hospitals are often the only health care providers inthe accessible area.
ActivityType;
Hospital
LeprosyControl
PreventionofDisabilities
Training
HealthEducation
EyeCare
Research
ReconstructiveSurgery
VocationalTraining
CommunityBasedRehab
DistrictTechnicalSupportTeams;
DistrictTechnicalSupportTeams(DTSTs)
providetrainingforPrimaryHealthCare(PHC)
staffequippingthemtomanageandtreat
leprosyindependently.Theteamsworkin
partnershipwiththeIndianGovernmentto
ensurethatalocal,sustainableandaccessible
supportstructureisinplacewithineach
community.
PROFILEOETHETLMHOSPITALFAIZABAD
TheleprosymissionhospitalFaizabadiscommunitybased
hospitalandvocationaltrainingcenterstabilizedonP.O
moti nagarfaizabad.
InOPD;
Registrationroom
Physiotherapydepartment
counselingroom
Diagnosticdivision
Pharmacy
fourdoctorsChamber
superintendentsoffice
emergencyward
operationtheater
10.Shockingdeportmentforulcerpatientandselfcare.
11.nursingstation.
InIPD;
Twonursingstation
twogeneralwardabouttwentybedded
oneleprosyward
twoulcerward
AndthreebeddedfiveroomforRCSpatient
onesnehaley wardthirtybedded
tensnehalay patienthouse
oneselfcareward
Physiotherapydepartmentforanpatient
10.Occupationaldepartment
11.Operationtheater
12.ProsthesisandShoedepartment
Workingprocessofhospital
Patientcomesinhospitalthenallprocessdonestepbystep;
Registration.
DiagnosethepatientleprosynonleprosybyPhysiotherapist.
Ifdiagnoseleprosypatientthevoluntarymuscleassessmentdone
byPhysiotherapist.
Pathologicalexamination.
Patientcounselingbycounselor
Vitalsign
AssessmentTreatmentgivenbydoctor.
SomeotherinvestigationlikeXRay,ECGandpathologicaltest.
Takemedicineonpharmacy.
fallowuppatientafter15daysor1monthaccordingtopatient
condition
Workinunder
Superintendent;Dr.Timothi Maximus
Medicalofficer;Dr.NeetaMaximus
Counceller: Mr.Ashish Samsan
HISTORYOFLEPROSY
FromtheoldrecordsavailableitisevidentthatLEPROSYis
averyancientdiseasedatingbackmanycenturies.
InIndiaLeprosywasreferredtoasKUSHTHAinthe
ancientvedic writingswrittenasforbackas1400B.C.
lowe statesthatthelowsofmenumentionthe
instructionsgivenforthepreventionofLeprosyinthose
days.Agooddescriptionofthisdiseaseanditstreatment
isgiveninSUSHRUTASAMHITAabookonsurgery
writtenbytheeminentIndiansurgeonSUSHRUTAheis
believedtohavewrittenthisbookin600B.C.heregarded
thisdiseaseasacontagiousdiseasecarriedfromaperson
sufferingfromthisdiseasetoahealthyperson.When
comparativestudiesaremadewiththeancientHindu
writingsthereisstrongevidencetoshowthatleprosywas
commonasfarbackas1400B.C.
ModernHistoryofLeprosy:atimeline
oftrialsandtreatments;
1873:Dr.GerhardHenrik Armauer HansenofNorwaywasthe
firstpersontoidentifythegermthatcausesleprosyundera
microscope.Hansen'sdiscoveryof Mycobacterium
lepraeproved thatleprosywascausedbyagerm,andwas
thusnothereditary,fromacurse,orfromasin.
early20
th
century:
Untilthelate1940s,leprosydoctorsallovertheworldtreated
patientsbyinjectingthemwithoilfromthechaulmoogranut.
Thiscourseoftreatmentwaspainful,andalthoughsome
patientsappearedtobenefit,itslongtermefficacywas
questionable.
ChaulmoograNut
ChaulmoograOilInjection
1921:U.S.PublicHealthServiceestablishedtheGillisW.Long
HansensDiseaseCenterinCarville,Louisiana,whichbecame
knownasCarville.Itbecameacenterofresearchandtestingto
findacureforleprosyandaliveintreatmentcenterforleprosy
patients.
1941:Promin,asulfone drug,wasintroducedasatreatmentfor
leprosy.ItwasfirstidentifiedandusedatCarville.Promin
successfullytreatedleprosybutunfortunatelytreatmentwith
Promin requiredmanypainfulinjections.
1950s:Dapsone pills,pioneeredbyDr.R.G.CochraneatCarville,
becamethetreatmentofchoiceforleprosy.Dapsone worked
wonderfullyatfirst,butunfortunately, M.lepraeeventually began
developingdapsone resistance.
.
1970s:Thefirstsuccessfulmultidrugtreatment(MDT)
regimenforleprosywasdevelopedthroughdrugtrialson
theislandofMalta.
1981:TheWorldHealthOrganizationbegan
recommendingMDT,acombinationofthreedrugs:
dapsone,rifampicin,andclofazimine.MDTwiththese
drugstakesfromsixmonthstoayearorevenmore,
dependingonstregnth ofleprosyinfection.
Now:MDTwithacombinationofdapsone,rifampicin,
andclofazimine isstillthebesttreatmentforpreventing
nervedamage,deformity,disabilityandfurther
transmission.Researchersareworkingondevelopinga
vaccineandwaystodetectleprosysoonerinorderto
starttreatmentearlier.
NowMDTBlisterPacks.
Symptoms(suchasdistinctiverashesthatdonotdisappear,enlarged
nerves,lossofthesenseoftouch,anddeformitiesthatresultfrom
muscleweakness)providestrongcluestothediagnosisofleprosy.
Examinationofasampleofinfectedskintissueunderamicroscope
(biopsy)confirmsthediagnosis.Becauseleprosybacteriadonotgrow
inthelaboratory,cultureoftissuesamplesisnotuseful.Bloodteststo
measureantibodiestothebacteriahavelimitedusefulnessbecause
antibodiesarenotalwayspresent.
CORDINALSIGNS;
HypopigmentedReddishSkinLesion(s)withDefiniteLossof
Sensation.
InvolvementofPeripheralNervesasDemonstratedbyDefinite
ThickeningWithLossofSensationandWeaknessoftheMusclesofthe
Hands,FeetorFace.
DemonstrationofM.Leprae inthelesions.
Thefirsttwocardinalsignscanbeidentifiedbyclinicalexamination
alonewhilethethirdcanbeidentifiedbyexaminationofslitskin
smear.
DIAGNOSIS OF LEPROSY
ClassificationofLeprosyDisease
Alltypesofleprosyarecausedbymycobacteriumleprae.The
amountofpatient'sresistancedetermineswhetherhe/shecanget
leprosyatallandifhecan,thenwhichtypehewillget.
Thethreemaintypesofleprosyare:
Tuberculoid
Borderline
Lepromatous
However,whentreatingneuritisitisnecessarytodivideborderline
leprosyinto3typesmakingfivetypesinall.Thesefivetypesare:
Tuberculoid Leprosy(TL)
BorderlineTuberculoid(BT)
BorderlineBorderline(BB)
BorderlineLepromatous(BL)
Lepromatous Leprosy(LL)
SymptomsofLeprosyDisease
Becausethebacteriathatcauseleprosymultiplyveryslowly,
symptomsusuallydonotbeginuntilatleast1yearafterpeople
havebeeninfected.Onaverage,symptomsappear5to7years
afterinfection.Oncesymptomsbegin,theyprogressslowly.
Leprosydiseaseaffectsmainlytheskinandperipheralnerves
Characteristicrashesandbumpsdevelop.Infectionofthenerves
makestheskinnumborthemusclesweakinareascontrolledby
theinfectednerves.
Tuberculoid leprosy:Arashappears,consistingofoneorafewflat,
whitishareas.Areasaffectedbythisrasharenumbbecausethe
bacteriadamagetheunderlyingnerves.
Lepromatous leprosy:Manysmallbumpsorlargerraisedrashesof
variablesizeandshapeappearontheskin.Therearemoreareasof
numbnessthanintuberculoid leprosy,andcertainmusclegroups
maybeweak.Muchoftheskinandmanyareasofthebody,
includingthekidneys,nose,andtestes,maybeaffected.
Borderlineleprosy:Featuresofbothtuberculoid andlepromatous
leprosyarepresent.Withouttreatment,borderlineleprosymay
becomelesssevereandmorelikethetuberculoid form,oritmay
worsenandbecomemorelikethelepromatous .
Themostseveresymptomsresultfrominfectionoftheperipheral
nerves,whichcausesdeteriorationofthesenseoftouchanda
correspondinginabilitytofeelpainandtemperature.Peoplewith
peripheralnervedamagemayunknowinglyburn,cut,orotherwise
harmthemselves.Repeateddamagemayeventuallyleadtolossof
fingersandtoes.Also,damagetoperipheralnervesmaycausemuscle
weaknessthatcanresultindeformities.Forexample,thefingersmay
beweakened,causingthemtocurveinward(likeaclaw).Musclesmay
becometooweaktoflexthefootaconditioncalledfootdrop.
Infectednervesmayenlargesothatduringaphysicalexamination,
doctorscanfeelthem.
Skininfectioncanleadtoareasofswellingandlumps,whichcanbe
particularlydisfiguringontheface.
OtherareasofthebodymaybeaffectedbyLeprosyDisease:
Feet:Soresmayalsodeveloponthesolesofthefeet,makingwalking
painful.
Nose:Damagetothenasalpassagescanresultinachronicallystuffy
noseandnosebleedsand,ifuntreated,completeerosionofthenose.
Eyes:Damagetotheeyesmayleadtoglaucomaorblindness.
Modeofspread
Themostimportantmodeofspreadof
Mycobacteriumleprae isbydropletsfromthe
sneezeofleprosypatients,whosenasalmucosais
heavilyinfected.Itisnotcertainwhetherthe
organismentersbyinhalationorthroughthe
skin.Theincubationperiodisbetween25years.
Theleprosydiseaseiscommonintropical
countrieslikeAsia,FarEast,TropicalAfrica,
CentralandSouthAmericaandinsomePacific
Islands.ThediseaseisstillendemicinSouthern
Europe,NorthAfricaandthemiddleEast.
Clinicalsignsandsymptoms
Skin
1.Shiny,oily,smoothandoedematous appearanceoftheskin.
2.Diffuseerythema ofskin.
3.Papulesornodulesonashiny,oedematous anderythematous
skin.
4.Suddenonsetofpainfulerythematous nodules.
5.Thickearlobes.
6.Thinningofeyebrowsorabsenceofeyebrowsparticularlyonthe
outerside.
NERVES
Ulnar nerve;
Mediannerve
Redialnerve
Lateralpopliteal
Posteriortibial;
Facialnerve7
th
cranialnerve;
Trigeminal5
th
cranialnerve;
HypopigmentedAnaestheticPatch
T1R
TuberculoidLeprosy
Lepromatous Leprosy(Nodules 5+)
NodularLeprosy
.
MB
Twotypesofreactionsonthebasisofimmunologicalchanges.
TypeIReactionandTypeIIReaction.
TypeIReaction
TypeIreactionoccursmorefrequentlyinborderline
typesofleprosy.
Clinicalfeatures
Skin:redness andswellingofexistingskinlesions
Extremities:Dactylitis,swellingofhandsandfeet,
pittingoedema andinflammationofsmalljointsand
bonesoffingers.

Reactionsinleprosy (Contd)
TypeIIReactions
Commonlyoccurinlepromatous and
borderlinelepromatous cases(LL&BL)
Antigen antibody complementcomplex
(immunecomplex)precipitatesinsmallblood
vesselsintissuesofskin,nervesandother
organs>vasculitis.
Erythema Nodosum Leprosum (ENL)
Painful,tender,rednodulesintheskin
Nodulesmayappearonanypartofthebodyincludingthe
face
Theyresolvein7 10days
Newcropsofnoduleswillcontinuetoappear(Ifuntreated)
PatientwithENLwilloftenhavesystemicsymptomslike
Fever,myalgia,arthralgia/arthritis.
Erythema Nodosum Leprosum
Eyecomplicationsinleprosy:
Cornealanaesthesia>cornealulcer>blindness
Lagophthalmos>exposurekeratitis>cornealulcer
>blindness
Iritis,iridocyclitis,episcleritis andscleritis
>glaucoma>blindness
Ciliary andsuperciliary madarosis
DeformitiesUlnar Median
Claw
Radial
Inabilityordifficultyinextendingthewrist(Wrist
drop).
MBMDTAdultdose.
PB BlisterCalendarPack
Infectivity
Itisnotabsolutelysurehowleprosyspreadsfromonepersonto
another.Weknowthatitismuchlessinfectiousthansmallpoxand
manyotherdiseases.Somepeoplehavesuchhighresistancethat
theydonotgetinfectedbyleprosydisease,nomatterhowclosely
theyareincontactwithanyinfectiousperson.Greatmajorityof
leprosypatientscannotinfectotherpeople.
Eventhefewinfectiouspatientsarenolongerinfectediftheyhave
beentakingadequatetreatmentfor36months,thoughtheydo
needtocontinuedrugtreatmentforaverylongtime.Thisfact
showsthatleprosyisnotdangerousasmostofthepeoplethink.
Itisachronicinfectiousdiseaseofonlymanandattacksmainly
nervesandskin.Itisdiagnosedandtreatedwithdrugsanditcanbe
controlledwithlittleprecautions,whichreducephysicaldamageor
disabilityfromoccuring.Leprosydiseasemaycausegreatemotional
distresstothepatientandtheirfamilies,anditmayseiously affect
thesociallifeofthepatient.
LeprosyTreatment
Thegoodnewsisthatleprosyiscurable.In1981,theWHOrecommendedtheuse
ofacombinationofthreeantibiotics usuallydapsone,rifampin,andclofazimine
fortreatment,whichtakessixmonthstoayearormore.
Duringthecourseoftreatment,thebodymayreacttothedeadbacteriawithpain
andswellingintheskinandnerves.Thisistreatedwithpainmedication,
prednisoneorthalidomide(underspecialconditions).
Multibacillary:Thestandardcombinationofdrugsisdapsone,rifampin and
clofazimine.Peopletakerifampin andclofazimine onceamonthunderahealth
carepractitioner'ssupervision.Theytakedapsone plusclofazimine onceadayon
theirown.Thisregimeniscontinuedfor12to24months,dependingonthe
severityofthedisease.
Paucibacillary:Peopletakerifampin onceamonthwithsupervisionanddapsone
onceadaywithoutsupervisionfor6months.Peoplewhohaveonlyasingle
affectedskinareaaregivenasingledoseofrifampin,ofloxacin,andminocycline.
Becausethebacteriaaredifficulttoeradicate,antibioticsmustbecontinuedfora
longtime.Dependingontheseverityoftheinfectionandthedoctor'sjudgment,
treatmentcontinuesfrom6monthstomanyyears.Somedoctorsrecommend
lifelongtreatmentwithdapsone forpeoplewithlepromatous leprosy.
Workinhospital
TherearetwoscaleworkIhavedoneandfill
thesescaleaccordingtoPatientconditionself
andcommunity
1
st
istheParticipationScalewhomaser
Stigmaanditsconsequence.
2
nd
istheSALSAScale(ScreeningActivity
LimitationandSafetyAwareness)TheSALSA
Scalemeasuresactivitylimitationsandwhen
consideredtogetherwithimpairmentand
participationrestrictionmeasurements,
AboutParticipationScale
Activityisdefinedastheexecutionofataskoractionbyan
individualandParticipationas
involvementinalifesituation.1Participationinthe
communityreferstothephenomenonof
executingonesroleinsocietyortakingpartinactivitiesin
agroupsituation.Stigmaandits
consequencesareasoldasthehistoryofmankind.Atany
pointintime,certainmembersofsociety
havefacedparticipationrestrictionsinvariousdomainsof
life,duetodisease,disability,deformity,
caste,creed,race,genderorotherstigmatising conditions.
Addressingparticipationrestrictionsisa
maingoalofmanyrehabilitationinterventions.Itis
thereforeofkeyimportancetobeabletomeasure
participationinordertoassessneeds,monitorprogress
andevaluatetheimpactofrehabilitation
Thedomainsofparticipationinclude:
Learningandapplyingknowledge(sharingskillsand
knowledge,solvingproblems,etc.)
Communication(conversation,expressingneedsand
ideas,participatingindiscussions,etc.)
Mobility(useofpublictransport,visitingpublicplaces,
walking,abilitytomoveabout,etc.)
SelfCare(washing,grooming,nutrition,hygiene,
clothesandappearance)
DomesticLife(householdtasks,assistingothers,etc.)
InterpersonalInteractions(relationships,etc.)
MajorLifeAreas(work,education,employment,
economiclife,etc.)
Community,SocialandCivic(communitylife,
recreation,leisure,religion,politicallife)
UseoftheParticipationScale
Typeofprogramme inwhichthescalewasused
(pleasecircleasmanyasapplicable):
Field orcommunitybasedrehabilitationprogramme
Hospitalbasedrehabilitationprogramme
Hospitalinpatientassessment
InanOccupationalTherapydepartmentinahospitalor
rehabilitationcentre
InaPhysiotherapydepartmentinahospitalor
rehabilitationcentre
InaSocialWorkdepartmentinahospitalor
rehabilitationcentre
CounselingHIVAids&GeneralDisease
SALSAscale
ObjectivesoftheSALSAScale:
TheSALSAScaleisascreeningtoolthataimsto:Identifypersonswith
activitylimitationAssesstheextentofActivityLimitationandtheriskof
increasingimpairmentTargetpeopleaffectedbyleprosy,diabetesorother
peripheralneuropathiesBeapplicableworldwide.Beusedincombination
withImpairmentandParticipationRestriction4toolsinorderto
measuredisablementfromaholisticpointofview.Provideameansto
measuretheresultsofinterventionswhosegoalistoimprovefunction
andselfcare.
DevelopmentoftheSALSAScale
TheSALSAScalewasdevelopedfrom2000 2006asastandardised toolto
measureactivitylimitationsandsafetyawarenessencounteredbypeople
affectedbyleprosy,diabetesandotherperipheralneuropathiesinboth
lowincomeanddevelopedareas.PhaseI:Listsofactivitiesofdailyliving
relevantforthetargetpopulationsweregeneratedthroughindividual
interviewsandfocusgroupdiscussions.Aquestionnaireof374items
(questions)wascompiledandadministeredto436personsaffectedby
leprosyand132affectedbydiabetesinfive
ApplicationsoftheSALSAScale
TheSALSAScalecanbeusefulinthefollowing
situations:
Screeningandidentifyingpersonswithactivity
limitationsScreeningandreferralofindividualsfor
furtherattentionbyatherapistAssessingthelevelof
activitylimitationinanindividualQuantifyingthelevel
ofactivitylimitationinagroupofpeopleaffectedby
peripheralneuropathyComparingthelevelofactivity
limitationbetweengroupsorpatientpopulations
Comparingthelevelofactivitylimitationinan
individualorgroupatdifferentmomentsintime(e.g.
beforeandafteranintervention)toevaluateprogress
UseoftheSALSAScale
Typeofprogramme inwhichthescalewasused
(pleasecircleasmanyasapplicable):
Field orcommunitybasedrehabilitation
programme
Hospitalbasedrehabilitationprogramme
Hospitalinpatientassessment
InanOccupationalTherapydepartmentina
hospitalorrehabilitationcentre
InaPhysiotherapydepartmentinahospitalor
rehabilitationcentre
InaSocialWorkdepartmentinahospitalor
rehabilitationcentre
HIVAidsCouncelling
ThankU