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Clinical, bacteriological, and

histopathological characteristics of
children with leprosy : A retrospective,
analytical study in dermatology outpatient
departement of tertiary care centre

Perceptor : dr. Resati Nando Panonsih Sp.KK


Penyaji : Arum mananti pradita
Robertus dery elvantora

Background
Leprosy is a major public health problem in developing countries.
According to National Leprosy Elimination Program report of March
2012, there were a total of about 0.13 million cases in India, 9.7% of
which were children. Studies pertaining to propotion and characteristics of
pediatric cases are few in number

Aim
The aim of the following study is to examine clinical, bacteriological and
histopathological characteristics of pediatric leprosy cases in community

Methods
This study is aimed at outlining the clinical, bacteriological and
histopathological characteristics of childhood leprosy. It was a retrospective,
analytical study of pediatric patients seen from 01 January 2009 to 30 June
2013 in dermatology out-patient department of a tertiary care center.

Introduction
Leprosy has been a major public-health problem in many developing countries for
centuries. The crucial role of frequency of leprosy in children as an indicator of the
level of transmission in the community has been acknowledged. Children are
believed to be the most vulnerable group to Mycobacterium leprae infection and
clinical manifestation is often seen in adolescence or young adulthood following
the long incubation period.
The World Health Organization (WHO) found a wide variation in the proportion of
children amongst newly detected cases in different regions. In the year 2007, in
Africa, this proportion ranged from 2.89% in Togo to 37.96% in the Comoros.
Within America, 14.02% of the Dominican Republics and 0.32% of Argentinas
new leprosy cases were children. South-East Asia, on the other hand showed a
narrower range with Nepal reporting 3.34% compared to 14.1% in Timor-Leste.

Results
A total of the 262 new cases were detected during the study out of which 24 (9.16%) were
children (16 males and 8 females). The age of the child hood cases detected during this study
ranged from 3 to 12 years. The mean age was 9.25 2.33 years. The mean duration of
symptoms was reported to be about 16.5 months (range: 1 - 48 months).
Study yielded 24 peditric cases of leprosy. The age of child leprosy cases ranged from 3 to 12
years with mean of 9.25 2.33. most of the cases were multibacillary (MB) (95.8%). A large
proportion of children (45.8%) had single skin lesion (SSL) Of the 11 SSL cases examined
histopathologically, 8 (72.7%) showed features of borderline tuberculoid, 1 (9%) each of
borderline lepromatous, indeterminate type and tuberculoid leprosy. Overall, one case had
deformity (grade 2) and 8.7% of MB cases were smear positive. Overall 2 patients had history
of contact.

Table 1 : clinical presentations of childhood leprosy


Number of skin lesion
Single
2-5
>5
Pure neuritic

Number of patients
11 (4 on face)
6
7
0

Clinical Findings
A majority of the child hood cases in the population were MB (22/24). Among the
MB cases, 40.9% (9/22) had single skin lesion (SSL) of which 36.36% (4/11) had
lesion on the face. No pure neural case was detected [Table 1]. On examination
for the grade of deformity, it was found that 23 children had no deformity; only
one had a Grade 2 deformity. One patient presented with type 2 lepra reaction.

Table 2 : clinical and histopathological classification


No. of skin lesions
1
2-5
>5
> total

Total

TT

Histopathological classification
BT BB BL
LL Indeterminate

0
0
0
0

9
5
5
19

11
6
7
24

0
0
0
0

0
1
2
3

0
0
0
0

2
0
0
2

Bacteriological and Histopathological Findings


On examination for bacteriological status using SSS, it was found that 2 MB cases
were smear positive with a BI of >2+ able. Both the PB cases were smear negative. Of
the 24 children examined histopathologically, majority showed characteristic features
of borderline tuberculoid (BT) leprosy (19/24), three were borderline leprosy (BL) and
2 indeterminate. Of the four facial lesions, which were examined histopathologically,
three showed features of BT leprosy and one was indeterminate. Notably, tuberculoid
leprosy (TT) features were not seen in any biopsy

Discussion

Figure 1 : A 10-year-old child with single hypopigmented


lesion on face.
Father is a known case of borderline tuberculoid Hansens

Figure 2: An 8-year-old child with a hypopigmented patch over left knee.


Father was a known case of borderline tuberculoid leprosy

This study also found a large proportion of children (45.83%) had SSL and
(36.3%) had it on the face. Single hypopigmented patch on the face in
children has high-risk of misdiagnosis, since there are numerous common
causes of hypopigmented patches in children. Notably, all the SSL biopsies
were proved to be cases of leprosy, as assessed by histopathology and none
of them were TT leprosy indicating progressive nature of the disease and
less likelihood of self-resolution. Similar findings have been documented
in an earlier study wherein 62.5% (30/48) and 12.5% (6/48) of SSL
showed cellular characteristic features of BT and borderline leprosy-BL,
respectively.Another finding was, majority of cases had BT (86.36%)
leprosy, which is similar to findings by Kumar et al (58.3%), Jain et al.
(66.3%) and Rao (68%).

That there is a four-fold risk of developing leprosy in presence of a contact


in the neighborhood and this risk increases to nine-fold if there is a contact
with leprosy patient within the household. This study found that only a
small proportion of children with leprosy had history of contact with
leprosy cases. This is a positive sign.
Only one child (4.2%) had deformity (Grade 2). These findings point to the
fact that most of these childhood leprosy cases were detected early during
the course of the disease. Only two cases were smear positive which is a
positive sign as they also represent a major source of infection.

Conclusion
The clinical, bacteriological and histopathological characteristics of cases
in children, especially the high percentage of MB cases evidently indicate
the grave nature of the problem of undetected child leprosy, recent active
transmission and highlight implications on individual patients and the
community.