|Year : 2014 | Volume
| Issue : 1 | Page : 16-19
Clinical, bacteriological, and histopathological characteristics of children with leprosy: A retrospective, analytical study in dermatology outpatient department of tertiary care centre
Mahim Jain, Chitra S Nayak, Ramaya Chokkar, Rashmi Aderao
Department of Skin and VD, BYL Nair Hospital and Topiwala National Medical College, Mumbai, Maharashtra, India
|Date of Web Publication||2-May-2014|
Department of Skin and VD, OPD-14, OPD Building, BYL Nair Hospital and Topiwala National Medical College, Mumbai Central, Mumbai - 400 008, Maharashtra
Source of Support: None, Conflict of Interest: None
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 of leprosy in India, 9.7% of which were children. Studies pertaining to proportion 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: A retrospective, analytical study of patients seen from 01 January 2009 to 30 June 2013 in dermatology out-patient department of tertiary care center in Mumbai, Maharashtra.
Results: Study yielded 24 pediatric 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.
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.
Keywords: Childhood leprosy, clinicopathological and bacteriological characteristics, retrospective study
|How to cite this article:|
Jain M, Nayak CS, Chokkar R, Aderao R. Clinical, bacteriological, and histopathological characteristics of children with leprosy: A retrospective, analytical study in dermatology outpatient department of tertiary care centre. Indian J Paediatr Dermatol 2014;15:16-9
|How to cite this URL:|
Jain M, Nayak CS, Chokkar R, Aderao R. Clinical, bacteriological, and histopathological characteristics of children with leprosy: A retrospective, analytical study in dermatology outpatient department of tertiary care centre. Indian J Paediatr Dermatol [serial online] 2014 [cited 2020 Feb 25];15:16-9. Available from: http://www.ijpd.in/text.asp?2014/15/1/16/131830
| Introduction|| |
Leprosy has been a major public-health problem in many developing countries for centuries. 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 crucial role of frequency of leprosy in children as an indicator of the level of transmission in the community has been acknowledged. 
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 Republic's and 0.32% of Argentina's 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. 
Fine  scrutinized the Global leprosy situation of 2006 and contemplated if the variation in case detection in younger age groups reflected the actual trend in infection. He deliberated that the observed trend could be the outcome of difference in case detection methods (primary surveys in schools) or lack of standard age criterion for the child category in different countries. A multistage cluster sampling survey in north Bangladesh demonstrated that the prevalence of previously undiagnosed leprosy in children (5-14 years old) was 8.6/10,000.  In the pediatric age group, leprosy often presents as a single hypopigmented patch, which may or may not be anesthetic and is hence, confused with other dermatological ailments. 
India accounts for 55% of the new leprosy cases detected globally in 2010.  According to the National Leprosy Elimination Program report of March 2012, there were a total of about 0.13 million cases of leprosy in India, 9.7% of which were children.  In a prospective study carried out in a tertiary facility in Southern-Gujarat (March 1999 to March 2002), 8.4% of new leprosy cases were found to be children.  Sardana, in his retrospective hospital based study in Northern-India, found 86 children (0-15 years old) among the 1115 leprosy cases (7.71%) detected between 1992 and 2003.  Though these studies provide information on child leprosy amongst reported cases, the information regarding the clinical, bacterial and histopathological characteristics of child leprosy cases in the community are very few.
| 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.
The children were examined clinically by dermatologists and classified as paucibacillary (PB), i.e. <5 lesions ≤1 nerve and multibacillary (MB), i.e. >5 lesions and >1 nerve as per IAL classification.  A slit skin smear (SSS) examination was performed using sterile scalpel blades using the standard techniques. The air-dried and heat fixed smear was stained by Ziehl Neelson carbol fuschin stain and graded as per Ridley's scale for bacteriological index (BI). 
A skin lesional biopsy was obtained using local anesthesia, following verbal consent from the patient (minor) and written informed consent from the guardian.
| 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).
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.
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 [Table 2].
History of Contact
Two children had history of contact with leprosy patients. It was observed that both of the children had history of contact with leprosy patients within the family [Figure 1] and [Figure 2].
|Figure 1: A 10-year-old child with single hypopigmented lesion on face.|
Father is a known case of borderline tuberculoid Hansen's
Click here to view
|Figure 2: An 8-year-old child with a hypopigmented patch over left knee. Father was a known case of borderline tuberculoid leprosy|
Click here to view
| Discussion|| |
There is a considerable burden of leprosy in children. The high percentage of MB cases evidently indicates the grave nature of the problem of undetected child leprosy, recent active transmission and highlights the implications of this on individual patients and the community. The frequency of leprosy in children is an indicator of the level of transmission in community.
The high male to female ratio amongst child leprosy cases observed in this study is similar to the findings of many studies conducted over the past few decades. , The mean duration of symptoms exceeded 1 year, which can be attributed to poor knowledge of leprosy or barriers in access to health care or its utilization.
In concurrence with other studies, 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%). ,,
It has been documented 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.
Not surprisingly, a large proportion of MB (91.6%) cases were observed amongst children in this study. This concurs with the findings in earlier studies. , MB cases are infectious and can contribute to transmission of the disease in the community. The large proportion of MB cases becomes a matter of concern.
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.
With only three countries having prevalence higher than elimination level for leprosy (Brazil, Nepal and Timor-Leste), the WHO has acknowledged the challenges faced by countries who have already attained elimination to maintain the political commitment and services particularly at the peripheral level.  Two retrospective studies carried out in Hyderabad and Surat cities of India spanning over the past two decades (1990-1999 and 2001-2006), illustrated a decline in new case detection rate in children, while the overall prevalence of leprosy in the city was above elimination level. , In another retrospective study carried out in tertiary care hospital settings between 2000 and 2009, childhood leprosy was detected in 5.1% of cases.  In contrast, active survey has shown a high proportion of children (34.1%) among the newly detected cases, highlighting the burden of undetected child hood leprosy. This indicates hidden cases as well as continuing active transmission in this community. Our study also highlights the importance of SSS and biopsy as an aid in diagnosis and classification.
| References|| |
|1.||Bryceson AG, Pfaltzgraff RE. Leprosy. 3 rd ed. Edinburgh: Churchill Livingstone; 1990. |
|2.||Browne SG. The age of onset of leprosy. Int J Lepr 1965;33:267-72. |
|3.||Bechelli LM, Garbajosa PG, Gyi MM, Dominguez VM, Quagliato R. Site of early skin lesions in children with leprosy. Bull World Health Organ 1973;48:107-11. |
|4.||Global leprosy situation, beginning of 2008. Wkly Epidemiol Rec 2008;83:293-300. |
|5.||Fine PE. Global leprosy statistics: A cause for pride, or frustration? Lepr Rev 2006;77:295-7. |
|6.||Moet FJ, Schuring RP, Pahan D, Oskam L, Richardus JH. The prevalence of previously undiagnosed leprosy in the general population of northwest bangladesh. PLoS Negl Trop Dis 2008;2:e198. |
|7.||Mahajan S, Sardana K, Bhushan P, Koranne RV, Mendiratta V. A study of leprosy in children, from a tertiary pediatric hospital in India. Lepr Rev 2006;77:160-2. |
|8.||World Health Organization. Global burden of leprosy at the end of 2010. Wkly Epidemiol Rec 2011;86:389-400. |
|9.||NLEP-Progress Report for the year 2011-12 ending on 31 st March 2012. Central Leprosy Division. New Delhi: Directorate General of Health Services Nirman Bhawan; 2012. Available from: http://www.nlep.nic.in/Revised%20Progress%20report%2031 st %20March%202011-12.pdf. [Last accessed on 2012 Dec 27]. |
|10.||Vara N. Profile of new cases of childhood leprosy in a hospital setting. Indian J Lepr 2006;78:231-6. |
|11.||WHO Expert Committee on Leprosy. World Health Organ Tech Rep Ser 1998;874:1-43. |
|12.||Ridley DS. The bacteriological interpretation of skin smears and biopsies in leprosy. Trans R Soc Trop Med Hyg 1955;49:449-52. |
|13.||Selvasekar A, Geetha J, Nisha K, Manimozhi N, Jesudasan K, Rao PS. Childhood leprosy in an endemic area. Lepr Rev 1999;70:21-7. |
|14.||John AS, Rao PS, Kundu R, Raju MS. Leprosy among adolescents in Kolkata, India. Indian J Lepr 2005;77:247-53. |
|15.||Shetty VP, Thakar UH, D'souza E, Ghate SD, Arora S, Doshi RP, et al. Detection of previously undetected leprosy cases in a defined rural and urban area of Maharashtra, Western India. Lepr Rev 2009;80:22-33. |
|16.||Kumar B, Rani R, Kaur I. Childhood leprosy in Chandigarh; clinico-histopathological correlation. Int J Lepr Other Mycobact Dis 2000;68:330-1. |
|17.||Jain S, Reddy RG, Osmani SN, Lockwood DN, Suneetha S. Childhood leprosy in an urban clinic, Hyderabad, India: Clinical presentation and the role of household contacts. Lepr Rev 2002;73:248-53. |
|18.||Rao AG. Study of leprosy in children. Indian J Lepr 2009;81:195-7. |
|19.||van Beers SM, Hatta M, Klatser PR. Patient contact is the major determinant in incident leprosy: Implications for future control. Int J Lepr Other Mycobact Dis 1999;67:119-28. |
|20.||Horo I, Rao PS, Nanda NK, Abraham S. Childhood leprosy: Profiles from a leprosy referral hospital in West Bengal, India. Indian J Lepr 2010;82:33-7. |
|21.||Sachdeva S, Amin SS, Khan Z, Alam S, Sharma PK. Childhood leprosy: A retrospective study. J Public Health Epidemiol 2010;2:267-71. |
|22.||Chudasama RK, Godara N, Tripathi VS, Patel M. An observation of leprosy situation in Surat district from 2001 to 2006. Indian J Dermatol Venereol Leprol 2007;73:434-5. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]