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ORIGINAL ARTICLE
Year : 2017  |  Volume : 18  |  Issue : 1  |  Page : 24-27

A clinico-epidemiological study of pediatric leprosy in the urban leprosy center of a tertiary care institute


Department of Dermatology and Venereology, Government Medical College, Trivandrum, Kerala, India

Date of Web Publication12-Dec-2016

Correspondence Address:
Sukumaran Pradeep Nair
Department of Dermatology and Venereology, Government Medical College, Trivandrum - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.187890

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  Abstract 


Introduction: The prevalence of leprosy in the pediatric age group indirectly points to active disease in the community. Aim: The main objective of this study was to study the clinico-epidemiological features and prevalence of pediatric leprosy cases in our urban leprosy care center.
Materials and Methods: This is an 18-year retrospective descriptive study of pediatric leprosy cases (1997–2014) done in the urban leprosy center of a tertiary care institute.
Results: There were sixty cases of pediatric leprosy (n = 60) in this study. There were 41 males (68.33%) and 19 females (31.67%). The mean age was 8.34 years. The age group of 10–12 years accounted for the maximum number of cases, 25 (41.67%). The mean duration of illness was 0.89 year. Family history of leprosy was present in four cases (6.67%). The most common primary skin lesion was macule present in 43 cases (71.66%), with the upper extremities being the most common site involved. Sensory impairment was present in 39 cases (65%). Peripheral nerve thickening was present in 27 cases (45%). Borderline tuberculoid (BT) was the most common type of leprosy seen in 33 cases (55%). Lepra reactions were present in three cases (5%) and Grade 2 deformity was present in three cases (5%).
Conclusions: This study showed a prevalence of 6.65% of pediatric leprosy cases. BT was the most common type of leprosy, and the prevalence of lepromatous leprosy, lepra reactions, and deformity was low.

Keywords: Borderline tuberculoid, pediatric leprosy, prevalence


How to cite this article:
Nair SP. A clinico-epidemiological study of pediatric leprosy in the urban leprosy center of a tertiary care institute. Indian J Paediatr Dermatol 2017;18:24-7

How to cite this URL:
Nair SP. A clinico-epidemiological study of pediatric leprosy in the urban leprosy center of a tertiary care institute. Indian J Paediatr Dermatol [serial online] 2017 [cited 2019 Aug 22];18:24-7. Available from: http://www.ijpd.in/text.asp?2017/18/1/24/187890




  Introduction Top


Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae, affecting all age groups, primarily affecting the nerves and skin and secondarily other organs. Leprosy in pediatric age group indicates a hidden reservoir of infective cases in the community, the usual source of contact being the family members, neighbors or contact from fellow students in the schools where they are studying. The prevalence rates of leprosy in the pediatric age group in various studies vary from 5.1% to 11.43% in India.[1],[2] Studies have also shown that the usual source of contact in children is from the borderline lepromatous (BL) and lepromatous leprosy (LL) cases. This is because the aforementioned types of leprosy are the infectious “open” cases of leprosy, as they harbor viable lepra bacilli in their nasal mucosa, and leprosy is predominantly spread by nasal droplets and less commonly spread by direct skin to skin contact. Due to the immature immune system in children, pediatric leprosy differs from the adult types in the following ways. Tuberculoid leprosy (TT) is more common than LL; lepra reactions are rare and deformities due to motor-sensory nerve deficits are also rare. We often do see pediatric leprosy cases in the urban leprosy center of our institute and hence decided to conduct this study. The main objective of this study was to study the clinico-epidemiological features of pediatric leprosy cases in our urban leprosy care center.


  Materials and Methods Top


This is an 18-year retrospective descriptive study (1997–2014) done in the urban leprosy center of a tertiary care institute. The study population included all cases of pediatric leprosy (1–12 years of age) who attended the aforementioned center in the study period. The data were collected from the leprosy cards of our center and recorded in a preformatted standard proforma. Age, sex, family history, and duration of illness were the main demographic data collected. The clinical features were thoroughly studied. Sensory-motor deficits of the patients were noted. Temperature, touch, and pain were the main sensations recorded. A thorough examination of the peripheral nervous system was done with special reference to thickening, nodularity, and tenderness of the nerves. Deformities such as facial palsy, ulnar nerve palsy, median nerve palsy, foot drop, and plantar ulcers were also studied. Slit skin smear slides stained with Ziehl–Neelsen technique and histopathological slides stained with hematoxylin and eosin and Wade-Fite stains were also reviewed. Smear-positive cases were expressed in terms of bacteriological index (BI) and morphological index (MI). After clinical examination and investigations, the leprosy cases were classified based on the Ridley–Jopling and Indian Association of Leprologists classifications.[3] The data collected were analyzed in terms of descriptive statistics.

Permission to conduct this study was forwarded to the Institutional Review Board of this institute, who recommended that since this is a retrospective case records-based study with no direct patient interaction, permission was not required.


  Results Top


A total of 901 leprosy cases attended the urban leprosy center of our institute in the 18-year study period, of which there were sixty cases of pediatric leprosy (n = 60), thus accounting for a prevalence of 6.65%. There were 41 males (68.33%) and 19 females (31.67%). The male–female ratio was 2.15:1. The age group distribution is given in [Table 1]. The mean age was 8.34 years. The age group of 10–12 years accounted for the maximum number of cases, 25 (41.67%). The youngest was 3 years of age and the oldest 12 years. The mean duration of illness was 0.89 year. Family history of leprosy was present in four cases (6.67%) and all the family members were of the LL type.
Table 1: Age group distribution (n=60)

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The most common primary skin lesion was macule present in 43 cases (71.66%), followed by plaque, four cases (25%), and papule, two cases (3.33%). The distribution of the skin lesions is given in [Table 2]. Sensory impairment to temperature, touch, and pain was present in 39 cases (65%). Peripheral nerve thickening was present in 27 cases (45%). Multiple nerves were involved in 12 cases (44.44%). Ulnar nerve was the most common nerve to be involved in 12 cases (44.4%), followed by radial cutaneous nerve in seven cases (25.93%). The different types of leprosy are given in [Figure 1]. Borderline tuberculoid (BT) was the most common type of leprosy seen in 33 cases (55%). Lepra reactions were present in three cases (5%), constituting two cases of Type 1 lepra reaction and one case of Type 2 lepra reaction. Grade 2 deformity was present in three cases (5%), constituting two cases of ulnar palsy and one case of foot drop. The mean BI was 5.33 and the mean MI was 40%. Forty-nine cases (81.66%) were given paucibacillary therapy while eight cases (13.33%) were given multibacillary therapy and three cases (5%) were given rifampicin, ofloxacin, minocycline therapy. During treatment, two cases (3.33%) developed allergy to dapsone and one case (1.67%) developed ulnar abscess during as episode of Type 1 lepra reaction.
Table 2: Distribution of skin lesions*

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Figure 1: Types of leprosy (n = 60)

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  Discussion Top


The prevalence of leprosy in the pediatric age group indirectly points to active disease in the community.[4] In this 18-year retrospective study, the prevalence of pediatric leprosy was 6.65%. The prevalence of leprosy in children in various other Indian studies ranges from 5.1% to 11.43%.[1],[2] The prevalence of pediatric leprosy in other countries, where leprosy is prevalent, is 2.9% in China, 7% in Nigeria, 7.9% in Brazil, and 11.9% in Indonesia.[5],[6],[7] Countries such as Brazil and Indonesia have a high prevalence of leprosy cases in the adults compared to India which explains the high prevalence in the pediatric age group. The male-female ratio in this study was 2.15:1 which is similar to other studies done in India where the ratio ranged from 1.25:1 to 3:1.[4] However, in the study by Horo et al., females predominated.[1] In adults also, leprosy is seen more often in males. In the present study, pediatric leprosy was most commonly seen in the age group of 10–12 years. This is similar to studies done in India and China.[5],[7] The mean duration of illness in this study was <1 year. This is in contrast to adult leprosy cases where the usual duration of illness is in years. This could be due to the early health care-seeking attitudes in concerned parents when their children develop skin lesions, especially hypopigmented lesions, as seen in cases of leprosy. In the present study, family history of leprosy was present in 6.67%. This compares with other studies where familial contact ranged from 6.06% to 47%.[4],[8],[9] Familial contact is very important in the spread of leprosy in children, especially if one of the parents is a smear-positive case of the BL or LL type [Figure 2]. This is because leprosy is predominantly spread through nasal droplets and proximity between parents and children facilitates this process.[10]
Figure 2: (a) Lepromatous leprosy in the father (b) indeterminate leprosy in son

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Extremities were the most common sites to be involved in this study. This is similar to other studies done in India.[10] Peripheral nerve trunk involvement was present in 45% cases, and 44.4% of these cases had multiple trunk involvement. Multiple trunk involvement in other studies in India ranged from 4.54% to 59.38%.[4] BT leprosy was the most common type of leprosy seen in this study (55%) which is the same as in most studies done in India and abroad.[2],[4],[5],[6],[7],[9],[10] BT is the most common type of leprosy in any age group [Figure 3]. However, in the study done by Horo et al., TT predominated.[1] Indeterminate leprosy accounted for 33% in this study. This is much higher than the other studies in India which ranged from 3.48% to 10.1%.[4] The reduced prevalence in other studies could be due to missed cases as this type of leprosy presents only with macules with or without sensory impairment and may be misdiagnosed as pityriasis alba, pityriasis versicolor, or postinflammatory hypopigmentation. The predominance of BT and indeterminate leprosy in this study also explains the fact of macules being the most common type of primary skin lesion seen in this study (71.66%), as these types of leprosy usually present with macules. There was only one case of LL in this study. BL and LL types of leprosy are usually rare in the pediatric age group as seen in our study and elsewhere due to the immature immune system seen in them. However, in the study by Palit and Inamadar, the prevalence of smear-positive leprosy cases in children was 8.19%.[11] However, even few cases of smear-positive leprosy cases in any region have got grave epidemiological consequences as they are the “open” cases who can infect others since they harbor viable bacilli in their nasal mucosa, and leprosy is predominantly spread by nasal droplets. There were no cases of histoid leprosy in this study as this is extremely rare in children.[12],[13] The prevalence of pure neuritic leprosy was also low in this study, similar to other studies in India.[10],[11],[12],[13] However, it is possible that cases may be missed or misdiagnosed as this type of leprosy presents only with nerve involvement and no skin lesions. The prevalence of lepra reaction was low in this study (5%). In other studies, it ranged from 1.36% to 29.7%.[4] Lepra reactions are rare in pediatric leprosy due to the aforementioned immature immunity in children as lepra reactions are predominantly immunologically mediated episodes in the course of leprosy. Grade 2 deformity was also low in this study (5%) compared to other studies where it ranged from 0% to 24%.[4] Deformities usually follow episodes of lepra reaction (usually Type 1) and since lepra reactions are rare in pediatric leprosy, we naturally also expect deformities to be rare. However, deformity due to leprosy in a child has got grave consequences since it implicates late diagnosis or late treatment.[14],[15]
Figure 3: (a) Hypopigmented anesthetic macule of borderline tuberculoid leprosy (b) skin biopsy showing epithelioid cell granulomas in the dermis (H and E, ×100)

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  Conclusions Top


This study showed that the prevalence of pediatric leprosy cases was 6.65%; age group of 10–12 years was the most common affected; macules were the most common primary skin lesion; the extremities were the most common site involved; BT was the most common type of leprosy; and the prevalence of LL, lepra reactions, and deformity was low.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
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.  Back to cited text no. 1
    
2.
Vara N. Profile of new cases of childhood leprosy in a hospital setting. Indian J Lepr 2006;78:231-6.  Back to cited text no. 2
    
3.
Ridley DS, Jopling WH. Classification of leprosy according to immunity. A five-group system. Int J Lepr Other Mycobact Dis 1966;34:255-73.  Back to cited text no. 3
    
4.
Palit A, Inamadar AC. Childhood leprosy in India over the past two decades. Lepr Rev 2014;85:93-9.  Back to cited text no. 4
    
5.
Yan L, Shen J, Zhou M, Zhang G. Survey on child leprosy patients and problems resulted from the disease in China. Lepr Rev 2015;86:75-9.  Back to cited text no. 5
    
6.
Ekeke N, Chukwu J, Nwafor C, Ogbudebe C, Oshi D, Meka A, et al. Children and leprosy in southern Nigeria: Burden, challenges and prospects. Lepr Rev 2014;85:111-7.  Back to cited text no. 6
    
7.
World Health Organization. Global leprosy: Update on the 2012 situation. Wkly Epidemiol Rec 2013;88:365-80.  Back to cited text no. 7
    
8.
Sasidharanpillai S, Binitha MP, Riyaz N, Ambooken B, Mariyath OK, George B, et al. Childhood leprosy: A retrospective descriptive study from Government Medical College, Kozhikode, Kerala, India. Lepr Rev 2014;85:100-10.  Back to cited text no. 8
    
9.
Prasad PV. Childhood leprosy in a rural hospital. Indian J Pediatr 1998;65:751-4.  Back to cited text no. 9
    
10.
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.  Back to cited text no. 10
    
11.
Palit A, Inamadar AC, Desai SS, Sharma P. Childhood leprosy in the post-elimination phase: Data from a tertiary health care hospital in the Karnataka state of South India. Lepr Rev 2014;85:85-92.  Back to cited text no. 11
    
12.
Dogra S, Narang T, Khullar G, Kumar R, Saikia UN. Childhood leprosy through the post-leprosy-elimination era: A retrospective analysis of epidemiological and clinical characteristics of disease over eleven years from a tertiary care hospital in North India. Lepr Rev 2014;85:296-310.  Back to cited text no. 12
    
13.
Nair SP, Nanda Kumar G. A clinical and histopathological study of histoid leprosy. Int J Dermatol 2013;52:580-6.  Back to cited text no. 13
    
14.
Singal A, Sonthalia S, Pandhi D. Childhood leprosy in a tertiary-care hospital in Delhi, India: A reappraisal in the post-elimination era. Lepr Rev 2011;82:259-69.  Back to cited text no. 14
    
15.
Sardana K. A study of leprosy in children, from a tertiary pediatric hospital in India. Lepr Rev 2006;77:160-2.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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