s
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Home Print this page Email this page Small font size Default font size Increase font size Users Online: 156

 Table of Contents  
LETTER TO EDITOR
Year : 2017  |  Volume : 18  |  Issue : 1  |  Page : 61-63

Clinical relapse in child hood leprosy


Regional Office of Health and Family Welfare and Regional Leprosy Training and Research Institute, Under DGHS, Government of India, Ministry of Health and Family Welfare, Lalpur Raipur, Chhattisgarh, India

Date of Web Publication12-Dec-2016

Correspondence Address:
Sunil Vilasrao Gitte
Deputy Director, Regional Office of Health and Family Welfare and Regional Leprosy Training and Research Institute, Under DGHS, Government of India, Ministry of Health and Family Welfare, Lalpur, Raipur -. 492 001, Chhattisgarh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.184437

Rights and Permissions

How to cite this article:
Gitte SV, Sahu P. Clinical relapse in child hood leprosy. Indian J Paediatr Dermatol 2017;18:61-3

How to cite this URL:
Gitte SV, Sahu P. Clinical relapse in child hood leprosy. Indian J Paediatr Dermatol [serial online] 2017 [cited 2019 Aug 21];18:61-3. Available from: http://www.ijpd.in/text.asp?2017/18/1/61/184437



Sir,

Early leprosy relapse is probably due to inadequate treatment and late relapse due to bacillary persistence or re-infection. Relapse of leprosy is an important quality of service indicators in assessing the long-term efficacy of chemotherapy, i.e., multi-drug therapy (MDT). Relapse in leprosy is compounded by irregular treatment, particularly in chronic disease. The predisposing factors for relapse include the presence of persister Bacilli, monotherapy (dapsone), inadequate or irregular therapy, the presence of multiple skin lesions and/or thickened nerves, etc.[1] After introduction of MDT for the control of leprosy, since, then, there has been a significant change in the leprosy scenario both at the global and national level, and the active case load came down drastically. Relapse rates in paucibacillary (PB) (0.65–3.0%) and multibacillary (MB) leprosy (0.02–0.8%) were estimated by various studies.[2] Reports from all over the world regarding effectiveness of MDT in MB and PB are very encouraging. However, some relapse may be and are occurring through small scale compared to the vast majority it benefits. Such relapse cases should be kept under surveillance. A 13-year-old male child was first diagnosed with PB leprosy in the year 2010. He has taken six pulses of MDT irregularly from the nearest primary health center and declared as release from treatment before reporting to our Institute.

In July 2015, after 5 years of completion of treatment (MDT), he has noticed new fresh hypo pigmented well defined patches with loss of sensation appeared over hand, leg, face and back since 3 and half months [Figure 1],[Figure 2],[Figure 3]. The patches are variable in size, flat, and brown. Patches were looking active, and margins are illdefined in nature. On examination of all peripheral nerves were not thickened or nontender. No any signs and symptoms of lepra reactions seen. He has known family contact history, i.e., grandmother, suffered from MB cases of leprosy. He was completed primary routine immunization schedule as revealed by the mother. The child underwent slit skin smear, motor, and sensory examination. Nerve function assessment was carried out by voluntary muscle testing for the function of muscles supplied by the nerve and sensory test testing for sensory loss in the areas supplied by the nerve and found normal. His slit skin smears examination shows zero bacillary index (BI) and the morphological index. He was clinically classified as a case relapse MB and put on MDT for 12 months as per WHO guidelines. A patient who has completed an adequate course of MDT, but who subsequently develops new signs and symptoms of the disease after taking a complete treatment were taken as relapse as per WHO. The insidious appearance of a new lesion or a definite increase in the size of the lesion and or appearance of new nerve thickening were noted in relapse cases. However, an increase in BI of even 2+ logs at any site over the previous BI in two successive examinations should be considered adequate supporting evidence for diagnosing relapse in patients who had earlier become negative or were showing a downward trend in BI after MDT treatment. In PB leprosy, the criteria for relapse depend primarily on clinical features since even histological examination cannot clearly distinguish between reactions and relapse.[3] The patient is residing in a locality where he was exposed to other infected patients. The duration of this dormant state may be a few months to a few years. In lepromatous leprosy case, there is impaired host cellular immune response to Mycobacterium leprae, so that a treated case of leprosy remains susceptible to re-infection even after completion of therapy. The risk is more prominent in endemic areas.[4] Patient once infected with leprosy may again be infected, if its cell-mediated immunity is low, so recurrence of disease in an MDT release after treatment case may be due to reinfection.[5],[6] The differences between relapse and reversal reaction was ruled out by clinical examination and history. In above case, the relapse occurred after completion of MDT therapy, and this could be due to irregular MDT or the multiplication of persister Bacilli or long survival of drug-sensitive persister, which might have multiplied slowly over the years after the stoppage of treatment. Hence, this is clear-cut a case of leprosy relapse. Such case report re-emphasizes that leprosy cases must be kept under clinical as well as bacteriological follow-up for as long as possible after completion of MDT regimens.
Figure 1: Patch over lower third flexor surface of the left thigh

Click here to view
Figure 2: A large hypo pigmented patch over left arm

Click here to view
Figure 3: Active patch over left cheek

Click here to view


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Thappa DM. Relapse in leprosy. Indian J Dermatol Venereol Leprol 2009;75:126-35.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Risk of relapse in leprosy. The Leprosy Unit, WHO. Indian J Lepr 1995;67:13-26.  Back to cited text no. 2
    
3.
Becx-Bleumink M. Relapses among leprosy patients treated with multidrug therapy: Experience in the leprosy control program of the All Africa Leprosy and Rehabilitation Training Center (ALERT) in Ethiopia; practical difficulties with diagnosing relapses; operational procedures and criteria for diagnosing relapses. Int J Lepr Other Mycobact Dis 1992;60:421-35.  Back to cited text no. 3
    
4.
Shaw IN, Ebenezer G, Rao GS, Natrajan MM, Balasundaram B. Relapse as histoid leprosy after receiving multidrug therapy (MDT); a report of three cases. Int J Lepr Other Mycobact Dis 2000;68:272-6.  Back to cited text no. 4
    
5.
Ramu G. Clinical features and diagnosis of relapses in leprosy. Indian J Lepr 1995;67:45-59.  Back to cited text no. 5
    
6.
Desikan KV. Relapse, reactivation or reinfection? Indian J Lepr 1995;67:3-11.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
References
Article Figures

 Article Access Statistics
    Viewed464    
    Printed2    
    Emailed0    
    PDF Downloaded103    
    Comments [Add]    

Recommend this journal