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REVIEW ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 112-116

Childhood leprosy: A review


1 Department of Dermatology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Pediatrics, SCB Medical College, Cuttack, Odisha, India

Date of Web Publication29-Mar-2019

Correspondence Address:
Dr. Swetalina Pradhan
Department of Dermatology, All India Institute of Medical Sciences, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_47_18

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  Abstract 


Leprosy in children is of special importance as it is the indicator of transmission in community. It affects both the child and family members psychologically and functionally. In this review, we will discuss regarding epidemiology of childhood leprosy in detail, types of leprosy in children, diagnostic difficulties in children, prevention of disabilities in children, and effect of childhood leprosy on the community.

Keywords: Childhood leprosy, community transmission, deformities, diagnosis, treatment


How to cite this article:
Pradhan S, Nayak BP, Dash G. Childhood leprosy: A review. Indian J Paediatr Dermatol 2019;20:112-6

How to cite this URL:
Pradhan S, Nayak BP, Dash G. Childhood leprosy: A review. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Sep 15];20:112-6. Available from: http://www.ijpd.in/text.asp?2019/20/2/112/255207




  Introduction Top


Leprosy is a disease known for its paralyzing deformities and social stigma. It is sad and unfortunate that even though WHO has declared leprosy to be eliminated in 2005, it has remained as endemic disease in various parts of the world specifically developing countries like India.[1] Although leprosy affects all age group, leprosy in children is of special importance as it is an indicator of transmission in the community. In this review, we have discussed regarding epidemiology of childhood leprosy in detail, types of leprosy in children, diagnostic difficulties in children, prevention of disabilities in children and effect of childhood leprosy on community.


  Epidemiology Top


A total of 135,485 new cases were detected during the year 2016–2017, which gives Annual New Case Detection Rate of 10.17/100,000 population, as against 127,334 cases in 2015–2016. A total of 88,166 leprosy cases are on record as on April 1, 2017, giving a prevalence rate of 0.66/10,000 population, as against 86,028 cases in April 1, 2016.[2] A high proportion (49.57%) of the new leprosy cases detected during 2016-2017 were multibacillary that included (8.7%) of children and grade II deformity was reported in 3.87%. A total of 11792 child cases were recorded indicating the child case rate of 8.7%. Proportion of child cases was more than 10% of new case detected in 10 States/Union territories, namely (i) Arunachal Pradesh-10.71%, (ii) Bihar - 13.70%, (iii) Jharkhand - 10.59%, (iv) Maharashtra - 10.18%, (v) Nagaland - 11.76%, (vi) Punjab - 17.25%, (vii) Tamil Nadu - 17.64%, (viii) Dadra and Nagar Haveli - 19.79%, (ix) Daman and Diu- 14.29%, and (x) Lakshadweep-11.11%.


  Classification of Leprosy Top


Although various types of classifications have been proposed for leprosy, Ridley-Jopling classification is the most accepted classification as it includes clinical, immunological, and histopathological spectrum of the disease. According to the above classification leprosy is of five types, tuberculoid(TT), borderline tuberculoid (BT), mid-borderline(BB), borderline lepromatous (BL) and lepromatous(LL).[3] For field healthcare workers, WHO has classified leprosy into two broad categories basing upon number of skin lesions: Paucibacillary (PB) and Multibacillary (MB). Paucibacillary (PB) leprosy is defined as five or fewer skin lesions without detectable bacilli on the skin. Multibacillary (MB) leprosy defined as six or more lesions and may be skin smear positive.[4]

In majority of studies, the age group that is most commonly affected by the disease among children under 15 years of age was found between 10 and 14 years of age, which can be justified by the disease's long incubation period of approximately 3–5 years.[5],[6],[7],[8],[9],[10],[11],[12] However, Santos et al.[13] identified a discrete predominance in the 5–9-year-old age group, in 54.54% (42/77), followed by 10–14-year-old age group 44.15%. Although theoretically leprosy should not occur in infants because of long incubation period of leprosy in years, it has been reported in infants as young as 2–3 months of age by Brubaker et al.[14]

PB leprosy is commonly found in children as compared to MB because of good immunity than adults.[8] In contrast, two studies found more number of multi-bacillary (60.65% and 91.66%) cases in children.[15],[16] In various studies, it has been found that BT leprosy is the most common form found in children followed by BL leprosy, indeterminate, lepromatous leprosy, and pure neuritic leprosy [Figure 1] and [Figure 2].[8],[15],[16],[17]
Figure 1: Borderline tuberculoid leprosy: Hypopigmented anesthetic patch covering almost entire face

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Figure 2: Borderline lepromatous leprosy: Hypoesthetic hypopigmented macules over trunk

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  Lepra Reaction in Children Top


In general, lepra reaction is rare in children under 15 years of age. Majority of the studies have reported the low frequency of lepra reaction in children varying between 1.36% and 8.33%.[5],[8],[10],[16],[17] However, some studies have reported greater percentage than expected varying from 18% to 29.7%.[6],[7],[11],[18],[19] In all of these studies, the type 1 reaction was most commonly found, which is expected, given that the most frequent clinical form was BT. Type 1 reaction is associated with neuritis. Severe neuritis can lead to sudden nerve palsy leading to deformities such as foot drop, wrist drop, and clawing. Hence, neuritis should be treated with adequate dose of corticosteroid to bring down inflammation and damage in the nerves.


  Nerve Involvement in Children Affected With Leprosy Top


Peripheral nerve involvement is the main cause of deformities in children affected with leprosy and associated lepra reaction compounds the problem.[20] Jain et al. found the involvement of peripheral nerves in 186 patients of a total of 306 evaluated children, with more than one thickened nerve in most cases; the ulnar nerve is the most affected.[6] In 2009, Rao reported polyneural involvement in 59.38% of the cases, with a predominance of ulnar nerve.[9] Similar findings were reported by Singal et al. with 70% of the patients having thickening of nerve, out of which nearly half of the patients had multiple nerve involvement with ulnar nerve being the most common.[11]


  Diagnosis of Childhood Leprosy Top


Diagnosis of leprosy is based on the cardinal signs of leprosy. The patient should have anaesthetic skin lesions, enlarged and/or tender peripheral nerve, and slit skin smear positive for acid-fast bacilli. Children usually present with PB leprosy where getting acid-fast bacilli in slit skin smear not always possible. Hence, diagnosis purely based on clinical examination most of the times. The most challenging part for a physician is to elicit sensory loss to fine touch in children which is impossible and inaccurate. Although pain sensation can be elicited, the child will not cooperate for the same and pain sensation is always last to go among all sensations. One of the easy techniques which can be done is checking for temperature sensation. One can take two test tubes containing warm and cold water. The patient is asked to close eyes and examiner can ask by touching the test tubes on skin to appreciate whether cold or warm. In doubtful cases, one can go for biopsy for confirmation of diagnosis. In a study, 35% of doubtful cases showed findings of Hansen's disease in histology.[21],[22]

It has been found in various studies that the skin lesions of leprosy usually undergo self-healing in children.[23],[24] Hence, in doubtful cases, one can wait and keep the child under observation (untreated) for a period to see whether the skin lesion is improving or definite sensory loss is appreciated. However, in endemic areas and with family members being affected with leprosy, it is always wise to start treatment.


  Treatment of Leprosy in Children Top


In children with PB leprosy, rifampicin and dapsone are given for 6 months, and those with MB leprosy and clofazimine is given in addition to rifampicin and dapsone. The dose of the drugs is different according to the age group [Table 1].
Table 1: WHO multidrug therapy regimen for children

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  Childhood Disability Due to Leprosy and Prevention of Disability Top


Disability is the most common cause of social stigma in leprosy. Leprosy causes disabilities through damage to peripheral nerves. Disabilities and deformities frequently persist even after successful treatment and affect psychologically and functionally both the children and their family members. It not only affects day-to-day activities in children but also can affect their education, interaction with their surrounding though studies pertaining to these aspects in children are lacking. In various studies, it has been found that children affected with leprosy have their initial presentation with deformities which suggests lack of awareness.[7],[18] Kar and Job suggested that children with neural thickening have 6.1 times more chances to develop deformities as compared to those without neural thickening. In their study, out of 275 children under 15 years of age, 10.5% cases had deformities, with the following risk factors: late diagnosis, multiple cutaneous lesions, MB disease, positive slit skin smear, various affected nerves, and reactional state at the time of the diagnosis.[7] The same risk factors were also found in the study by Singal et al. with 12.8% incidence of deformities in the hands, feet, and eyes.[11] Hence, the most important factor to prevent disability in leprosy patients is early detection and adequate treatment of neural impairment.


  Effect of Childhood Leprosy on Community Top


The main transmission and acquisition pathways for leprosy are the upper airways.

Leprosy in children indicates continuing transmission in the community.[14] Source of infection in children could be familial or nonfamilial close contacts.[6] Household contact increases the risk of transmission to 9 folds in children because of early and continuous exposure to the leprosy bacillus.[25] In a study from South India, family history of leprosy was present in 18·2% of the childhood cases and all the affected parents and grandparents who were the household contacts of these children had smear positive, multibacillary leprosy.[15] Community-based survey of leprosy patients in defined rural and urban areas of Maharashtra state (2007), has found that 19% of the children in the studied rural area and 47% of the children in urban area had history of close contacts with leprosy patients.[26] Hence houshold contact surveys should be an effective way of case finding when the index case is a child. Conversely, children in a household where a new leprosy case has been diagnosed are at increased risk compared with the general population and even compared with adults in the household: the risk to children aged 1–14 years was much higher than in older people.[11]


  Resistance Top


The emergence of drug resistance is the main cause for concern in leprosy because limited number of drugs are available for treatment. Usually, a combination of more than two drugs, with different mechanisms of action, taken regularly for a sufficient period, will prevent the emergence of drug resistance. Resistance to rifampicin, dapsone, and quinolones is reported due to mutations in the binding sites of these drugs in large number of samples by molecular biological methods.[27],[28] Clofazimine and minocycline resistance have not yet been reported. Development of resistance to first-line drugs is becoming serious threat to the efficacy of existing multidrug therapy (MDT) program. Patients suspected to be rifampicin resistant are also expected to be resistant to dapsone. In the year 1998 WHO, technical advisory committee recommended the following regimen for adults with suspected rifampicin resistance:[29]

  1. Daily administration of 50 mg of clofazimine, together with 400 mg ofloxacin and 100 mg of minocycline for 6 months, followed by
  2. Daily administration of 50 mg clofazimine, together with 100 mg of minocycline or 400 mg of ofloxacin, for at least an additional 18 months.


Newer drug regimens suggested for leprosy in 2009 by the “WHO Report of the Global Programme Managers' Meeting on Leprosy Control Strategy”[30],[31]

For rifampicin susceptible MB patients, a fully supervised monthly regimen could include Rifapentine 900 mg (or rifampicin 600 mg), moxifloxacin 400 mg, and clarithromycin 1000 mg (or minocycline 200 mg) for 12 months. For rifampicin-resistant patients, the intensive phase could include moxifloxacin 400 mg, clofazimine 50 mg, clarithromycin 500 mg, and minocycline 100 mg daily supervised for 6 months. The continuation phase could comprise moxifloxacin 400 mg, clarithromycin 1000 mg, and minocycline 200 mg once monthly, supervised for an additional 18 months.

A single-dose combination of rifapentine, moxifloxacin, and minocycline killed 99.9% of the viable Mycobacterium leprae and was more bactericidal than a single dose of rifampicin, ofloxacin, and minocycline or rifampicin alone. In the same study, it was also observed that the combination of moxifloxacin-minocycline was more bactericidal than the combination of ofloxacin-minocycline.[32],[33]

These drugs such as ofloxacin, moxifloxacin (quinolone), and minocycline are contradicted in childrens. No alternate regimens are designed for children.


  Drug Reactions Top


In cases of severe adverse reactions, an alternative multidrug therapy regimen is recommended.[34] In adults, the alternative regimens use ofloxacin (quinolone) and minocycline (tetracycline), which are contraindicated in children under 10 years of age, due to the risk of the early closure of the epiphysis as well as dental and bone alterations, respectively.


  Relapse Top


Mostly relapse occurs in leprosy due to inadequate treatment. It is an important quality of service indicator in assessing the long term efficacy of MDT. The predisposing factors include the presence of persister bacilli, monotherapy (dapsone), inadequate or irregular therapy, the presence of multiple skin lesions and/or thickened nerves, etc. The majority of relapse cases in a study belonged to the 12–15 years age group. Nearly 80% of the relapses occurred during PB treatment, and 70% had received previous treatment from other institutions. Inadequate treatment of MB as PB might have contributed to higher relapsing rate.[35]

In another study,[5] despite completing 6 months of MDT-PB prescribed according to body weight, relapses occurred in 13 out of 784 children with PB leprosy. Three occurred during the 2-year surveillance period after completion of treatment, and another five, two, and three occurred 6, 1 2, and 1 8 months after surveillance.


  Counseling Top


Parent must be counseled about the duration of treatment and to complete treatment without default. In addition, they should be informed regarding the signs and symptoms of lepra reactions and to report to the physicians immediately while encountered with such sign and symptoms. In children having anaesthesia of hands and feet, the parents should be taught how to take care of anaesthetic hands and feet to avoid trophic ulcers. Parents and siblings of the index case must be examined for leprosy.


  Conclusion Top


In summary, the incidence of childhood leprosy still high in various states of India. Diagnosis of leprosy in children is difficult compared to adults. In case of doubt, it is better to keep the child under observation for few months, however, in endemic areas, it is always wise to treat the cases at the earliest. The parents should be warned regarding the signs of both types of lepra reactions, so that the treatment can be instituted to avoid deformities due to nerve damage in type 1 reaction and systemic complications in type 2 reactions. All the family members should be examined for evidence of leprosy and treated.

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.



 
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Abstract
Introduction
Epidemiology
Classification o...
Lepra Reaction i...
Nerve Involvemen...
Diagnosis of Chi...
Treatment of Lep...
Childhood Disabi...
Effect of Childh...
Resistance
Drug Reactions
Relapse
Counseling
Conclusion
References
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