Indian Journal of Paediatric Dermatology

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 21  |  Issue : 2  |  Page : 105--109

Clinicoepidemiological profile of childhood leprosy in Western Odisha: A retrospective, hospital-based study


Swetalina Pradhan1, Bibhu Prasad Nayak2, Tanmay Padhi3, Kananbala Sahu4,  
1 Department of Dermatology, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Pediatrics, SCB Medical College, Cuttack, Odisha, India
3 Department of Dermatology, VIMSAR, Burla, Odisha, India
4 Department of Dermatology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Correspondence Address:
Bibhu Prasad Nayak
Department of Pediatrics, SCB Medical College, Cuttack, Odisha
India

Abstract

Background: At this postelimination era, childhood leprosy is still a major concern for the society. Studies regarding the clinicoepidemiological profile of childhood leprosy from Western Odisha are unavailable despite the area being endemic to leprosy. Aim and Objective: The aim and objective was to study the clinicoepidemiological profile of childhood leprosy in Western Odisha. Materials and Methods: Patients aged <18 years with a clinical diagnosis of Hansen's disease were included in the study. Data regarding demographic profile, type of Hansen's disease, family history of Hansen's disease, various types of deformities, lepra reactions, treatment status, and any side effects of treatment were collected from the leprosy register and proformas. Results: Out of the total 1460 leprosy patients, 239 (16.4%) patients were children. The mean age of the patients was 13.43 ± 1.09 years. Borderline tuberculoid leprosy was the most common type of presentation (141 cases). Family contacts were identified in 33.2% of cases, with majority being multibacillary. Disabilities and lepra reactions were found in 9.3% and 19.2% of children, respectively. Mononeuritis was found in 141 (59%) patients. Ulnar nerve was the most commonly involved nerve in 97 (67.8%) cases, followed by common peroneal nerve in 44 (31.2%) cases in patients with mononeuritis. Out of 98 patients presenting with polyneuritis, ulnar nerve was the most common nerve enlarged clinically in 66 (67.3%) patients followed by common peroneal in 51 (52.04%), great auricular in 7 (7.14%), radial cutaneous nerve in 5 (5.1%), sural in 4 (4.1%), posterior tibial in 3 (3.1%), and superficial peroneal in 1 (1.02%) patients. Out of 239 cases, 11 had completed treatment, 37 cases were continuing treatment from outside, and 191 new cases (13.1%) had started treatment. At the end of 2 years, a total of 157 cases had completed treatment and the rest were continuing treatment. No defaulter and relapse case were found within the 2-year period. Side effect profile of antileprosy treatment was available in 47 patients with dapsone hypersensitivity syndrome in 2 cases, maculopapular drug reaction in 5 cases, and clofazimine-induced pigmentation in all. Conclusion: Higher proportion of childhood leprosy indicates transmission of leprosy in Western Odisha. Clustering of multibacillary cases in family suggests that family contact tracing is mandatory in all cases. Though less commonly found, physicians should be aware of the side effects of antileprosy treatment and counseling should be done regarding the side effect profile while initiating treatment.



How to cite this article:
Pradhan S, Nayak BP, Padhi T, Sahu K. Clinicoepidemiological profile of childhood leprosy in Western Odisha: A retrospective, hospital-based study.Indian J Paediatr Dermatol 2020;21:105-109


How to cite this URL:
Pradhan S, Nayak BP, Padhi T, Sahu K. Clinicoepidemiological profile of childhood leprosy in Western Odisha: A retrospective, hospital-based study. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 May 31 ];21:105-109
Available from: http://www.ijpd.in/text.asp?2020/21/2/105/281729


Full Text



 Introduction



The WHO has declared leprosy to be eliminated from India in 2005, but still, it has remained in several endemic pockets in various parts of India like Odisha. According to the progress report by the National Leprosy Eradication Program (NLEP) 2015, a total of 125,785 new leprosy cases were detected during the year 2014–2015, making the annual case detection rate 9.73/100,000 population. The proportion of childhood cases reported was 9.04%.[1] These data indicate that leprosy transmission is actively taking place in the country and the situation may explode at any moment. The magnitude of leprosy in pediatric populations signifies active and recent transmission of the disease. It is also a sensitive epidemiological indicator to assess the progress of leprosy control programs and awareness in the community.[2] Western Odisha has been considered an endemic area of leprosy. Studies regarding the clinicoepidemiological profile of childhood leprosy from Western Odisha are unavailable. Hence, the present study was undertaken to analyze the clinicoepidemiological profile of childhood leprosy in Western Odisha.

Aim and objective

The aim and objective was to analyze the clinical and epidemiological profile of childhood leprosy in Western Odisha.

 Materials and Methods



Study design

This was a retrospective, observational study conducted in a tertiary care hospital from December 2014 to December 2016. Patients aged <18 years with a clinical diagnosis of Hansen's disease were included in the study. Institutional ethics committee approval was obtained prior to initiation of the study.

The patients were diagnosed on the basis of clinical signs and symptoms, and the diagnosis was confirmed by slit-skin smear examination in all cases. Records of the patients were analyzed for the following clinical and epidemiological parameters: age, sex, rural/urban background, type of leprosy, treatment given (paucibacillary/multibacillary), presentation with lepra reaction and family contacts with leprosy, various deformities, and any side effects to treatment.

All patients were classified depending on the number of lesions, their morphology, distribution, and related nerve involvement, according to the Ridley–Jopling spectrum as tuberculoid (TT), borderline TT (BT), mid-borderline (BB), borderline lepromatous (BL), and lepromatous (LL).[3] Some patients were also classified as indeterminate or pure neuritic leprosy (PNL), when applicable. Diagnosis of Type 1 lepra reaction was made if the patient had redness, swelling, or tenderness of preexisting lesions, with or without the appearance of new lesions; presence of edema of the hands, feet, or face; or tenderness of one or more nerves, with or without nerve function impairment.[4] Patients presenting with sudden appearance of multiple, small, tender, evanescent nodules or plaques, with or without constitutional symptoms such as fever, malaise, lymphadenitis, and myalgia, were considered to have Type 2 lepra reaction.[4] Disabilities were classified according to the standard WHO grading system.[5] In contact screening, data of only family contacts were recorded regarding the type of leprosy in family contacts and their treatment status. In treatment status of childhood leprosy cases, data regarding the number of cases who have already completed treatment, continuing treatment, and new cases who have started treatment; any defaulters; relapse of disease in those who had completed treatment; and any side effects to treatment were recorded.

Statistical analysis

Results were analyzed using simple statistics by SPSS 16.0 software (SPSS Inc., SPSS for Windows, Chicago, Illinois, USA). All data were measured as mean, average, and standard deviation. The primary outcome (clinical spectrum among patients, families, and deformities) of the study was expressed in terms of frequency/percentage.

 Results



Out of the total 1460 leprosy patients, 239 (16.4%) patients were children. The mean age of the patients was 13.43 ± 1.09 years. Male children outnumbered female children (158/81). Majority of the cases belonged to rural area (rural/urban: 169/70). BT leprosy was the most common type of presentation (141 cases) [Figure 1] followed by BL (35 cases) and TT leprosy (30 cases) [Figure 2] and [Figure 3] [Table 1]. Household contacts were identified in 33.2% of cases and majority of the household contacts were multibacillary [Table 2]. Visible deformities were found in 9.3% of children, with trophic ulcer [Figure 4] being the most common followed by claw hand [Table 3].{Figure 1}{Figure 2}{Figure 3}{Table 1}{Table 2}{Figure 4}{Table 3}

Mononeuritis was found in 141 (59%) patients. Among patients presenting with polyneuritis, 2 nerves were involved in 69 (28.9%) cases, 3 nerves were involved in 18 (7.5%) cases, 4 nerves were involved in 9 (3.8%) patients, and 5 nerves were involved in 2 (0.8%) patients. Ulnar nerve was the most commonly involved nerve in 97 (67.8%) cases, followed by common peroneal nerve in 44 (31.2%) cases in patients with mononeuritis. Out of 98 patients presenting with polyneuritis, ulnar nerve was the most common nerve enlarged clinically in 66 (67.3%) patients followed by common peroneal in 51 (52.04%), great auricular in 7 (7.14%), radial cutaneous nerve in 5 (5.1%), sural in 4 (4.1%), posterior tibial in 3 (3.1%), and superficial peroneal in 1 (1.02%) patients.

Nearly 19.2% of cases had reaction (Type 1 and Type 2) [Table 1]. Out of 239 cases, 11 had completed treatment, 37 cases were continuing treatment from outside, and 191 cases (13.1%) were new and were started treatment at our institute. At the end of 2 years, a total of 157 cases had completed treatment and the rest were continuing treatment. No defaulter case was found in the study within the 2-year period. Out of 157 cases who completed treatment, none had relapse within 6 months of follow-up. Data regarding side effects to treatment were available in 47 patients. Out of them, drug hypersensitivity syndrome to dapsone was found in 2 cases [Figure 5], 5 cases had maculopapular drug reaction, and clofazimine-induced pigmentation was found in all.{Figure 5}

 Discussion



According to the NLEP data in the year 2016–2017, a total of 11,792 new child cases (8.7%) were detected. More than 10% of new cases were detected in 10 states/union territories, namely (i) Arunachal Pradesh, (ii) Bihar, (iii) Jharkhand, (iv) Maharashtra, (v) Nagaland, (vi) Punjab, (vii) Tamil Nadu, (viii) D and N Haveli, (ix) Daman and Diu, and (x) Lakshadweep.[6] In our study, the proportion of new child cases was 13.1% in Western Odisha. The proportion of children among newly detected cases of leprosy is a strong indicator of disease transmission in the community. Hence, high proportion of childhood leprosy in Western Odisha indicates continued leprosy transmission in the community.

The mean age of the patients in this study was 13.43 ± 1.09 years. In the study by Nair and Dogra et al., the mean age of the patients was found to be 8.3 and 10.06 years, respectively.[2],[7] This may be due to the relatively long incubation period of leprosy, failure to report in the early stages of the disease, or delayed diagnosis of lesions in children. In our study, boys outnumbered girls, which is comparable to the study by Dogra et al. and Sehgal and Chowdhary.[1],[8] This could be due to negligence toward the female children compared to male children in seeking medical treatment in our country.

The most common type of leprosy found in children in the present study was BT (59%) followed by BL (14.6%) and TT (12.6%). Nearly 8.8%, 3.8%, and 1.3% cases were LL, indeterminate, and PNL, respectively. In studies of childhood leprosy by Dogra et al., Nair, and Rao, BT was the most common type found, similar to our study.[2],[7],[9] In contrast, TT was the most common type found in the study by Horo et al.[10]

The usual mode of entry of lepra bacilli into the body is through respiratory tract in the form of droplets.[11] Hence, children usually get infection from nasal secretions of close family contacts, which mandates to examine all family members of the affected child for leprosy and treat them to decrease the continued transmission and disease burden in the community. In the study by Nair et al. and Rao et al., family contacts were found in 8.7% and 18% of cases, respectively. In contrast, our study had high number of family contacts in 33.2% of cases. Majority of the family contacts in our study were multibacillary (70%). Multibacillary cases have high bacterial load who can transmit disease both to the family and community. Finding high number of multibacillary family contacts in Western Odisha region denotes the requirement of stringent contact-tracing activities by national leprosy control programs.

Lepra reaction was found in 19.2% of cases in our study, with Type 1 reaction in 11.3% and Type 2 reaction in 7.9% of cases. However, in the study by Nair et al. and Rao et al., the rate of lepra reaction found was 5% and 6%, respectively. In contrast, the study by Dogra et al. had 33.9% of cases with lepra reaction. Multiple nerve thickening was found in 41% of cases and mononeuritis in 59% of cases, which varies in contrast to the study by Dogra et al. where multiple nerves were thickened in 18 (56.2%) children and single nerve in 4 (12.5%) children.

Disabilities were found in 9.3% of children in the current study, with trophic ulcer being the most common followed by claw hand, foot drop, and wrist drop. In contrast in the study by Dogra et al., 40.7% of cases had disabilities. Lower proportion of disabilities in our study could be due to earlier presentation, diagnosis, and treatment. Disabilities usually follow Type 1 reaction because of neuritis, which was low in our study, thereby leading to lesser proportion of disabilities. However, similar to our study, the proportion of disabilities was also low in the study by Nair et al. and Rao et al.

Regarding treatment status, we did not find any defaulter in our study. Those who had completed treatment did not have relapse within 6-month follow-up. However, in the study by Dogra et al., relapse was seen in 5.1% of cases. Zero defaulter in our study could be due to the availability of blister pack at our institute along with at nearest primary health care level where we refer the patients for free blister pack for convenience of the patient. Zero relapse in our study could be due to lack of long-term follow-up.

Data regarding the side effect profile of anti-leprosy drugs were available only in 47 cases only. Out of all side effects, clofazimine-induced pigmentation was found in all cases. Dapsone syndrome was found in two cases. Dapsone (DDS) syndrome, also called the “5-week dermatitis,” usually occurs 5–6 weeks after the administration of dapsone and subsides on cessation of dapsone therapy.[12] It presents with exfoliative dermatitis and/or other skin rashes, generalized lymphadenopathy, hepato-splenomegaly, fever, and hepatitis.[13] In addition, hemolytic anemia, methemoglobinemia, eosinophilia, raised erythrocyte sedimentation rate, increased level of serum bilirubin, and raised liver enzymes are found. It could prove to be fatal unless taken care early.[13] Our cases were diagnosed basing on the clinical features and laboratory findings. Two cases were of BT leprosy and were treated with high-dose systemic corticosteroids after stoppage of dapsone. After cure, clofazimine was substituted in the place of dapsone. Among the existing studies on childhood leprosy, data on the side effect profile are nonexistent, hence we could not compare our data. However, findings from our study suggest that counseling regarding the various side effect profiles of antileprosy drugs should be done to the family members of the child while starting treatment so that they can report at earliest when encountered with such fatal conditions.

 Conclusion



The limitations of our study were the retrospective analysis of the data and small sample size. It is a single-center, hospital-based study, which reflects only the iceberg of the disease burden in our communities. However, our study can guide the implementation of leprosy control programs at community level of Western Odisha.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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