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ORIGINAL ARTICLE
Year : 2022  |  Volume : 23  |  Issue : 1  |  Page : 38-42

Pediatric leprosy in a tertiary care hospital in Hubballi – Are we walking on a thin ice?


1 Department of Dermatology, Venereology and Leprosy, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India
2 Department of Dermatology, Venereology and Leprosy, The Oxford Medical College Hospital and Research Centre, Bengaluru, Karnataka, India
3 Department of Dermatology, Venereology and Leprosy, Shimoga Institute of Medical Sciences, Shimoga, Karnataka, India
4 Department of Dermatology, Venereology and Leprosy, Sambhram Institute of Medical Sciences and Research, Kolar, Karnataka, India

Date of Submission08-Jan-2021
Date of Decision03-Mar-2021
Date of Acceptance10-Nov-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Sanjay Ramachandra Thejaswi
Department of Dermatology, Venereology and Leprosy, The Oxford Medical College Hospital and Research Centre, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.ijpd_1_21

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  Abstract 


Context: Leprosy is a major public health problem in developing countries where districts and blocks are reporting high prevalence indicating ongoing transmission. According to the National Leprosy Elimination Program Report of March 2017, there were about 0.13 million cases of leprosy in India, 8.7% of which were children. This study offers insight into the current status of the pediatric leprosy. Aims: The aim of the study is to assess the current scenario and clinical profile and to describe the clinico-epidemiological features of childhood leprosy at our tertiary care hospital in Hubballi. Settings and Design: This study was a 13-year retrospective analysis of hospital data from April 2005 to March 2018. Subjects and Methods: A retrospective, record-based study was carried out on patients diagnosed and registered in urban leprosy center of our tertiary care hospital in Hubballi (April 2005–March 2018). Data regarding demographic details, clinical features, treatment started, and complications were noted and analyzed. Results: Of total 1305 patients, 189 (14.48%) pediatric patients were seen. Age group of 12–18 years constituted 64.02% of patients. Male: female ratio was 1.3:1. Family history was present in 22 (11.6%). 142 had lesions ranging from 1 to 5 (75.13%), among them single lesion was common. Skin lesions are most often seen on the upper limb (52.38%). Borderline tuberculoid leprosy was common (72%). Majority had ulnar nerve involvement. Deformity was present in 21 patients. Majority received multibacillary multidrug therapy. Conclusions: This study showed a prevalence of 15.6% of pediatric leprosy cases. Pediatric leprosy reflects that there are active infectious cases in the community, which needs active intervention including vigilant and rigorous screening for early diagnosis and treatment initiation, which are essential components for leprosy elimination and disability prevention.

Keywords: Borderline tuberculoid, childhood leprosy, pediatric leprosy


How to cite this article:
Shendre ME, Thejaswi SR, Ningaraju A, Rathod RM, Kaivalyam ED. Pediatric leprosy in a tertiary care hospital in Hubballi – Are we walking on a thin ice?. Indian J Paediatr Dermatol 2022;23:38-42

How to cite this URL:
Shendre ME, Thejaswi SR, Ningaraju A, Rathod RM, Kaivalyam ED. Pediatric leprosy in a tertiary care hospital in Hubballi – Are we walking on a thin ice?. Indian J Paediatr Dermatol [serial online] 2022 [cited 2022 May 20];23:38-42. Available from: https://www.ijpd.in/text.asp?2022/23/1/38/334658




  Introduction Top


Leprosy is one of the oldest diseases known to human. Despite advances in all spheres of medical science, leprosy continues to be a public health challenge in developing countries such as India.[1] Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae, affecting all age groups, primarily affecting the nerves and skin and secondarily other organs.[2] Introduction of multidrug therapy (MDT) in 1981, on the recommendation of the World Health Organization (WHO), has led to a sharp decline in the prevalence rate (PR) of leprosy, from 57.60 in 1981 to 0.66 per 10,000 population in 2017.[3] Leprosy continues to be an important public health problem, and leprosy in pediatric age group is a useful indicator of recent disease and active foci of transmission of the disease in a country, reflecting the failure of the health system and local control programs to control the disease.

The PRs of leprosy in the pediatric age group in various studies vary from 5.1% to 11.43% among Indian population.[4],[5] The usual source of contact was the family members, neighbors, or contact from fellow students in the schools where they are studying.[2]

Due to immature immune system in pediatric age group, pediatric leprosy differs from adult leprosy – where tuberculoid type is more common than lepromatous type and lepra reactions and deformities are rare.[2] Deformities in children are worrying and unacceptable as they reflect a long delay in diagnosis and treatment which highlights the failure in the health service system and gaps to approach to control the disease.[6]

We often do see pediatric leprosy cases in our leprosy care center of our institute, and hence, we decided to conduct this study with the aim to study clinico-epidemiological features, complications, treatment compliance, and prevalence of childhood leprosy patients presenting to our tertiary level center.


  Subjects and Methods Top


This is a retrospective descriptive analysis of all leprosy cases less than or equal to 18 years of age, registered at the urban leprosy center, Hubballi, Karnataka, from April 2005 till March 2018.

This center is a tertiary care teaching hospital catering to a large population of Dharwad district of Karnataka. The hospital caters for a mixed population of both rural and urban background with many migrated families. Patients who come to the hospital with symptoms suggestive of leprosy and those referred from other departments of the same hospital or other nearby hospitals and private practitioners are registered in the leprosy clinic attached to the department of dermatology rather than active case finding or surveys.

A case of leprosy was defined as an individual with one or more of the three cardinal signs; hypopigmented or erythematous skin lesions with definite loss or impairment of sensation, definite thickening of peripheral nerve with sensory impairment, and skin smear-positive for acid-fast bacilli (AFB).

Details of age, sex, state of origin, duration of symptoms, possible source of contact, and clinical findings extracted from predesigned pro forma were analyzed. A “household” or “intrafamilial” contact was defined as any person in the immediate family (parents, siblings, and grandparents) living in the same house and partaking in meals from a common kitchen with a current or past history of leprosy. Known cases from immediate neighborhood of the patient's house were considered as “extrafamilial” contacts. Clinical details included number and distribution of lesions, pattern of nerve involvement, and complications including lepra reactions, neuritis, and deformities. Slit skin smears results were collected which were prepared from three sites – eyebrow, ear lobule, and a characteristic skin lesion. The bacillary index (BI) was calculated as the mean of separate BIs from the three sites and ranged from 0 to 6 þ. The classification was based upon Ridley–Jopling classification[3] and as per the criteria laid down under National Leprosy Elimination Program (NLEP). As per NLEP (in collaboration with Global Alliance for Leprosy Elimination and WHO), the 260 A. Singal et al. disease is classified as multibacillary (MB) if there are six or more lesions and/or more than one nerve involvement and/or a positive skin smear from any site.[4] Treatment given, compliance, and number of defaulters and relapses were also assessed. Although many definitions have been proposed for relapse in leprosy, the one suggested by the WHO (1988) states – “A patient who successfully completes an adequate course of MDT, but who subsequently develops new signs and symptoms of the disease, either during the surveillance period (2 years for paucibacillary [PB] and 5 years for MB leprosy) or thereafter” was considered to define relapse in our study.

Data collected were entered in MS EXCEL and analyzed. Frequency and percentage were calculated for descriptive study.

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 1305 leprosy cases attended the urban leprosy center of our institute in the 13-year study period, of which there were 189 cases of pediatric leprosy (n = 189), and the average child proportion over 13 years was 14.48% [Table 1]. There were 108 males (57%) and 81 females (43%). The male-to-female ratio was 1.3:1 [Table 2]. The age group distribution is given in [Table 2].
Table 1: Year-wise distribution of childhood leprosy cases

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Table 2: Age and sex distribution

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The mean age was 12.58 ± 3.8 years. The age group of 12–18 years accounted for the maximum number of cases (64.02%). The youngest was 4 years of age and the oldest 18 years. History of familial contact was present in 23 cases (12%), and multiple members were affected in only one family.

The distribution of the skin lesions is given in [Chart 1]. 142 patients had lesions ranging from 1 to 5 (75.13%), majority of whom had single lesion. The most common site of skin lesion was upper limb (51.3%).



Peripheral nerve thickening was present in 100 cases (52.9%) [Chart 2]. Multiple nerve thickening was present in 75 cases (39.68%). Ulnar nerve was the most common nerve to be involved in 81 cases (42.85%), followed by common peroneal nerve in 56 cases (29.62%), radial cutaneous nerve in 30 cases (15.87%), and greater auricular nerve in 22 cases (11.11%).

Borderline tuberculoid (BT) was the most common type of leprosy seen in 136 cases (72%) followed by tuberculoid (TT) in 12 cases (12.69%), borderline lepromatous (BL) and lepromatous (L) in 9 cases (4.76%) each, and indeterminate in 7 (3.70%) and 4 cases (2.11%) of pure neural leprosy registered during this period [Table 3].
Table 3: Clinical spectrum of childhood leprosy cases in the study

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Slit skin smear was done from three sites – eyebrow, ear lobule, and a characteristic skin lesion. A positive smear for AFB was found in 8 (4.23%) cases.

Seventy-four cases (39%) were given PB therapy while 115 cases (61%) were given MB therapy. Lepra reactions were present in 15 cases (5%), constituting 13 cases of Type 1 lepra reaction and two cases of Type 2 lepra reaction. Deformity was present in 21 (11.11%) patients [Chart 3]: claw hand - 10, trophic ulcers - 8, wrist drop - 1, foot drop - 1, and saddle nose - 1.




  Discussion Top


Leprosy is one of the major public health problems, and India accounts for over one-half of the global burden of leprosy cases.[7] According to a recent report by the NLEP, there were a total of approximately 1.27 lakh new cases of leprosy in India, of which 8.94% were among children.[3] In our 13-year retrospective study, the prevalence of pediatric leprosy was 14.48%. A high proportion of new cases of pediatric leprosy reflect a high level of transmission of the disease in a given population. Only if the transmission of leprosy reduces in an area, we can expect the proportion of children affected will also decrease.[8] Pediatric leprosy also determines the efficiency of ongoing disease control programs; therefore, WHO, Regional Office for South-East Asia (WHO SEARO) has declared leprosy as a Flagship Program that intends to achieve zero child cases and Grade 2 disability by 2020.[9]

Majority of pediatric leprosy cases in our study were observed in the older age group that is above 12 years. Previous studies also reported a lesser occurrence in children <5 years.[10],[11],[12],[13],[14] This may be due to the relatively long incubation period of leprosy, chances of misdiagnosing indeterminate skin patches as pityriasis alba and tinea versicolor in the initial stages which may lead to delayed detection in these cases.

Male cases outnumbered female cases in a ratio of 1.3:1, which is in accordance with previous Indian Studies ranged from 1.25:1 to 3:1.[15] May be due to their greater mobility and increased opportunities for contact. However, in the study by Horo et al., females predominated.[4] Detection in girls may be lower than boys due to the neglect of the female child.

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 may be due to early healthcare-seeking attitudes in parents when their children develop skin lesions, especially hypopigmented lesions, as seen in cases of leprosy.[2]

In the present study, family history of leprosy was present in 12%. This is similar to other studies where familial contact ranged from 6.06% to 47%.[15],[16],[17] All the positive contacts were interfamilial, father being the most common source of contact, and no extrafamilial contact history was available which may be due to stigmatic lack of disclosure of the disease in the neighborhood if any. The risk of a person developing leprosy is four times higher when there is neighborhood contact and up to 9 times higher when the contact is interfamilial.[18]

In the present study, single skin patch was the most common symptom or sign of leprosy in children, which is similar to the observation from previous studies.[10],[19] Upper limb (52.38%) followed by face (49.20%) was the most common site to be involved in our study. A possibility of leprosy should arise if a child presents with skin patch even if the sensation is intact, and such cases should be observed for early detection.

Peripheral nerve thickening was present in 100 cases (52.9%), and 75 cases (39.68%) had multiple nerve thickening. This is consistent with other studies done in India which ranged from 4.54% to 59.38%.[15] BT leprosy was the most common type of leprosy seen in 136 cases (71.95%), which is same in most of the studies done in India[15] followed by TT type in 22 (11.64%). Indeterminate leprosy also accounted for seven cases (3.70%) which is consistent with other studies done in India – 3.48%–10.1%.[15] However, a study done by Nair reported that indeterminate leprosy accounted for 33%,[2] and the reduced prevalence in our study may be due to missed cases as they present with macules with or without sensory impairment and also due to misdiagnosing them as postinflammatory hypopigmentation and pityriasis alba. BL and LL types of leprosy are rare in the pediatric age group due to the immature immune system, but our study accounted for nine cases each in BL and TT types.

Smear-positive leprosy is considered uncommon in childhood and has been reported in <10% cases in many previous studies,[10],[12],[14] which is similar to our study where 8 cases (4.23%) recorded were smear-positive. Only a few studies have reported higher smear-positivity rates ranging from 17.4% to 30%.[10],[11],[12] High smear positives have got grave epidemiological consequences as they are the “open” cases who can be a source of infection to many because they harbor live bacilli in their nasal mucosa, and this disease predominantly spread through nasal droplets.

Based on the NLEP criteria, we observed MB leprosy to be more common than PB in children. This was consistent with a study done in Delhi.[10] This is in contrast to most of the previous studies where PB was common type in pediatric leprosy.[11],[12] This difference is most likely due to the use of a different set of criteria for disease classification by previous workers such as the 1988 or 1998 WHO classification. While 1998 WHO classification included the number of lesions as a criterion (not present in the 1988 classification), neither considered the number of involved nerves as a differentiating factor. However, the inclusion of the number of involved nerves as a criterion increases the sensitivity of this classification and prevents under treatment of many patients deserving MB-MDT.[10] In our series too, a significant number of patients with BT leprosy qualified for MB disease due to more than one nerve trunk involvement. This stresses on a thorough examination of peripheral nerves at the time of diagnosis to avoid under treatment.

The incidence of lepra reaction in children was low in our study (15 cases, 5%) in comparison with Jain et al., who reported a high incidence of neuritis and reaction (29.7%);[12] in other studies, it ranged from 1.36% to 29.7%.[15] The occurrence of deformities in children is truly unfortunate. Grade 2 deformities were low in our study (11%) compared to other studies ranging from 0% to 24%.[15] Factors that may contribute to deformities in children are the older age, multiple skin and nerve lesions, MB disease, presence of reaction, smear positivity, and delayed diagnosis.[20] Rehabilitative measures such as physiotherapy and corrective surgeries should also be offered to selected patients.

Limitations

This is a retrospective study, data analysis was based on departmental records, and hence, bias in reporting cannot be totally ruled out. We could include only the cases presenting to our own center which happens to be tertiary care referral center. It could be safely assumed that more complicated cases were being recorded. Community-based surveys covering the district population could help clarify this issue.







Leprosy continues to be a communicable disease of concern in this postelimination era, and from the analysis of trends of childhood leprosy, in our study, we could offer an insight into the current status of disease and which is an indicator of active transmission of leprosy in a community. High PR and high MB disease patients in our study alarm us the need to restart active screening of schoolchildren for hypopigmented patches and also to intensify the process of contact screening, early case detection, conduct more and regular effective health education campaign, ensuring regular and complete treatment with MDT, and referral activities in the pediatric population to reduce the burden of leprosy and sustain elimination.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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