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- DOI 10.18231/j.ijced.2020.072
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Clinical and microbiological profile of Hansen’s diseases in a tertiary care centre of southwest Bihar
Introduction
Leprosy or Hansen’s disease is a slowly progressive infection caused by mycobacterium Lepra. It is a chronic granulomatous disease that primarily effect skin. Mycobacterium leprae causes two strikingly different patterns of disease tuberculoid and lepromatous which is determined by T-helper lymphocyte response to it.[1], [2]
Leprosy is oldest recognised disease of civilisation and considered as contagious, mutilating and incurable. It has a terrifying image in the history as patient develops deformity and excluded from the society.[3] But with the effort of World health organisation and government of individual country and introduction of MDT it became curable and deformity was prevented. Now WHO has launched "Global Leprosy Strategy 2016–2020: Accelerating towards a leprosy-free world".[3] Bihar is state in India share high number of leprosy cases having prevalence rate of 1.18 (21,353 new cases) in 2017-18.[4], [5]
After going through various literatures we have found that there are different views among researcher about clinicoepidemiology and microbiological profile of Hansen disease in India. Semwal S, Joshi D, Goel G, Asati D, Kapoor N from central India has reported that early clinical detection, and morphological diagnosis is a challenge in new patients. He has further added that histological finding should be correlated with clinical finding.[6] Thakkar S, Patel SV from Gujarat has reported that histopathological finding is must in doubtful cases.[7] Ramesh Marne Bhat, Prakash Chaitra study from south India points towards high circulation of lepra bacilli in the community in the elimination era of Hansen disease.[8] Wagh AN, Mugudalabetta S, Gutierrez NO, et al has pointed towards a serious concern about community-based leprosy case detection campaigns in Bihar. ”They have reported from Bihar that false positive diagnosis is a major issue and decline in false positive diagnosis is not statistically significant."[9]
Present study has been designed primarily to study the clinical presentation and microbiological profile of patients presenting with symptoms of Hansen disease and secondarily to know the smear positivity of patients with clinical manifestation of leprosy.
Materials and Methods
This is a prospective cross sectional observational study conducted in the department of dermatology and microbiology Narayan Medical College and Hospital Jamuhar, Rohtas.(Bihar) from September 2018 to August 2020.
Ethics
Before start of this study an approval from institutional ethics committee was taken. A written informed consent was obtained from all patients before enrolling them for study.
Selection of patients
During the study period patients attending dermatology outpatient department with the clinical manifestation of Hansen disease were enrolled for this study. Patients who were diagnosed previously and taking treatment were excluded from this study. Based on these criteria 144 patients were enrolled for this study.
Method
After enrolment of patients a detail clinical examination was done and demographic information of patient was recorded on predesigned Performa. After taking consent from enrolled patients slit skin smear was obtained as pre standard protocol. Smears were stained with modified Ziehl-Neelsen stain 0.5% Sulphuric acid was used as decolouriser. Slide was examined under oil emersion microscope. Ridley's logarithmic scale was used for Bacteriological Index (BI).[10], [11]
Statistical analysis
Data were recorded in excel sheet and statistical Analysis was done with software SPSS-14 version. Quantitative data were calculated as percentage and proportions.
Result
In present two year prospective observational study 32884 patients were attended dermatology OPD and out of them 144 patients have clinical manifestation of Hansen’s disease that was 0.43% of total dermatological OPD.
|
Variables |
Number |
Percentage |
|
|
Total OPD patients in DVL in study period |
32884 |
100% |
|
|
Patients with clinical manifestation of leprosy |
144 |
0.43% |
|
|
Number of Slit skin smear done for AFB |
144 |
100 % |
|
|
Finding of staining |
Negative |
114 |
79.16% |
|
Positive |
30 |
20.83% |
|
|
Sex |
Male |
100 |
69.44% |
|
Female |
44 |
30.55% |
All patients with clinical manifestation were underwent slit smear examination for acid fast bacillus. Among these 144 patients, 114 (79.16%) patients were slit skin smear for AFB negative and rest 30 (20.83%) were positive for AFB. There was male predominance (69.44% vs 30.55%).
|
Bacteriological index |
Number |
Percentage |
|
1+ |
8 |
26.27% |
|
2+ |
2 |
6.67% |
|
3+ |
2 |
6.67% |
|
4+ |
1 |
3.34% |
|
5+ |
1 |
3.34% |
|
6+ |
16 |
53.34% |
Among 30 patients with 16 (53.34%) patients have bacteriological index 6+ and 8 patients have bacteriological index 1+. Bacteriological index 2+ and 3+ was present in 6.675 % patients each.
|
Age of patients |
Smear staining done (n=144) |
AFB positive (n=30) |
|
0-10 |
3(2.028%) |
0 |
|
11-20 |
24(16.66%) |
0 |
|
21-30 |
33(22.91%) |
6(20%) |
|
31-50 |
55(38.19%) |
18(60%) |
|
51 and above |
29(20.13%) |
6(20%) |
All patients below 20 years of age were slit smear staining smear negative for AFB. In our study 55(38.19%) patients with clinical manifestation were from 31 to 50 years of age among them 18(30 % of total AFB positive) was AFB positive. Number of patients from 20 to 31 years was 22.91% and among them 6(20% of total AFB positive) were slit smear positive for AFB. Similarly 29 22.91% patients above 51 years of age was and among them 6(20% of total AFB positive) were slit smear positive for AFB.
|
Type of lesion |
Total patients |
Smear positive |
|
Nodule/plaque |
12(8.34%) |
7(23.34%) |
|
Hypopigmented macule |
122(84.72%) |
22(73.34%) |
|
Loss of sensation |
10(6.94%) |
1(3.34%) |
Regarding type of lesion as per [Table 4], nodule and papule was present in 12(8.34%) patients out of them 7 (23.34% of total AFB positive) were smear staining positive for AFB. Hypopigmented macule was present in 122(84.72%) patients out of them 22 (73.34% of total AFB positive) were smear staining positive for AFB. Loss of sensation was present in 10(6.94%) patients out of them only 1 (3.34% of total AFB positive) was smear staining positive for AFB.
Discussion
Hensens disease is a slowly progressive chronic granulomatous disease caused by Mycobacterium Leprae. Appropriate diagnosis with histopathological correlation has become essential in present situation when the cases of Hansen’s diasease are on decline. In present study we have observed that out of all patients attending dermatology in two year duration 0.43% patients were presented with clinical manifestation of Hansen’s disease and we have taken sample for slit smear staining from all patients. Among 144 patients 20.83% were AFB positive and there was male predominance. Mahajan R, Ninama K, et al has reported 112 cases in one year duration, Tralsawala K, Umrigar D.et al reported 329 cases in his 5 year of study and Das NK, De A, Naskar B et al has reported 114 cases in his 2 year of study. So there is variation in the number of cases in various studies from different region of India. But in all study there is male predominance which supports our study.[12], [13], [14] In our study 20.83% patients has slide positive for AFB, it is higher in the study (38%) of Subhash Bishnoi et al but supported by the work of Giridhar, M & Arora et al (21%).[15], [16]
We have observed that most of the patients (53.34%) have lesions with bacteriological index 6+, and 26.27% patients have bacteriological index 1+. Bacteriological index 2+ and 3+ was present in 6.675 % patients each and bacteriological index 4+ and 5 + was present in 3.34% patients. So in our study patients with high bacterial load is more in our community. This finding is supported by the work of Ghosh, R.R. & Sikdar, S. & Ghosh, A.P. & Chatterjee, M.. (2018) et al and Kilikdar, M., Gedam, D., Pisey, A., Ambhore, N., & Karykarte, R et al. [17], [18] Vinay KN, Hedge SG et al from south India reported that in his study patient with bacteriological index 1+ were most common.[19]
Most common age group presented with clinical symptom and AFB positive were in 3rd and 4th decade of life. Ages below 20 years was less commonly effected and were AFB negative. Which corroborates with the study of Jindal, Nidhi & Shanker et al and Kalita JM, Nag VL, Yedale K et al. [20], [21]
Regarding clinical presentation Hypopigmented macule were common presentation and AFB positive was most frequent in them which is supported by the work of Moorthy BN, Kumar P et al.[22] Roy P, Dhar R, Patro P et.al has reported that multiple well-defined hypopigmented plaques with loss of sensations was more common lesion in his study which partially support our study.[23]
Conclusion
From present study we can conclude that there was male predominance and in most of the patients who were smear staining positive have bacteriological index more than 6+. Most common age group presented with clinical symptom and AFB positive were in 3rd and 4th decade of life. Hypopigmented macules were common presentation and AFB positive was most frequent in them. So even in post eradication era patients with high bacterial load were common and microbiological and histopathological examination is important to reduce false positive diagnosis.
Source of Funding
No financial support was received for the work within this manuscript.
Conflict of Interest
The authors declare they have no conflict of interest.
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