Leprosy

Leprosy (leprosy) is a chronic infectious disease caused by mycobacteria of leprosy, characterized by a predominant lesion of the skin, mucous membranes and peripheral nervous system, as well as the eyes, some internal organs. Its causative agent is an obligate intracellular parasite.

Currently, in the world, filed by WHO, there are 3 million leprosy patients. It is most common in countries of Asia and Africa. The only source of infection is a sick person. In the spread of infection, great importance is attached to socio-economic factors. The main route of infection is airborne, less often percutaneous (with damage to the skin). The possibility of transmission by bloodsucking insects is allowed. The incubation period averages 3-7 years.

Clinical picture. There are several clinical types of leprosy.

Lepromatous type, the most malignant, is characterized by the presence in the lesions of a large number of mycobacteria. These patients are especially contagious, since they release a large number of pathogens. Damaged skin, mucous membranes, eyes, lymph nodes, peripheral nerve trunks, as well as the endocrine system and some internal organs. On the skin of the face, the extensor surfaces of the forearms, shins, back of hands, buttocks, there are erythematous-pigment spots of various shapes and sizes that do not have clear boundaries. Gradually the spots infiltrated, protruding above the surface of the skin, increase in size. As a result of diffuse infiltration of the skin of the face, the superciliary arches protrude sharply, the nose deforms, the cheeks, lips and chin acquire a lobed form-develops the "lion face" (Facies Iconics). Eyebrows drop out from the outside.

The skin in the zone of infiltrates becomes strained, glossy, its pattern is smoothed, no hair is left. Sometimes it looks like an orange peel, it becomes shiny due to excessive secretion of sebaceous glands. In the late stage, sweating in the lesions stops, the infiltrates acquire a bluish-brown fork. On the skin (both in the zone of infiltration and out of them) there are tubercles and nodes-leproms - in size from 2-3 mm to 2 cm and more densely-elastic consistency, reddish-rusty color.

Gradually leproms ulcerate. Ulcerous surfaces usually have steep, sometimes undercut infiltrated margins, can merge, forming extensive ulcerative defects that slowly heal with an uneven scar. The mucous membrane of the nose affects almost all patients, becoming hyperemic, edematic, with a large number of small erosions (lepromatous rhinitis). In the future, its atrophy develops and separate leproms and diffuse infiltrations appear, which complicate nasal breathing. During the decay leprom the nose is deformed (flat-depressed, proboscis, lorgnette, bulldog nose).

In severe course, the mucous membranes of soft and hard palate, larynx, and tongue are affected. The defeat of the peripheral nerves, usually bilateral and symmetrical, develops relatively late. Initially, in the affected areas, the temperature sensitivity weakens, and then disappears, the pain and tactile sensation. A feature of lepromatous neuritis is their ascending character. The most commonly affected are the ulnar, median, fibular, large auricular nerve, the upper branch of the facial nerve. Nerve trunks thickened, dense, smooth. Gradually develop trophic and motor disorders (lagophthalmus, paresis of masticatory and facial musculature, amyotrophies, contractures, trophic ulcers).

The tuberculoid type is characterized by a lighter course, usually affecting the skin and peripheral nerves. Mycobacteria are detected in the lesions with difficulty, in the scrapings of the nasal mucosa are usually absent. Clinical manifestations of tuberculoid type are characterized by the appearance on the skin of a few different in shape and size erythematous spots, as well as papular elements, which are the main sign of the disease. Papules are usually small, flat, reddish-cyanotic, polygonal, prone to fusion into plaques with sharply contoured, cylindrically raised, rounded or polycyclic margin. Plaques are prone to peripheral growth. Favorite localization of rashes is the face, neck, limb flexor surfaces, back, buttocks.

Gradually, the central part of the plaques becomes atrophied, hyperpigmented, begins to peel off, and along the edge of them there is an erythematous border with a width of up to 2-3 cm and more - a figured tuboculoid. Areas of hypopigmentation or skin atrophy remain on the site of the rash. In the foci of lesions, salo-and sweating were disrupted, and hairless hair falls out. Lesions of peripheral nerve trunks, skin nerves of nerves, vasomotor disorders are detected very early (sometimes to skin manifestations). There are disorders of temperature, pain and tactile sensitivity, often beyond the rash (with the exception of tactile sensitivity).

The ulnar, radial and peroneal nerves are most often affected, which is manifested in their diffuse or clear-cut thickening and soreness. Gradually this leads to the development of paresis, paralysis, finger contractures, atrophy of small muscles, skin, nails, mutilation of hands and feet (seal paw, hanging brush, monkey's paw, falling foot, etc.). The tendon reflexes decrease.

Border types of leprosy are characterized by the appearance on the skin of spotted rashes with geographical outlines - hypochromic, erythematous, mixed. Initially, peripheral nerve damage is absent, and then a specific polyneuritis develops, leading to sensitivity disorders in distal limbs, small muscle atrophy, finger contractures, trophic ulcers. On the skin, eruptions can occur on both lepromatous and tuberculoid types, followed by complete transformation into the corresponding type.

During all types of leprosy, progressive, stationary, regressive and residual stages are distinguished. Transformations of one type into another are possible.

Leprosy lesions of the eyes are characterized by diffuse infiltration or leproms of the eyelids; epiccperitis, keratitis with a characteristic sign-leprosy pannus is more rare (appearance of vessels in the cornea sprouting from the conjunctiva of the eyeball); Iritis, accompanied by pericorneal injection of vessels, photophobia, lacrimation, pain and deposition on the surface of the iris fibrinous exudate, which can lead to fusion of the pupil edges and secondary glaucoma.

The state of the reactivity of the macroorganism in relation to the causative agent of leprosy is characterized by the lepromine test: 0.1 ml of mycobacterium leprosy suspension (integral lepromine) is administered intradermally. A specific reaction develops in 2-3 weeks in the form of a tubercle with necrosis. In patients with lepromatous type of leprosy this test is negative, tuberculoid type - positive (as well as in healthy people); At the boundary type, the sample can be either positive or negative. The sample is used for differential diagnosis of various types of leprosy and for examination of groups of people with an increased risk of the disease (identification of persons with negative breakdown).

The diagnosis should be confirmed, especially in the early stages, by positive results of a bacterioscopic and histological examination. Bacterioscopy is subjected to scraping from the nasal mucosa and scarifications from the affected area of ​​the skin, as well as the skin of the superciliary arches, earlobes, chin, distal extremities. It is necessary to study all kinds of surface sensitivity. Differential diagnosis is carried out with sarcoidosis, syphilis, vitiligo, tuberculosis lupus.

Treatment is complex, combining specific drugs with general strengthening and stimulating. Among the first are the main anti-leprosy drugs (diaphenylsulfone, solesulfone, diucifon and other derivatives of the sulfone series), as well as rifampicin, luprene, prothionide, and ethionide. The second - gamma globulin, pyrogenal, methyluracil, vitamin preparations, immunomodulators, etc. Treatment is carried out (in the progressive stage in leprosarium) courses lasting up to 6 months at intervals of 1 month. The effectiveness of treatment is assessed by the results of bacterioscopic control and histological examination.

Prevention - early detection, rational treatment of patients, examination of population groups in epidemic outbreaks, preventive treatment of persons in close contact with a sick leprosy.