“EFFICACY OF BCG AS IMMUNOMODULATOR IN

MULTIBACILLARY LEPROSY”

Dissertation Submitted in partial fulfillment of the

University regulations for

MD DEGREE IN

DERMATOLOGY, VENEREOLOGY AND LEPROSY

(BRANCH XX)

MADRAS MEDICAL COLLEGE

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY,

CHENNAI INDIA.

MAY 2020

CERTIFICATE

This is to certify that the dissertation titled “EFFICACY OF BCG AS

IMMUNOMODULATOR IN MULTIBACILLARY LEPROSY” is a

bonafide work done by Dr.R.YAZHINI, Post graduate student of the Department

of Dermatology, Venereology and Leprosy, Madras Medical College, Chennai - 3,

during the academic year 2017 – 2020 . This work has not previously formed the

basis for the award of any degree.

Prof. Dr. R. JAYANTHI, MD., FRCP(Glasg). Prof Dr.S.NIRMALA MD

DEAN Professor and Head,

Madras Medical College & Department of Dermatology

Rajiv Gandhi Govt. General Hospital, Madras Medical College &

Chennai-600 003. Rajiv Gandhi Govt. General Hospital,

Chennai-600 003.

DECLARATION

The dissertation entitled “EFFICACY OF BCG AS

IMMUNOMODULATOR IN MULTIBACILLARY LEPROSY” is a

bonafide work done by Dr.R.YAZHINI at Department of Dermatology,

Venereology and Leprosy, Madras Medical College, Chennai – 3, during the

academic year 2017 – 2020 under the guidance of Prof. Dr. S. NIRMALA

M.D.(DERM), Professor, Head of Department, Department of Dermatology,

Madras Medical College, Chennai -3.

This dissertation is submitted to The Tamil Nadu Dr. M.G.R. Medical

University, Chennai towards partial fulfillment of the rules and regulations for the

award of M.D Degree in Dermatology, Venereology and Leprosy (BRANCH –

XX)

Prof. Dr. S. NIRMALA, M.D.(DERM),

Professor and Head of Department

Department of Dermatology

Madras Medical College

Chennai-3.

DECLARATION

I, Dr. R. YAZHINI solemnly declare that this dissertation

titled “EFFICACY OF BCG AS IMMUNOMODULATOR IN

MULTIBACILLARY LEPROSY” is a bonafide work done by me at Madras

Medical College during 2017-2020 under the guidance and supervision of

Prof. Dr. S. NIRMALA M.D.(DERM), Professor and Head of Department,

Department of Dermatology, Madras Medical College, Chennai-600003.

This dissertation is submitted to The Tamil Nadu Dr. M.G.R. Medical

University, Chennai towards partial fulfillment of the rules and regulations for the

award of M.D Degree in Dermatology, Venereology and Leprosy

(BRANCH – XX).

PLACE : Chennai

DATE : (Dr. R. YAZHINI)

SPECIAL ACKNOWLEDGEMENT

My sincere thanks to Prof. Dr. R. JAYANTHI., M.D., F.R.C.P (Glasg),

Dean, Madras Medical College, Chennai-3 for allowing me to do this dissertation

and utilize the Institutional facilities.

ACKNOWLEDGEMENT

I am gratefully indebted to the Professor and Head of the Department of

Dermatology, Prof. Dr. S. NIRMALA M.D. (DERM), for her advice, guidance

and encouragement for my study. She has been a source of constant motivation

and encouragement throughout the study. I am extremely grateful to her for

guiding me throughout the study.

I would like to express my sincere and heartfelt gratitude to

Prof. Dr. S. KALAIVANI M.D., D.V., Director and Professor, Institute of

Venereology, for her kindness and support throughout the study.

I express my sincere gratitude to Rtd Prof. Dr. U.R.DHANALAKSHMI,

M.D., D.D., DNB, Professor of Dermatology for her invaluable guidance and

encouragement

I am grateful and thankful to my guide Prof. Dr. S. NIRMALA

M.D.,D.D., Professor and Head of Dermatology for her guidance, support and

encouragement in completing my study.

I sincerely thank Prof. Dr. R. PRIYAVATHANI ANNIE MALATHY,

M.D., D.D., D.N.B., M.N.A.M.S., Professor of dermatology for her help and

support.

I thank Prof. Dr. A. RAMESH M.D., D.D., D.N.B., Professor of

Dermatology for his advice and encouragement.

I thank Prof. Dr. V. SAMPATH M.D., D.D., Professor of Dermatology

for his advice, constant support and encouragement.

I would like to express my gratitude to Prof. Dr. AFTHAB JAMEELA

WAHAB, M.D., D.D., Professor of Dermatology for her kind gesture, constant

support, advice and encouragement.

I extend my gratitude to Dr. S. VIJAYA BASKAR, M.D(DERM),

D.C.H., Dr. Dr.R. MADHU M.D(DERM), D.C.H., Dr.G.K. THARINI M.D.,

Dr.K. RAJKUMAR M.D, D.D, Dr. SAMUEL JEYARAJ DANIEL

M.D.D.V.L., Associate Professors, Department of Dermatology for their kind

support and encouragement.

I wish to thank Dr. S. ARUNKUMAR, M.D (STD), F.M.M.C. Associate

Professor, Institute of Venereology for his guidance.

I humbly thank my Co-Guide, Dr.C.L.CHITHRA MD (DVL), Assistant

Prof. of dermatology for her valuable guidance throughout my work. I would like

to express my sincere and heartfelt gratitude for the time which she has devoted

for my research project.

I also thank my Assistant professors, Dr. R. MANIPRIYA MD(DVL),

DCh., Dr. TAMIZHSELVI MD(DVL), Dr. K. DEEPA MD(DVL),

Dr.S.VENKATESAN D.N.B., D.D., for their encouragement, guidance and

support

I express my thanks to Dr. V.N.S. AHAMED SHARIFF M.D.D.V.L.,

Dr. B. VIJAYALAKSHMI MD (DVL) my former assistant professors,

Department of Dermatology, for their support and help.

I also thank my Assistant Professors Dr. P. PRABHAKAR, M.D.D.V.L.,

Dr.H.DHANASELVI, M.D.D.V.L., Dr.K.GAYATHRI, M.D.D.V.L.,

Dr.E.BALASUBRAMANIAN, M.D.D.V.L, Dr.R.SNEKAVALLI,

M.D.D.V.L., Dr.T.VASANTHI M.D.D.V.L, Dr.T.VANATHI, M.D.D.V.L and

Dr.DURGAVATHY, M.D., D.D., Institute of Venereology for their able

guidance.

I would like to sincerely thank Dr. ARUN PRABHAKARAN, MD

PATHOLOGY, Assistant Professor, SMC, Chennai for his great help and

guidance.

I am thankful to my colleagues for their support throughout the study. I am

also grateful to all paramedical staffs for rendering timely help to complete my

study. Last but not the least I am profoundly grateful to all patients for their co-

operation and participation in this study. They have been the principal source of

knowledge which I have gained during the course of my clinical research.

CONTENTS

S.NO TITLE PAGE

NO.

1 INTRODUCTION 1

2 REVIEW OF LITERATURE 3

3 AIM AND OBJECTIVES 54

4 METHODOLOGY 55

5 OBSERVATION AND RESULTS 60

6 CLINICAL IMAGES

7 DISCUSSION 83

8 CONCLUSION 88

9 REFERENCES 90

10 ANNEXURES

ABBREVIATIONS

MASTER CHART

PROFORMA

INFORMATION SHEET

CONSENT FORM

ETHICS COMMITTEE APPROVAL CERTIFICATE

PLAGIARISM DIGITAL CERTIFICATE

Introduction

1

INTRODUCTION

Leprosy (Hansen‘s disease) is a chronic inflammatory disease caused by

Mycobacterium leprae. It principally affects skin and the peripheral nerves, and in

highly bacillated state, internal organs are also affected1. The main tissue

manifestation of leprosy is the formation of distinct granulomas as a result of

chronic inflammation. These granulomas cause considerable host tissue damage,

mostly of the skin and nerves. Hence, leprosy is also known as a granulomatous

disease.

Leprosy presents in the form of a spectrum of different manifestations.2

The Ridley and Jopling classification involves clinical, pathological, bacillary and

immunological criteria, that allows a thorough characterization of six forms of

leprosy: the polar tuberculoid (TT), the intermediate borderline tuberculoid (BT),

mid-borderline (BB), borderline lepromatous (BL) and polar lepromatous leprosy

(LL) forms. A sixth classification, indeterminate leprosy (IL), is also commonly

used. The clinical presentation mainly depends on the ability of the host to induce

cell-mediated immunity (CMI) against M. leprae. The manifestations of the

disease in various clinicopathological patterns is determined by the type of

immune response which varies from person to person.3

Large scale and successful implementation of present day multidrug

therapy (MDT), composed of rifampicin, clofazimine and dapsone has brought

down the prevalence of disease substantially. However, new cases are still being

2

reported globally, which needs to be addressed for ultimate eradication of the

disease. Chemotherapy/MDT kills most of the susceptible live organisms but

―persisters‖/ metabolically dormant bacilli and dead organisms do remain in the

body for long duration, particularly in patients with high bacillary load

(lepromatous spectrum). Thus, immune modulators like vaccines, drugs or

cytokines are required to modulate the immune response to regulate the immune

system and optimize the immune response.

The addition of immunotherapy to chemotherapy could be useful in

augmenting the CMI leading to more efficient killing of viable bacilli including

persisters and faster clearing of dead bacilli, thereby reducing the risk of reactions

and relapse.

Review of Literature

3

REVIEW OF LITERATURE

Leprosy is a chronic infectious disease caused by Mycobacterium leprae,

an obligate intracellular organism. It is a slowly progressive disease, principally

affecting skin and the peripheral nerves. Although it seldom kills, leprosy

represents a deforming, disabling and stigmatizing disease.4

EPIDEMIOLOGY

About 4 million people are affected by leprosy. There is apparent fall in

registered patients from 12 million in 1988 to 0.25 million in 2014.5 The

substantial reduction in the number of affected individuals reflects the impact of

multidrug therapy.6 The goal of the World Health Organization (WHO) is a

prevalence rate of less than 1 case per 10 000 persons, which has been achieved in

all but a few countries.7

GLOBAL LEPROSY SITUATION:

In April 2016, WHO launched a 5-year ―Global leprosy strategy 2016–

2020‖ titled 'accelerating towards a leprosy-free world'.8 This strategy is built

around three pillars:

(i) to strengthen government ownership, coordination, and partnership

(ii) to stop leprosy and its complications

(iii) to stop discrimination and promote inclusion.

4

There is a special focus on women and children, strengthening the referral

systems, more effective contact tracing, assessing the value of chemoprophylaxis

and monitoring drug resistance.9 The global prevalence at the end of 2018 was

184, 212 cases with a registered prevalence rate of 0.2 per 10,000 population.

CURRENT SITUATION OF LEPROSY IN INDIA:

In India, the National Leprosy Eradication Programme (NLEP) is the

centrally sponsored health scheme of the Ministry of Health and Family Welfare,

Government of India. India achieved elimination target in December 2005.

Despite the above success, the fact remains that India continues to account for

60% of new cases reported globally each year. Total number of new cases

recorded in year 2017 was 1,26,164 with 3.6% of cases having grade 2 disability.

NLEP annual reports of the last 4 years have consistently observed that the

four states namely Orissa, Chandigarh, Delhi and Lakshadweep, which achieved

elimination earlier in 2011–2012, have shown a prevalence of >1 per 10,000

population.10

In addition, although the average national child leprosy rate is ~ 9%,

the proportion of child cases was more than 10% of new cases detected in eleven

states/UTs of India, with 6 of them (Tamil Nadu, Punjab, Bihar, Dadra & Nagar

haveli, Mizoram, and Arunachal Pradesh) showing very high rates ranging from

14% to 23%.

The SPARSH Leprosy Awareness Campaign (SLAC) was launched on

30th

January 2017. This program is intended to promote awareness and address the

issues of stigma and discrimination.11

The anticipation of the present strategy is

5

that, with increasing awareness and reducing stigma, more hidden cases will self-

report for diagnosis and treatment.

DEFINITION OF A LEPROSY CASE

According to the 8th

WHO Expert Committee (2010),12

Leprosy is

diagnosed when atleast one of the following cardinal signs is manifested:

Definite loss of sensation in an erythematous or hypopigmented skin patch

Nerve thickening associated with sensory impairment or weakness of the

muscle supplied by that nerve

Skin smear positive for acid fast bacilli

BACTERIOLOGY OF LEPROSY

Gerhard Armauer Hansen discovered the causative agent of leprosy,

Mycobacterium leprae in 1873. It is an obligate intracellular mycobacterium,

found more commonly within the macrophages and schwann cells of nerves, but

also within muscles, endothelial cells, melanocytes and chondrocytes. It is a

strong acid-fast rod shaped organism with parallel sides and rounded ends. This

unique property of acid fastness is mainly attributed to the presence of mycolic

acid in the cell wall of the organism. It closely resembles tubercle bacilli.

However M.leprae is less acid and alcohol-fast compared to M.tuberculosis. It

has a slow rate of multiplication with a generation time of 12-14 days.

The organism shows optimal growth at temperature less than 37°C. Thus it

affects cooler tissues like skin, peripheral nerves, upper respiratory tract and testis,

6

sparing warmer areas of the body.13

It is susceptible to drying, air, cold and

disinfectants.

TRANSMISSION OF LEPROSY:

The human being is the only known reservoir of M. leprae. Untreated

leprosy case is the only source of infection. Multibacillary cases are the major

source of transmission than paucibacillary cases. The two main portal of exit of

M. leprae are the skin and nasal mucosa. Bacteriologically positive cases shed

millions of bacilli from their nasal mucosa.14

The two portal of entry being

considered are upper respiratory tract and skin.15

The possible methods of transmission16

are,

- By Contact (direct/indirect)

- Inhalation

- Ingestion

- In utero transmission

- Through insects (inoculation)

Viability of M. leprae outside the human host

M. leprae can survive for up to 9 days in nasal secretions under tropical

conditions17

The incubation period varies from few weeks to even up to years. In South

India, the mean incubation period was studied to be 4.4 years18

7

CLASSIFICATION OF LEPROSY:

At present, the most common classification in use are,

- WHO classification for treatment purpose and

- Ridley - Jopling classification for research and academic purpose

WHO CLASSIFICATION:

1) Paucibacillary leprosy [incudes smear negative cases belonging to

Indeterminate, tuberculoid (TT) and borderline tuberculoid (BT) cases]

2) Multibacillary leprosy [Includes all smear positive cases19

and mid-

borderline (BB), borderline lepromatous (BL) and lepromatous leprosy

(LL) cases]

RIDLEY-JOPLING CLASSIFICATION:

It is a five-group classification with two polar forms and three

immunologically unstable borderline group.20

Those are,

Tuberculoid (TT), Borderline tuberculoid (BT), Borderline borderline

(BB), Borderline lepromatous (BL) and Lepromatous leprosy (LL).

BB is the most unstable form of the leprosy.

CLINICAL FEATURES:

Leprosy is unique as an infectious disease, as it exhibits wide spectrum of

signs and symptoms. Clinical features are mainly the result of host immune

response to the presence of bacilli rather than direct damage due to bacillary

invasion21

8

INDETERMINATE LEPROSY:

The patient is usually a child presenting with single or multiple, small to

medium sized hypopimented patches. It is often situated on the extensor aspect of

the thigh, limbs, buttock and the face with rather vague edges. Hair growth and

nerve function are unimpaired.22

The diagnosis can be confirmed by a biopsy

showing typical perineurovascular infiltrate or the presence of scanty acid-fast

organisms. Newer diagnostic methods like PCR is of definite value in doubtful

cases.23

Three out of four indeterminate lesions undergo spontaneous resolution

and the rest become determinate and enter the clinical spectrum.24

TUBERCULOID LEPROSY:

The typical lesion is a well defiend plaque, that is erythematous or copper

colored with a raised and clear‐cut edge sloping towards a flattened and

hypopigmented centre. The surface of the lesion is dry, hairless with definite

sensory loss and sometimes scaly. Number of skin lesions may be single or up to

three in number. Peripheral nerve trunk adjacent to the skin lesion is affected and

hence the nerve damage is often asymmetrical and unilateral. Majority of the

patients with true TT undergo self healing even without treatment.25

BORDERLINE TUBERCULOID:

The skin lesions resemble those of tuberculoid leprosy, but the margins are

less well defined and less infiltrated and the border in part may streams off

gradually into the normal skin. Satellite lesions or pseudopodia are often seen near

the edge of the larger lesions. The number of lesions may vary from three to 10.

9

Loss of sensations, dryness, erythema and scaling are less conspicuous than in TT.

Several large peripheral nerves may be enlarged in an asymmetrical pattern.26

Nerve damage is an important characteristic of this spectrum.

MID-BORDERLINE:

This is the most unstable part of the spectrum and dimorphous feature is

the rule. Number of skin lesions are often multiple (10-30). Lesions may be

macules, papules, plaques, circinate lesions and rarely even nodules that greatly

vary in size, shape and distribution. Geographic lesions and annular inverted

saucer shaped lesions are characteristic. Nerve damage is variable. Skin smears

show moderate number of AFBs.

BORDERLINE LEPROMATOUS:

Numerous skin lesions presenting as slightly infiltrated macules with

coppery hue, varies in size and shape, but are usually small (2–3 cm), not so

perfectly symmetrical in distribution. Signs of nerve damage starts sooner in BL

than in LL. Peripheral nerve trunks are thickened at the sites of predilection but

lack symmetry. Prognosis is variable and if left untreated it progresses to subpolar

LL.27

LEPROMATOUS LEPROSY:

Manifestations in this spectrum are due to absence of any resistance

mounted by the host leading to multiplication and spread of the bacillus. Early

lesions are macules, that are widely and symmetrically distributed. Lesions are ill-

defined, smaller in size, slightly infiltrated and shiny. Sensation is usually

10

unimpaired in the early lepromatous lesions. Lepromatous leprosy with infiltrated

lesions present in three distinct forms

- Diffuse Lepromatous leprosy

- Infiltrated Lepromatous leprosy

- Nodular lepromatous leprosy

Diffuse Lepromatous Leprosy:

There is slight infiltration of the skin, which is better appreciated by touch

or by pinching the skin rather than by sight. Thickening of the skin is more

obvious over the skin of face (forehead, Eyebrows, malar areas, ear lobes)

Infiltrated Lepromatous Leprosy:

This is advanced stage of macular LL, where there is visible infiltration of

the skin. Lesions are shiny and succulent in consistency.

Nodular Lepromatous leprosy:

This stage is the result of progressive deterioration of diffuse or infiltrated

LL. Nodules may be seen over the ear lobes, face, trunk, buttock and extremities.

Nodules are erythematous/coppery/skin-colored, firm on palpation with sloping

edges onto the surrounding infiltrated skin. The infiltration of the skin of the face

causing accentuation of skin folds results in characteristic leonine facies.

Peripheral nerves become thickened, firm and fibrosed symmetrically at the sites

of predilection.

11

Apart from the skin and peripheral nerves, the other organ systems affected

include bones, eyes, upper respiratory tissues, kidneys, liver and testes. Other

features of lepromatous leprosy include,

- Madarosis

- Leprous alopecia (residual hair seen only over the course of arterial

supply to the scalp)

- Corneal anesthesia (bacillary infiltration of corneal nerves)

- Upper respiratory tract involvement ( Epistaxis, Septal perforation

leading to saddle nose deformity)

- Facies leprosa (nasal collapse and loss of upper central incisors)28

- Symmetrical sensory loss (typical glove and stocking anesthesia)

- Nails may become lusterless, thin, ridged and curved29

- Weakness of intrinsic muscles of hands and feet

- Fusiform swelling of the digits

- Resorption of bones of terminal phalanges (Penciling)

- Testicular atrophy

- Gynaecomastia

Lepromatous leprosy usually does not itself remit, however in few patients,

it seems to burn out. Death occurs due to secondary infections like pneumonia,

tuberculosis, renal failure and amyloidosis. Even LL may ensure better prognosis

and quality of life with adequate treatment with anti-leprosy medications for

adequate duration along with anti-inflammatory drugs when needed.

12

UNUSUAL EXPRESSIONS OF MULTIBACILLARY LEPROSY:

- Localized lepromatous disease

- Histoid leprosy

- Spontaneous skin ulcerations

- Lucio leprosy

LOCALIZED DISEASE:

It presents as single nodule30,31

or as papulo-nodular lesions in a localized

area, having very high bacterial index while the rest of the body surface appears

normal.

HISTOID LEPROSY:

This term introduced by Wade.32

It is a rare type of lepromatous leprosy

which exhibits unique clinical, histopathological, and microbiological features33

.

It is characterized by well defined succulent hemispherical, nontender soft to firm

nodules which may be cutaneous or subcutaneous and appearing on an apparently

normal looking skin. Mouse footpad sensitivity tests have shown that the bacilli

present in the histoid lesions are often resistant to dapsone34

(DDS).

SPONTANEOUS SKIN ULCERATIONS:

It occur in patients with severe, long-standing, untreated LL. Lesions

appear in the areas of chronic panniculitis. This is most commonly seen over

anterior thighs, calf, dorsum of forearm or triceps area. These ulcers are not due to

trauma, rather the skin dies and sloughs off leaving behind irregular and often

triangular defects.

13

LUCIO LEPROSY:

Lucio leprosy is a pure, primitive and diffuse non-nodular form of LL35

,

commonly seen in Mexico and Costa Rica. In Mexico, it is termed as ―lepra

bonita‖(beautiful leprosy). It presents as diffuse infiltration of the ear lobes and

forehead, loss of eyebrows and sometimes eyelashes, and even all body hairs.

There may be hoarseness of voice, numbness and edema of hands and feet

mimicking myxedema36

. Lucio phenomenon develops in this type of leprosy.

LABORATORY DIAGNOSIS:

SLIT SKIN SMEAR

Slit-skin smear technique was first developed by Wade and Rodriguez in

1927, standardized by Cochrane in 1947. It was described by International

Federation of Antileprosy Associations (ILEP) in detail.37

Of all the laboratory

tests for leprosy, slit-skin smear examination is the most simple and valuable one.

Role of Slit skin smear:

It helps in confirming the diagnosis, assess the disease activity and classify

the disease. It also helps in monitoring the progress of the disease during follow-

up.

14

TECHNIQUE:

The lesion is cleaned with ether and a portion of it is gripped between the

thumb and the index finger until it blanches. With a small-bladed scalpel (Bard

Parker No. 15), make a cut on the skin fold 5 mm long and 3 mm deep, pressure

of the fingers being maintained. The blade is then turned at right angles to scrape

out fragments of tissue and fluid from the bottom and side of the cut. This is

gently smeared on the glass slide. The smear is fixed over a flame before being

sent for staining. Slide is then stained by Ziehl-Neelsen Method. The site of the

smears are recorded, so that the same sites can be smeared during the course of

treatment.

Examination of the smear:

Slide is examined using a light microscope under an oil immersion

objective. The number and the morphology of the bacilli are noted. It is

considered that solid staining organisms are probably live and viable; whereas the

granular, broken and fragmented ones are dead and nonviable.38

Bacteriological Index (BI) :

This is the standard method of assessing bacterial load in a leprosy patient.

It is graded as follows,

6+ : Over 1000 bacilli and globi in an average microscopic field

5+ : Over 100 bacilli but less than 1,000 in an average microscopic field

4+ : Over 10 bacilli but less than 100 in an average microscopic field

15

3+ : 1–10 bacilli in an average field

2+ : 1–10 bacilli in 10 fields

1+ : 1–10 bacilli in 100 fields

0 : No bacilli observed after searching atleast 100 microscopic fields

Total BI is arrived at by adding the values from all the skin sites examined

(usually 4) and by dividing the total by the number of sites examined.

Morphological Index (MI) :

It is the percentage of solid stained bacilli and is calculated after examining

200 bacilli lying singly.

HISTOPATHOLOGICAL EXAMINATION

It is better that every patient of leprosy should undergo skin biopsy for

histological examination. The present day applications of histopathology include:

1) Confirmation of diagnosis in a clinically ambiguous or suspect case

2) Diagnosis of reaction state, differentiation of type 1 reaction from type 2

reaction and relapse

3) Defining the spectral position of a given case for treatment purpose

4) Assessment of disease activity and response to therapy

5) Application of the technique related to immunology and molecular biology

16

CELLS PARTICIPATING IN LEPROSY LESIONS:

Granuloma formation is the hallmark in leprosy. A granuloma is defined as

a compact aggregate of macrophages or cells derived from them.39

Monocytes of

bloodstream migrate to the tissues and transform to macrophages which are tissue

based phagocytes. In response to the presence of M. leprae, if the immunity is

effective, granuloma develops by the interaction of the macrophages and

lymphocytes. Macrophages being activated by CD4+ cells eliminate the bacilli

and transform into epithelioid cells. As an inherent tendency, several epithelioid

cells fuse to form giant cells. This process of eliminating the organisms is

executed only by the immune cells and hence it is called cell-mediated immunity

(CMI). Depending on the predominant cell type, a granuloma is called either

macrophage granuloma or epithelioid cell type. Macrophages belong to an

extensive system of cells and tissues called the reticuloendothelial system, which

is presently renamed as mononuclear phagocytic system (MPS).40

These cells

contribute to both the innate and adaptive immunity.

GRANULOMA FRACTION:

Granuloma fraction (GF) is the percentage of dermis-width occupied by the

granuloma. It is estimated by focusing granuloma in its highest width under low

power and expressed as multiples of 10. It can more accurately be measured by a

planimeter. It can be used for assessing the response to therapy.41

17

Histology of various types of leprosy are as follows.

INDETERMINATE LEPROSY:

Ridley suggested early and late stages of indeterminate leprosy.42

Early

stage shows perineural or perivascular lymphocytic infiltrate. Nerve parenchyma

are normal. Occasional AFB may be seen. In the late stage neural inflammation as

evidenced by lymphocyte infiltration of the nerve parenchyma or Schwann cell

proliferation is seen.

TUBERCULOID LEPROSY:

Compact granuloma composed of large epithelioid cells, giant cells and

lymphocytes. Granuloma always erodes a chunk of epidermis by obliterating the

subepidermal clear zone. Lymphocytes form a dense mantle around the epitheloid

cells. Dermal nerves are obliterated or surrounded and eroded by dense

lymphocyte cuffs and may show central caseation. Caseation is mostly confined to

nerve lesions.43

Acid-fast bacilli are rarely found.

BORDERLINE TUBERCULOID LEPROSY:

Granuloma is composed of epithelioid cells with some admixture of

macrophages and lymphocytes. Epithelioid cells are loosely distributed. Clear

subepidermal zone (SEZ) is the rule. Granulomas are seen around the

neurovascular bundles and sweat glands and erector pili muscles. Nerve erosion

and obliteration are typical. Bacterial index (BI) of the granuloma ranges from 1+

to 2+.

18

BORDERLINE BORDERLINE LEPROSY:

Granuloma shows a mixture of epithelioid cells and macrophages with

predominance of the former. lymphocytes are scanty. Epidermis is usually normal

with a clear SEZ. Transverse section of nerves may show cut-onion appearance

due to proliferation of perineural cells.44

BI ranges from 3+ to 4

+.

BORDERLINE LEPROMATOUS LEPROSY:

Granuloma is predominantly composed of macrophages with isolated

clumps of epithelioid cells. Lymphocytes are sparse and scattered over most part

of the granuloma. Nerves show cut-onion appearance. BI ranges from 4+ to 5

+.

LEPROMATOUS LEPROSY:

Epidermis is thinned out with flattening of rete ridges. Diffuse leproma of

foamy macrophages with few scattered lymphocytes and plasma cells are seen.

The infiltrate causes the destruction of the cutaneous appendages and also extends

into the subcutaneous fat. In rare cases, AFB even as globi is seen in cells of

epidermis.45

Bacilli are innumerable and BI ranges from 5+ to 6

+.

OTHER INVESTIGATIONS:

Evaluation of peripheral neural involvement in cases of neuritis and

primary neural leprosy is done with the help of Electroneuromyography and

imaging tests such as simple radiography, ultrasound, computed tomography, and

magnetic resonance imaging. Sural nerve biopsy may also be helpful in neuritic

leprosy. New tools such as, serological tests with the phenolic glycolipid 1 antigen

19

(PGL-1) and protein antigens, immunohistochemistry with antibodies against

PGL-1, bacillus Calmette-Guerin (BCG) and S-100 protein, and PCR with

several primers aiming at various genomic targets of M. leprae are currently

available for research purposes.46

IMMUNOLOGY OF LEPROSY :

The defense against pathogens is first initiated by the innate immune

response and subsequently by the acquired immune response after a lag period.

Both function through cells as well as soluble factors which are usually

glycoproteins. The acquired immune response involves highly specific interaction

through ligand receptor interaction. The major players of acquired immune system

are lymphocytes, dendritic cells, macrophages and their lineage. Lymphocytes are

known to be of two major types based on their cell surface markers and functions.

The B-cells bearing immunoglobulin surface marker produce antibodies and lead

to humoral immunity that can capture circulating free microbes. Antibodies

cannot cross the cell membrane and thus are unable to attack intracellular

pathogens like M. leprae. T-cells have the surface CD3 marker which are

responsible for cellular immunity are thus required for limiting and killing

intracellular pathogens.

INNATE IMMUNITY:

Entry is the first step for intracellular pathogens such as M. leprae.

Receptors to complement fragments of CR1, CR3 and CR4 help in phagocytosis.

Phenolic glycolipid-1 (PGL-1), an M. leprae specific cell wall lipid is recognized

20

by complement 3.47

Susceptibility to leprosy is linked to genes that are involved in

macrophage functions, such as iron transporter natural resistance-associated

macrophage protein 1 (NRAMP 1), which assists in iron transport into the

phagosome and in viability/multiplication of pathogen within the macrophage.

The human homologue of the gene encoding this protein has been identified to

chromosome 2q35.48

The other susceptibility gene is PARK2/PACRG, which is

responsible for the synthesis of a ligase in the proteosome pathway suggesting its

role in innate immune based defects.49

Initial interaction between the host and M. leprae is mediated by pattern

recognition receptors called Toll-like receptors (TLR) that detect pathogen-

associated molecular patterns (PAMPs).50,51,52

TLRs are highly conserved family

of proteins, primarily expressed by cells such as macrophages and dendritic cells.

They are crucial for recognition of microbial pathogens. Since they are

transmembrane molecules, they may play a role in signaling following their

engagement. The cytoplasmic tail is linked to transcription factors such as nuclear

factor kappa-light-chain-enhancer of activated B-cells (NF-kB), which induces

many cytokines. TLR2 and TLR4 are the two major receptors involved in

Hansen‘s disease.53,54,55

These receptors recognize mycobacteria and release IL-

12, a cytokine that further induces proinflammatory cytokines such as Interferon-

gamma (IFN-γ). IFN-γ along with granulocyte macrophage colony-stimulating

factor (GM-CSF) enhance TLR1 expression which leads to an inflammatory

response through the production of tumor necrosis factor alpha (TNF-α).

21

Activation of TLR2 has been observed with 19 kDa and 33 kDa lipopeptides of

M. leprae.

C-type lectin receptors present on mature macrophages bind to the

carbohydrate moieties, mannose-capped lipoarabinomannan present on M. leprae

and influence macrophage functions such as phagocytosis, prostaglandin E2

(PGE2), nitric oxide (NO) and TNF-α production.56

Dendritic cell specific intercellular adhesion molecule-3-grabbing

nonintegrin (DC-SIGN),57

langerin granules of Langerhans cells have also been

implicated in the uptake of non-peptide mycobacterial antigens.58

Vitamin D also

contributes to innate immunity through its antimicrobial property.

ACQUIRED IMMUNITY:

There are two principal defence mechanisms, one is the humoral immune

response, which depends on a group of small lymphocytes called B lymphocytes

(B cells) and the other being the cellular immune response, depending on a group

of lymphocytes called T lymphocytes (T cells). T cells constitute 75-80% of blood

lymphocytes and B cells constitute 10-20%.59

Humoral Immune Response:

B cells within the lymphoid tissues of the body are stimulated by antigen to

proliferate and transform into plasma cells which in turn produce

immunoglobulin. Immunoglobulins are serum proteins with antibody activity and

are classed according to the antigens which stimulate their production as IgG,

22

IgM, IgM, Igd, IgE. In order for the antibody to have a cytotoxic effect, an extra

protein substance is required, called complement.60

A subset of T cells called helper or inducer T cells helps in enabling the B

cells to respond to the antigens which they otherwise would not recognize. On the

other hand, a subgroup of T cells called suppressor T cells exert a regulating

effect on the B cells. These ‗helper‘ or suppressor factors are proteins generated

by lymphocyte activation and are called ―lymphokines‖.61

These factors play an

important role in modulating and amplifying the lymphocyte-lymphocyte and

lymphocyte-macrophage interactions by which humoral and cell mediated

immune responses are regulated.62

Humoral immune response is unimpaired in leprosy. Patients with leprosy

usually have raised levels of serum immmunoglobulins, with highest levels being

in LL. Since the organisms are intracellular, antibodies are unable to kill the

organisms. Antibodies may actually be harmful as they can react with the M.

leprae antigens in the tissues, with the deposition of immunoglobulin and

complement in damaged tissues as occurring in Type II reaction.63

Several specific serological tests have been developed in the last few

decades. These tests have been reported to be useful mainly for determining

exposure to M. leprae, as the antigens and resultant response persist for a long

time after subsidence of clinical or subclinical disease.

23

Cell Mediated Immune Response (CMI):

T cells can penetrate most of the tissues to mediate cellular immune

response to antigen. T cells responding to antigen undergo blast transformation

and proliferate in the thymus dependent regions of lymphoid tissue. Such

activated T cells have complex reaction with the macrophages, leading to release

of lymphokines from the T cells, which are MIF (migration inhibiting factor) and

MAF (macrophage activating factor). MIF concentrate macrophages at the sites

where their activity is required. MAF renders the macrophages capable of killing

pathogenic micro-organisms.

There are two methods for measuring T cell activity in vitro. These include

lymphocyte transformation test (LTT) and leukocyte migration inhibition test

(LMIT). An in vivo method for testing CMI is by injecting antigen intradermally

and studying local reaction after 48-72 hours. This reaction is called delayed type

hypersensitivity reaction (DTH or DH).

Non-specific CMI in leprosy:

There is non-specific impairment of CMI in leprosy. This had been

demonstrated by negative or poor response of DH reaction to various skin test

antigens and LTT in untreated LL and normal response in TT. However, such

non-specific impairment of CMI in leprosy is not associated with increased risk of

predisposition to viral, bacterial, protozoal or fungal infections.

24

Specific CMI in leprosy:

Deficient cell mediated immunity and delayed hypersensitivity to M.

leprae is responsible for the development of leprosy in an individual exposed to

the bacterium. The degree of deficiency determines the type of leprosy in the

individual (Fig. 1).

In vitro tests for specific CMI

- Delayed hypersensitivity to M. leprae

- Lymphocyte stimulation test

- Lymphokine production by the T cells

In vivo test for specific CMI

- Lepromin test

- Lymph node examination for the analysis of cells in the paracortical

area

- Graft versus host reaction

LL BL BB BT TT

Fig.1 Spectrum of immunity in leprosy

25

Two main types of T helper cells studied in CD4 + T response pathway are

Th1 lymphocytes associated with the tuberculoid form and Th2 lymphocytes

associated with the lepromatous form. 64,65,66

CD8+ T lymphocytes are primarily

involved in the development of cytotoxicity by promoting the release of

granzymes and perforins that destroy the co-infected cells in patients with a type-1

reaction.67,68

The Th1/Th2 PARADIGM

Based on the characterization of immune response, the disease classically

presents two clinical forms both of which are considered to be antagonistic. Th1

and Th2 subsets of CD4 cells produce mutually exclusive IFN-γ and IL-4 which

are considered to be responsible for delayed type hypersensitivity and humoral

immunity respectively. When both cytokines are produced the phenotype is

considered to be Th0. Th0 lymphocytes differentiate into Th1 and Th2

lymphocytes and the main cytokines involved in the process are IL-2, IL-12 (Th1)

and IL-4 (Th2). Th1 cells express CCR5 and CXCR3 chemokine receptors,

whereas Th2 cells express CCR4, CCR8 and CCR3 to a lesser extent.69

In the initial studies, tuberculoid leprosy patients were shown to have Th1

subset, whereas Th2 subset seemed to be the predominant in LL. Th1 response

pattern is associated with decrease in bacillary load where the production of TNF-

α and IFN-γ activate macrophages and induce the production of iNOS (inducible

nitric oxide synthase) that destroys the bacillus. Th2 lymphocytes response in the

lepromatous form is associated with a greater number of lesions with the presence

26

of foamy macrophages and bacilli as globi. This is due to the production of

cytokines such as IL-4, IL-10, and TGF-β that negatively regulates the Th1

response by inactivating the microbicidal response of macrophages, thereby

facilitating the survival of the bacillus (Fig. 2).70,71

However, several other studies

showed that there was a mixture of Th phenotypes in leprosy patients. 50% of

tuberculoid patients had Th1 and 60% of LL patients had Th2 phenotype with the

remainder of tuberculoid and LL patients having Th0 phenotype.72

Fig. 2 Immune paradigm of Th1/Th2 response

in the polar forms of leprosy

27

NEW CYTOKINE PROFILES IN THE CLINICAL EVOLUTION OF

LEPROSY:

With the advancement in the knowledge about cellular and humoral

immunology, new populations of lymphocytes and macrophages such as M2, M4,

and M17 types have been identified suggesting great complexity of the immune

response. Considering the cytokine profiles, new subtype of T cells (Fig. 3) such

as Treg, Th9, Th22, and Th17 have been identified and with the emergence of

these cellular subpopulations, interpretation of the long-established pattern of

polar forms of the disease has changed.

Fig.3 Development of Th phenotypes and regulatory T-cells

from a CD4 precursor cell

In the pathogenesis of the neural lesion, it is observed that regardless of the

way the bacillus reaches the nerves or Schwann cells (either by retrograde axonal

flow, phagocytosis by the perineural cells or through endoneural vessels), the

28

presence of M. leprae within the endoneural macrophages and the rupture of the

cells resulting from bacillary replication triggers a perineural inflammatory

response leading to myelin destruction and neural damage.73,74

On the other hand,

in an attempt of the host to prevent this neural damage, neural regeneration is

induced by the cytokines of Th17 or Th22 profiles, such as TGF-β and FGF, or

through NGF production which may induce regeneration of nerve.75

The role of these new lymphocytic profiles in the dimorphic or borderline

forms of leprosy have been considered. Several cytokines that are characteristize

these profiles play a major role in determining the reactional forms. Regarding the

classical Th1 and Th2 duality, the predominant profile may assume patterns with

increased levels of pro-inflammatory or anti-inflammatory cytokines or mixed

patterns, depending on the clinical form considered. The presence of Treg

lymphocytes may be more frequently present in the borderline lepromatous and

lepromatous leprosy.

Th1 profile cytokines such as IL-2, INF-γ and TNF-α, which promote the

differentiation of naïve T lymphocytes, as well as the cytokines like TGF-β, IL-17

and IL-23 and in addition T regulatory cells (Treg) are involved in the

pathogenesis of the type I reaction or reversal reaction. IL-17 plays an important

role in tuberculoid leprosy. Th9 cytokine profile plays a role in tuberculoid

leprosy and its characteristic IL-9 expression shows synergistic biological actions

with IFN-γ and IL-12, suggesting its role in type I reaction. IL-1, IL-4, IL-6, and

TNF-α are the major cytokines involved in the pathogenesis of type II reaction or

29

erythema nodosum leprosum.76

Cytokines of Th22 profile may also contribute to

the evolution and pathogenesis of type 2 reaction.

IMMUNOLOGICAL UNRESPONSIVENESS:

Genetic basis of leprosy has been extensively investigated and it is found

that HLA class II genes are responsible for susceptibility to leprosy. This class of

HLA is important for presentation of antigens to T-cells. Though T-cells of

lepromatous subjects do not respond to antigens of whole bacilli, many of them

respond to synthetic peptides based on the predicted amino acid sequence of the

M. leprae genome indicating residual T cell function. It is thought that the lack of

T-cell responsiveness is due to peripheral factors. Antibody-mediated suppression

was initially thought to be the cause, but that theory lost ground subsequently and

the concept of suppressor T cells gained popularity in 1980s. CD8 T-cells was

thought to indicate suppressor T-cells both in circulation and in lesions. Studies

on Indian patients showed that in lepromatous patients, macrophages or

macrophage factors suppressed T-cell lymphoproliferation and IL-2 production.77

Such factors were nonspecific and includes PGE2, thromboxane, leukotrienes and

IL-10. PGL, the specific antigen of the leprosy bacillus was also thought to be

responsible for T-cell suppression.78

However, this could not explain the unique

antigen specificity seen in LL. Thus the concept of suppressor T-cells lost

credibility in 1990s as no phenotype or gene could be associated with this

function. Currently, the concept of negative regulation in the form of FOXP3

regulatory T-cells (Fig. 3) is making reappearance.

30

There is an increase in FOXP3+ Treg cells in LL as compared to

tuberculoid leprosy in both peripheral blood and skin lesions, which is detected

using gene expression and flow cytometry studies.79

These cells secrete tumor

growth factor beta (TGF-β)80

or IL-1081

which may be responsible for their

suppressor role. Monocytes derived factors such as prostaglandins, leukotrienes

and thromboxanes play a role in the induction of FOXP3 gene expression and

induced Treg function in human CD4+ T-cells.82

In summary, it is evident that T-

cell biology involves a complex interaction between effector and regulatory cells

and is a double-edged sword which may lead to protection through elimination of

the pathogen or immunopathology as a result of tissue damage caused by DTH.

IMMUNONOLOGICALLY MEDIATED COMPLICATIONS:

Reactions in leprosy are due to sudden change in the immunological

response of the body against the causative organism. These are episodes of acute

or subacute inflammation affecting skin, nerves and other sites. Except,

indeterminate leprosy, reactions may occur in any type of leprosy and if

inadequately treated, they can result in deformity and disability. Three types of

reactions are recognized

1) Type 1 Reaction

2) Type 2 Reaction or Erythema Nodosum Leprosum

3) The Lucio Phenomenon

31

TYPE 1 REACTION (T1R) :

The T1R is usually observed in borderline spectrum83

of the disease and

rarely in lepromatous leprosy (LL)84

. It is characterized by episodes of increased

inflammatory activity in skin lesions, peripheral nerves or both. It is associated

with increased cellular immune responses (DTH reaction) to M. leprae antigens in

the skin and nerves.

Upgrading or Reversal Reaction

If there is shift in the spectrum from borderline spectrum toward

tuberculoid pole, it is called upgrading or reversal reaction (RR). This is seen with

increase in the immunity. The term, ‗reversal reaction‘ is used because of the

natural tendency of downgrading of the spectrum without treatment, is reversed

with treatment.

Downgrading Reaction

Downgrading reaction is observed with reduction in the immunity and

there is sudden shift toward the lepromatous pole. There are conflicting opinions

regarding the existence of this form of T1R. Moreover, as the management is

same, no distinction is recommended to be made and all T1Rs are labelled as RRs.

Immunopathogenesis:

The tissue damage is probably directly mediated by a DTH reaction against

bacillary antigens which damage the surrounding tissues as an innocent bystander.

The localization of M. leprae in the schwann cells of the peripheral nerves along

32

with the DTH reaction in combination, are responsible for most of the nerve

function loss and deformities associated with leprosy. These is marked infiltration

of activated CD4 T lymphocytes, especially of Th1 class,85,86

with increased

expression of adhesion molecules on endothelium, increased IL-2 and IFN-γ,

leading to increased lymphocytic infiltration in skin and the nerve.

HISTOPATHOLOGY:

At initial stage, only mild extracellular edema with some proliferation of

fibroblasts with increased number of lymphocytes may be seen in the leprosy

granuloma. Later, there is increased edema and a change in the cellular

composition in and around the epithelioid cell granuloma,87

due to influx of

lymphocytes that are mainly of CD4 subtype. It also manifests in nerves showing

Schwann cell destruction, ischemia of nerve fibers

Clinical features:

The various clinical terms used to describe the course of the reaction are as

follows

Acute: Symptoms persisting up to or less than 1 month

Subacute: Symptoms persisting for more than 1 month upto 6 months

Chronic: Symptoms persisting for more than 6 months

Recent: Includes both acute and subacute types

Late reversal reaction (LRR): RR occurring any time after completion of

MDT

33

Recurrent/Repeated reactions: Episodes recurring after 3 months of

stopping anti-reaction treatment

Symptoms:

Patients may complain of pain, burning or stinging sensations which may

be accompanied by loss of strength or sensory perception.

Signs:

1) Few or all of the pre-existing skin patches or plaques become

erythematous, swollen and may be tender

2) New crops of inflamed skin lesions in the form of plaques may appear in

previously clinically uninvolved skin lesions.

3) Neuritis of one or more peripheral nerves is common

4) Edema of the face or extremities

5) Sometimes loss of nerve function occurs suddenly without other signs of

inflammation, the so called ‗silent neuritis‘

6) Tinel sign may be positive, i.e. pressure exerted on the nerve gives distally

a tingling pain.

Rarely, tenosynovitis of dorsum of hands or foot, necrosis and deep

ulcerations, systemic manifestations like fever, malaise, vomiting, epistaxis and

joint pain may occur.88

34

GRADING OF REVERSAL REACTIONS:

Reversal reactions (RRs) can be graded as mild or severe in form

Mild

Few skin lesions showing features of reaction clinically, without any nerve

pain or loss of function.

Severe

- Nerve pain or paresthesia

- Increasing loss of nerve function

- Fever or discomfort

- Edema of hands, feet

- Reaction of skin lesion on the face

- Mild reaction persisting for more than 6 weeks

- Ulcerative skin lesion.

Criteria for diagnosis of type 1 reaction (T1R)

Major :

Pre-existing and/or new skin lesions become inflamed, red and swollen

Minor :

One or more nerves become tender and may be swollen

Crops of new lesions appear

Sudden edema of face and extremities

35

Recent loss of sensation in hands and feet or signs of recent nerve damage

(loss of sweating, sensation, muscle strength) in an area supplied by a

particular nerve

It requires the presence of 1 major criteria or, atleast 2 minor criteria

(without signs of ENL) for the diagnosis of T1R89

Course

If properly and adequately treated, T1R seldom persists for more than a

few months. Inadequate therapy is usually associated with recurrences.

TYPE 2 REACTION (T2R)/ ENL:

Type 2 reaction, known as ENL is an immune complex syndrome that is

seen mainly in BL and LL spectrum. Patients with high bacillary index are more

prone to get ENL.90

―ENL‖ is used as an alternative term for T2R because, the

major lesions on the skin are of erythema nodosum type.

Immunopathogenesis:

There is minimal increase in the number of lymphocytes, mainly of CD4+

Th2 subtype.91

M. leprae antigens, IgG, IgM antibodies, complement (C3d) and

IL-4 mRNA are all identified in ENL lesions. There are evidences showing

involvement of both immune complexes and cell mediated immunity in ENL. The

major cytokines present during ENL reaction are IL-4, IL-5, TNF-α, and INF-γ.92

36

HISTOPATHOLOGY:

There is dense infiltration of the superficial and/or deep dermis and/or

subcutaneous tissue by neutrophils (sometimes forming microabcesses).

Vasculitis is a predominant feature in some cases. Damage to collagen and elastic

fibers is commonly seen.

Clinical features:

Type 2 reaction occurs mostly during the course of antileprosy treatment. It

is characterized by sudden appearance of crops of skin lesions in the form of

painful/tender evanescent papules, nodules or plaques of variable size, associated

with constitutional signs and symptoms. ENL lesions may appear deep in the

dermis and subcutaneous tissue and these lesions may not be clinically apparent

on the skin surface. The common sites of ENL are outer aspects of thighs, legs

and face. However, they may appear anywhere on the skin except the warmer

areas of the body, scalp, axillae, groin and perineum. They are distributed

bilaterally and symmetrically. Uncommonly ENL lesions may be vesicular,

pustular, bullous and necrotic and break down to produce ulceration called,

erythema nodosum necroticans.93,94

Over a period of 24–48 hours, an individual

ENL lesion shows a color change from pink/red to bluish and in a week or 10

days, it become brownish and finally dark. The ENL lesions subside with

desquamation

Systemic disturbance is usual in ENL. Some of the signs and symptoms

that are commonly associated with ENL are fever, malaise, nerve pain, muscle

37

pain (myositis), periosteal pain, pain and swelling of joints, rhinitis, epistaxis,

painful dactylitis, acute iritis, acute epididymo-orchitis, tender lymphadenopathy,

hepatosplenomegaly and proteinuria.

GRADING OF TYPE 2 REACTION:

Type 2 reaction is graded as mild or severe in form. With the presence of

following symptoms, the reaction is considered severe.95

- Multiple red, painful nodules in skin, with or without ulceration

- Ulceration/necrosis of the skin lesions

- Neuritis involving one or more nerves

- Constitutional symptoms like fever, arthralgia

- Marked edema of the limbs and face

- Eye involvement (pain/tenderness of eye, with or without loss of visual

acuity)

- Recurrent ENL (Four or more episodes in a year)

- Tender lymphadenopathy

- Systemic involvement like epididymo-orchitis

- Persisting long even with oral steroids

38

CLINICAL TESTS

Certain clinical tests give clue for diagnosis of T2R

Ryrie Test:

Stroking the sole of the foot with the back of a reflex hammer elicits a

burning pain which may be noticed when watching the patient walk, that seems as

if he is walking on hot coals

Ellis Test:

Squeezing the wrist elicits a painful reaction; this does not occur in RRs

unless the radial cutaneous nerve is tender

Criteria for diagnosis of T2R

It may be used for research purpose, proposed by Naafs and his team

includes one major criterion or at least three minor criteria.

Major:

Sudden eruption of erythematous tender red papules, nodules or plaques,

which may ulcerate

Minor:

- Fever

- Tender enlarged nerves

- Increased loss of sensation or muscle power

- Arthritis

- Lymphadenitis

39

- Epididymo-orchitis

- Iridocyclitis or episcleritis

- Edema of extremities or face

- Positive Ryrie or Ellis test

THE LUCIO PHENOMENON

This is a special type of reaction observed in Lucio leprosy, which is an

untreated, uniformly diffuse infiltrative, non-nodular form of LL. It is chiefly

encountered in Mexicans.96

It is associated with massive infiltration of the

endothelium by M. leprae resulting in necrosis.97

DISABILITY IN LEPROSY AND ITS GRADING:

Neuritis in leprosy if unattended, can result in a wide range of nerve

function impairment (NFI) especially of hands, feet and eyes, ultimately leading

to anesthesia, muscle weakness, deformities and resultant disabilities. The WHO

proposed deformity grading of these impairments in 1988. Each limb and eye

should be assessed and classified separately.

WHO disability grading with its modifications98

Hands and feet

Grade 0 - No anesthesia and no visible deformity/damage

Grade 1 - Anesthesia is present but no visible deformity/damage

Grade 2 - Visible deformity/damage is present

40

Eyes

Grade 0 - No eye problem and no evidence of visual loss due to leprosy

Grade 1 - Eye involvement due to leprosy is present, but without severely

affecting the vision (vision 6/60, can count fingers at 6 meters)

Grade 2 - Severe visual impairment (vision < 6/60, inability to count

fingers at 6 meters. It also includes lagophthalmos, iridocyclitis and corneal

opacities)

The highest leprosy deformity grade for any part of the body should be

taken as overall deformity grading for the patient. The best ways to prevent

disabilities is early diagnosis and prompt treatment of leprosy and leprosy

reactions.

CHEMOTHERAPY OF LEPROSY

In 1981, World Health Organization (WHO) lauched multidrug therapy

(MDT), containing the powerfully bactericidal drug rifampicin and either one or

two additional drugs to replace dapsone monotherapy.99

MDT for Paucibacillary cases (PB-MDT):

Duration: 6 months dosage, to be completed within a period of 9 months

Adults:

Rifampicin 600 mg and dapsone 100 mg as monthly supervised dose and

Daily self-administered dose of dapsone 100 mg

41

Children (10-14 years):

Rifampicin 450 mg and dapsone 50 mg as monthly supervised dose

Daily self-administered dose of dapsone 50 mg

Children (<10 years):

Rifampicin 10mg/kg and dapsone 2mg/kg as monthly supervised dose and

Daily self-administered dose of dapsone 2mg/kg

MDT for Multibacillary cases (MB-MDT):

Duration: 12 months dosage, to be completed within a period of 18 months

Adults:

Rifampicin 600 mg, clofazimine 300mg and dapsone 100 mg as monthly

supervised dose and

Daily self-administered dose of dapsone 100 mg and clofazimine 50mg

Children (10-14 years):

Rifampicin 450 mg, clofazimine 150mg and dapsone 50 mg as monthly

supervised dose

Daily self-administered dose of dapsone 50 mg and clofazimine 50mg

Children (<10 years):

Rifampicin 10mg/kg, clofazimine 6mg/kg and dapsone 2mg/kg as monthly

supervised dose

Daily self-administered dose of dapsone 2mg/kg and clofazimine

1mg/kg100

42

MANAGEMENT OF REACTIONS:

MILD REACTIONS

Mild reactions are treated symptomatically without steroids. Reassurance

to the patient as well as to family members is very important.

Treatment includes:

MDT: Start MDT, if person has come for the first time. Patients must be

continued on anti-leprosy treatment (MDT) along with the drugs for managing

reactions. Those who are released from treatment do not need anti-leprosy

treatment.

Analgesics and Anti- inflammatory agents: Mild cases of both the types

of reactions can be managed symptomatically with analgesics and anti-

inflammatory drugs such as aspirin (Adult dose 600 mg, given upto 6 times a day)

and other NSAIDs like paracetamol (adult dose 1 gm, upto 4 times a day)

MANAGEMENT OF SEVERE REACTION

If any of the features of severe reaction (mentioned above) are present,

treatment with steroids is necessary.

Management includes:

Bed rest: Admission and bed rest for few weeks duration as required

Rest to the affected nerve using splint: It is provided by use of static

splint. Splint is applied involving the joint that is in vicinity of the affected nerve.

43

Splinting prevents injury to the affected nerve which may occur due to repeated

movement of the joint. Affected portion is kept in the functional position while

applying splint. It is applied for 24 hrs and removed only for exercise. Initially,

gentle passive exercises are carried out for the splinted joint whereas the adjoining

joints are moved twice daily with full range of movement to avoid stiffness. Once

pain and inflammation subsides, passive exercises are started to maintain the

range of movements involving all the adjacent joints. Later, active exercises are

started to restore strength of the affected muscle

Analgesics: Analgesics and anti-inflammatory drugs are given as required.

Prednisolone: Corticosteroids are the cornerstone of therapy and are

considered to be the drug of choice.

The usual adult dose of steroids to begin with, is 1 mg/kg of body weight

(BW). Duration of treatment varies from 12 weeks to 24 weeks depending on the

severity of reaction and response to therapy. If pain and inflammation of skin &

nerve subsides and there is no new nerve involvement, the dose of Prednisolone is

gradually tapered and eventually stopped.

Prednisolone is given in the following regime/doses:

Treatment with prednisolone is not linked to MDT i.e. It can be given after

adequate MDT is given and stopped

1) Start Tab. prednisolone dose at 1 mg/kg BW/day, which is given as a

single morning dose after breakfast.

44

- It has to be continued till improvement in skin lesions is visible/nerve

pain and tenderness subsides.

- Consider giving tab ranitidine 150 mg along with prednisolone

2) After the reaction is controlled, prednisolone is tapered by 5mg every 1—2

weeks.

- The crucial maintenance dose of prednisolone should be around 15–20

mg for several weeks/months.

3) In the follow-up period, the dose should be cut by 5 mg every 2–4 months.

Management of severe type 2 reaction

Oral corticosteroids:

Oral steroids constitute the first line armamentarium in the management of

severe T2R. They act by inhibiting both the early and late phases of inflammation.

World Health Organization (1998) recommends prednisolone for severe ENL

reaction in doses similar to that given for RR.

Prednisolone should be started in a dose of 1 mg/kg/day. This dose is

continued till clinical improvement, then the dose is tapered every week by 5–10

mg over a period of 6–8 weeks. A maintenance dose of 20–30 mg/day for several

weeks may be needed to prevent recurrent reactions. Quick response to

prednisolone is observed in most of the cases in the first attack of T2R. Tapering

the dose of steroid is often associated with recurrence of reaction.

Patients with T2R have increased risk of becoming steroid dependent

because of its chronic course. Persons who cannot be weaned from steroids and

45

those who suffer from persistent ENL need drugs other than prednisolone like

higher doses of clofazimine or thalidomide for the management of the reaction.

Clofazimine:

Clofazimine is less potent than steroids. It often takes 4 – 6 weeks to

develop its full effect; it is extremely useful in reducing or withdrawing

corticosteroids in steroid dependent patients. Total duration of clofazimine

therapy should not exceed 12 months.

Clofazimine is given with corticosteroids in the following regime:

- One capsule (100mg) 3 times a day x 12 weeks

- One capsule (100mg) 2 times a day x next 12 weeks

- One capsule (100mg) once a day x next 12 wks

Thalidomide:

Although thalidomide is considered as treatment of choice for the

management of severe T2R, it is kept as second option due to several reasons like

its teratogenic effects, difficulty in monitoring, cost and nonavailability at all

places. Thalidomide seems to suppress all clinical manifestations of T2R within

48–72 hours. The drug acts faster and it is more effective than aspirin, clofazimine

and pentoxyphylline. Thalidomide shows better improvement and less recurrence

rate compared to steroids. Thalidomide is essentially nontoxic and well-tolerated

even during long-term administration and hence can be tried as a complimentary

medication for tapering the steroid dose.

46

Start thalidomide at a dose of 400 mg at bedtime or 100 mg, four times

daily. This dose controls the reaction within 48 hours in most of the cases. The

dose is then reduced slowly by 100 mg each month. During this period, the patient

should be regularly assessed and should be stabilized on the lowest dose that

controls the symptoms. Continue at this dose for a period of 2–3 month.

IMMUNONOLOGICAL INTERVENTION:

The manifestations of the disease varies and it largely depends on the

immune response of the host. Majority of the individuals exposed to the organism

do not manifest the disease, and/or in a few cases self heal. However a small

proportion of the exposed individuals manifest the disease in the skin and/or in the

peripheral nerves101

.

The present day multidrug therapy (MDT) has brought down the

prevalence of disease substantially. However, new cases are still being reported

globally which needs to be addressed for ultimate eradication of the disease. MDT

kills most of the susceptible live organisms but ―persisters‖/ metabolically

dormant bacilli and dead organisms remain in the body for long and variable

duration. Presence of such dormant and dead bacilli can precipitate a leprosy

reaction, nerve damage and resultant deformities. Therefore, besides MDT which

primarily targets the live organisms, immune modulators are required to modulate

the immune response in the host.

47

Vaccines/ immunomodulators are biological substances that improve the

immunity to a particular disease. They are antigenically similar to the pathogen

and are capable of evoking an immune response in the host.

They are broadly classified as:

1) Killed vaccines – Use killed organisms that have lost its infectivity but

retains its antigenicity to provoke an immune response

2) live attenuated vaccines - provoke a protective response in the host, but do

not cause disease per se

3) Vaccines using antigenically related nonpathogenic organism – they cross-

react with the pathogen and hence are able to evoke an immune response in

the host

4) Immunogenic ―subunit(s)‖ of the organism - prepared by recombinant

DNA technology

Factors that may influence the protective efficacy of the vaccine are,

1) Route of administration

2) Age of the recipient at the time of vaccination

3) Nutritional status of the recipient

4) Coverage of vaccination in the population

5) Duration of follow-up

6) Endemic diseases in the population

48

Immunoprophylaxis:

Immunoprophylactic agents or vaccines that have the capacity to provoke

an immune response, enabling the host to effectively deal with the infecting

organism and thereby reduces the frequency of development of the disease. It also

includes procedures to boost the immune response after infection to prevent the

progression of clinical disease.

Immunotherapy:

Immunotherapy implies immunological intervention in patients with

established clinical disease. Even though the present day MDT is very effective in

the management of leprosy, certain problems do remain and those include:

- Relatively long duration of treatment

- Strict adherence to the treatment regimen

- Occurrence of reactions and nerve damage before, during and as well as

after treatment

- Persistence of disease activity after stoppage of therapy

- Relapses and recurrences

The addition of immunotherapy to chemotherapy has been considered to

overcome the above deficiencies and optimize the treatment102

. It helps in,

1) Achieving more efficient killing of viable bacilli, including the

persisters

2) Faster clearing of dead bacilli and their components from the body

49

3) Reducing the incidence and severity of reactions

4) Restoring effective immunity so that relapses/reinfection can be

prevented

In leprosy, procedures for immunotherapy and immunoprophylaxis are

often similar. Vaccines which have been tried in general population for leprosy

are,

1) Bacillus Calmette-Guerin: Bacillus Calmette-Guerin (BCG),

2) Bacillus Calmette-Guerin + killed M. leprae

3) Mycobacterium indicus pranii (MIP)

4) Indian Cancer Research Centre

5) Mycobacterium vaccae

ANTIGENICALLY RELATED MYCOBACTERIA

These are mycobacteria that share some antigens or show cross reactivity

with M. leprae.

M. bovis BCG (Bacillus Calmette-Guerin):

Bacillus Calmette-Guerin (BCG), a live attenuated vaccine prepared from a

strain of Mycobacterium bovis has been used worldwide for prevention of

mycobacterial diseases: tuberculosis and leprosy. The original strain of M. bovis

BCG strain was developed in 1921 at the Pasteur Institute with attenuation

through serial passage of an isolate from a cow with tubercular mastitis. Animal

studies using mice demonstrated the protective efficacy of BCG against M.

leprae.103

Later it was found to be useful in humans also.104,105

50

BCG, as an anti-leprosy vaccine was tried in Karinaul, Papua, New Guinea

and was reported to be efficacious.106

It has shown both nonspecific, as well as

specific immunomodulatory effects in leprosy. Studies have shown enhanced

bacterial killing and clearance in borderline lepromatous (BL)/ lepromatous

leprosy (LL) smear positive patients treated with combination of standard MB-

MDT and BCG. In one study, BCG was given along with MDT every 6 months

till the end of treatment.107,108,109

There was faster bacteriological clearance, more

rapid killing of viable bacilli as observed by mouse foot pad inoculation and

adenosine triphosphate (ATP) estimation from tissue biopsies and decreased

incidence and severity of reactions in comparison with patients receiving MDT

alone. In Narang et al study, BCG exhibited slightly better and faster effect on

bacteriological clearance and clinical improvement as compared to Mw vaccine in

borderline lepromatous (BL)/ lepromatous leprosy (LL) patients.110

Adverse effects:

Globally BCG vaccine is used extensively. Despite this extensive use, few

severe adverse events have been reported. The diagnosis in few cases

(disseminated BCG infection) depends on culturing M. bovis BCG to distinguish

this from other forms of Mycobacterial disease.

Mild adverse events

Mild local reactions occur despite correct intradermal administration of the

vaccine and these may include,

51

1) Tender red papule in 2-4 weeks, which progress to an ulcer that heals in 2-

3 months

2) Superficial scarring

3) Swelling of the ipsilateral regional lymph nodes (usually axillary)

The extent of the reaction will depend on number of factors like, strain

used in the vaccine, number of viable bacilli in the batch and variation in injection

techniques. No treatment is required for mild injection site reactions with or

without mild regional lymphadenopathy

Severe adverse events

Local

1) Injection site reactions - subcutaneous abscess and Keloid

2) Lymphadenitis

3) Suppuration (onset 2-6 months)

Systemic (1-12 months onset time)

1) Cutaneous skin lesions111

2) Osteitis and osteomyelitis

3) Disseminated BCG infection112

4) Immune Reconstitution Syndrome113

5) Rare side effects : sarcoidosis, erythema nodosum, ocular lesions

(conjunctivitis, choroiditis, optic neuritis), tuberculous meningitis

52

Mycobacterium indicus pranii (MIP):

MIP is a rapid growing, saprophytic, cultivable mycobacteria belonging to

Runyon Group IV classification of mycobacteria. It was initially isolated from a

lepromatous patient. It is administered as a killed vaccine. It shares several

antigens with M. leprae and M. tuberculosis.114

Its immunomodulatory effect has

been tested in vitro and in experimental animals.115

This vaccine has also been

tried in humans.

The whole genome has recently been sequenced. It is safe and well

tolerated. Blister/nodule formation may appear at the local site of inoculation in

3–4 weeks which heals by its own in another 6–8 weeks. Studies have shown

earlier achievement of smear negativity, a more rapid bacterial clearance, rapid

killing of viable bacilli and histological upgrading when the vaccine is

administered along with MDT compared with MDT alone.116

ICRC Vaccine:

This is a cultivable mycobacteria probably belonging to M. avium

intracellulare (MAI) complex. This organism was isolated from leprosy patients.

It showed cross-reactive antigens to M. leprae in both in vitro and in vivo

experiments. It has also been tried in humans with reported beneficial

effects.117,118

The authors observed that, this vaccine also achieved a significant

and rapid fall in BI when given to lepromatous patients along with chemotherapy.

53

Mycobacterium vaccae:

It is a rapidly growing, nonpathogenic mycobacteria. This organism also

shares some antigens with M. leprae and M. tuberculosis. It has been shown to

induce immune reactivity in leprosy patients both in vitro and in vivo.119

It is

administered as a killed vaccine intradermally in the dose of 108 organisms/ml.

The vaccine is safe and well tolerated. It produces a scar similar to that seen with

BCG. Its immunomodulatory effects were enhanced when combined with BCG.

BCG with killed M. vaccae is likely to be a better vaccine for leprosy than BCG

alone.120

Other organisms:

There are few other mycobacteria which possess some antigenic similarity

with M. leprae and has shown some degree of cross-sensitization. These include

M. habana,121

M. phlei and M. gordonnae. These mycobacteria have not been

adequately investigated as immunotherapeutic agents for use in leprosy.

54

AIM & OBJECTIVE

OBJECTIVE / AIM

To study the Immunomodulatory efficacy of BCG administered along with

MB-MDT in Multibacillary leprosy patients

Materials & Methods

55

METHODOLOGY

Study design:

Interventional study

Place of study:

Department of Dermatology,

Madras Medical College & Rajiv Gandhi Government General Hospital,

Chennai- 3.

Period of study:

One and half years (December 2017- May 2019)

Sample size: 30

Inclusion criteria:

All untreated (newly diagnosed) and less than 3 months treated

Multibacillary leprosy cases of age group 15-70 years.

Exclusion criteria:

1. Children < 15 years, elderly patients > 70 years

2. Pregnant and lactating women

3. History of pulmonary tuberculosis/ other systemic illness such as

Uncontrolled hypertension, Uncontrolled Diabetes mellitus, cancer, renal,

hepatic and cardiac disease.

4. HIV positive patients

56

SCREENING PROCEDURES/VISITS:

All untreated newly diagnosed and less than 3-month treated multibacillary

leprosy patients (BB, BL and LL Hansen) attending Hansen OPD were included

in the study.

The details of the study undertaken were properly explained to the patients

selected for the study and consent was obtained from them assuring

confidentiality.

Detailed case history of each patient with reference to the disease onset,

symptoms, duration of illness, history of drug intake and other co-morbidities

were noted.

General examination of the patient was done. Following this, cutaneous

examination was done to look for the number, size and extent of the

hypopigmented patches, infiltrated plaques and nodules. Scoring was done using

Ramu’s clinical scoring system based on the morphology of skin lesions. In this

scoring system, body was divided into seven regions – face, head and neck, chest

and abdomen, right and left upper limbs, right and left lower limbs. Each region

was scored independently as follows.

Score 1 - Predominantly macular lesions

Score 2 - Diffuse infiltration

Score 3 - Few papules or plaques

Score 4 – Papulo-nodular lesions

57

Temperature, touch and pain sensations were tested over the skin lesions

and extremities. Peripheral nerves were examined for thickening, tenderness and

for the presence of any nerve function impairment. Patients were examined for

trophic changes like ichthyosis, callosities, blisters, non-healing fissures and

ulcers. Then, oral mucosal examination was done to look for nodular infiltration,

restricted movement/destruction of uvula and macrochelia. Nasal mucosa was

examined for nasal crusts, septal perforation, thickening and destruction of

inferior turbinate. Ocular examination was done for madarosis, lagophthalmos,

iridocyclitis, keratitis and corneal ulcer. Examination of musculoskeletal system

for the presence of any abnormality of facial contour, weakness and deformities in

the extremities was done. External genitalia was examined for size, consistency,

tenderness of the testicles along with testicular sensation. Following this systemic

examination was done.

Then, all patients was subjected to slit skin smear examination. SSS was

done from hypopigmented patches, infiltrated plaques, nodules and both ear lobes

depending upon the clinical presentation of the patients. Slide was stained using

Ziehl Neelson technique and examined under oil immersion(100X) for the

presence of acid fast bacilli. Bacteriological index was determined using Ridley

Jopling logarithmic scale.

Blood investigations including complete blood count, liver function test,

renal function test, urine routine analysis, VCTC and VDRL were taken.

58

Skin biopsy was done for all patients. On histopathological examination,

granuloma fraction was estimated using ImageJ software and measured in

microns.

The patients were randomly allocated into two groups.

- One group received MB-MDT WITH BCG at 3 months interval (4 doses)

- 0.1mg in 0.1ml injected intradermally

- Other group received MB-MDT alone (without BCG) serves as control.

All clinical, histological and bacteriological parameters were assessed

periodically and compared in both groups.

FOLLOW UP PROCEDURES/VISITS:

Patients enrolled in the study group were given four doses of BCG vaccine

at 3 monthly interval. Control group patients were given MD-MDT alone. All the

patients were educated about side effects of MDT and the features of reaction.

Study group patients were explained about the adverse effects of the vaccine and

asked to report for any adverse effects.

All patients were followed up every month.

Disease activity is assessed clinically every 3months by Ramu‘s clinical

scoring system. Occurrence and type of reaction both before and after the

intervention and severity of reactions were recorded and graded.

Slit skin smear was taken initially and then at 6months and 12months of

starting treatment from the same site.

59

Skin biopsy was taken initially at the onset of the study from the most

representative skin lesion and after 12months of treatment from the same

site.

If the patient was found to suffer from reactions, then based on the severity,

patient was treated. In case of mild reaction, analgesics were prescribed.

For severe reactions, systemic corticosteroids was started along with other

supportive measures. They were advised to review every 2 weeks till

resolution of symptoms.

STATISTICAL ANALYSIS:

The data collected was analysed in Microsoft Excel. This data was

exported to IBM Statistical Package for Social Sciences software (SPSS) version

23.0. Mean, standard deviations (SD) and range were used for continuous

variables, while for dichotomous variables frequency distributions were obtained.

Independent sample T test was done to analyze difference in the response among

various groups.

ETHICAL ISSUES:

Institutional ethics committee of Madras Medical College reviewed the

study proposal for ethical consideration and approval of the committee was

obtained prior to the study.

Observations & Results

60

OBSERVATION AND RESULTS

Analysis of following parameters were made.

1) Clinical assessment using Ramu‘s clinical scoring system

2) Slit skin smear for Bacteriological Index

3) Skin biopsy for granuloma clearance

4) Occurrence and type of reaction

STUDY DEMOGRAPHY

The study involved 30 untreated, newly diagnosed patients having

multibacillary leprosy (BB,BL and LL) with 15 patients each in Group A (Study

group) and Group B (Control group)

61

Table 1: Age group

Age(Years) N (%)

20-30 9

30-40 6

40-50 5

50-60 3

>60 7

Age distribution of the sample ranged from 21 to 70 years. The mean age

of the sample is 42.2 years.

The mean age of patients in each group is similar (37.07 ± 13.57 in the

Study group and 47.33 ± 16.15 in the Control group)

0

1

2

3

4

5

6

7

8

9

20-30 30-40 40-50 50-60 >60

9

6

5

3

7

No

.of

pat

ien

ts

Age

AGE DISTRIBUTION

62

Table 2: Gender

Group Male Female

Study group 9 6

Control group 12 3

TOTAL 21(70%) 9(30%)

Males outnumbered females with the ratio of 2.3:1 in the study which

included 21 males and 9 females

70%

30%

SEX DISTRIBUTION

MALE FEMALE

63

Table 3: Distribution of patients in each spectrum based on gender

Among 21 males, 9 patients were LL, 9 were BL and 3 were BB. Among 9

females, 4 were LL, 4 were BL and the remaining one was BB

0

2

4

6

8

10

BBBL

LL

3

9 9

1

4 4

No

. of

pat

ien

ts

Spectrum

GENDER DISTRIBUTION BASED ON SPECTRUM

MALE

FEMALE

GENDER BB BL LL TOTAL

MALE 3(14%) 9(43%) 9(43%) 21(100%)

FEMALE 1(12%) 4(44%) 4(44%) 9(100%)

64

Table 4: Spectrum

Spectrum Study group Control group Total no of cases

(%)

LL 4 9 13 (43%)

BL 8 5 13 (43%)

BB 3 1 4 (13%)

4

13

13

SPECTRUM

BB

BL

LL

65

Among 30 patients, 13 cases were LL, 13 cases were BL and 4 were BB.

In this, 8 patients in the Study group and 5 patients in the Control group were BL,

4 Study group patients and 9 Control group patients were LL, 3 Study group

patients and 1 Control group patient were BB.

0

1

2

3

4

5

6

7

8

9

LL BL BB

4

8

3

9

5

1

No

of

pat

ien

ts

Spectrum

DISTRIBUTION OF PATIENTS IN EACH SPECTRUM

Study group Control group

66

OUTCOME ANALYSIS:

Table 5: Initial status of the patients in both groups

The clinical scores, BI and histological parameters at the start of treatment

were analysed. It was observed that the patients in both the groups were

comparable by all of these parameters

0 10 20 30 40 50

Mean clinical score

Mean BI

Granuloma fraction

16.53

3.93

46.17

16.4

4.13

42.13

BASELINE VALUES OF PARAMETERS IN BOTH GROUPS

MDT ALONE (Control group) MDT + BCG (Study group)

Group No. of patients Mean clinical

score Mean BI

Granuloma

fraction

MDT + BCG

(Study group) 15 16.53 3.93 46.17

MDT ALONE

(Control group) 15 16.40 4.13 42.13

67

GROUP A (STUDY GROUP, MDT+BCG):

Table 6: Clinical scores (mean) before, during and after treatment

Study group Initial After

3 months

After

6 months

After

12 months

Mean score 16.53 13.93 10.60 7.80

16.53

13.93

10.6

7.8

0

2

4

6

8

10

12

14

16

18

0 3 6 12

cln

ical

sco

re

Months

REDUCTION IN CLINICAL SCORE - STUDY GROUP

68

Table 7: Bacteriological index (mean) before, during and after treatment

Study group Initial After 6 months After 12 months

Mean BI 3.93 2.53 1.33

The mean clinical score of the patients in this group was 16.53; the BI was

3.93. At 3 months after the first vaccination, there was no appreciable fall in

clinical score. At 6 months, the clinical score fell to 11 and the mean BI was 2.53.

At 12 months, the clinical score fell to 7.80 and the mean BI was 1.33.

3.93

2.53

1.33

0

1

2

3

4

5

6

0 6 12

Clin

ical

sco

re

Months

REDUCTION IN BI - STUDY GROUP

69

Table 8: Granuloma fraction (GF) (mean) at baseline and after treatment

Study group Initial After 12 months

Mean GF(microns) 46.17 11.07

The mean granuloma fraction in study group was 46.17. All patients in

study group showed significant reduction in the GF. The mean GF at the end of 12

months was found to be 11.07

0

10

20

30

40

50

1

2

46.17

11.07

Gra

nu

lom

a fr

acti

on

(GF)

Time(months)

REDUCTION IN GF OVER TIME - STUDY GROUP

Mean GF

70

Table 9: Occurrence of reactions in Study group during the course of the

study

Reaction No. of patients

Type 1 reaction 5

Type 2 reaction 2

No reaction 8

During the course of the study, the number of patients who experienced

type 1 reaction were 5 (33%) and type 2 reaction were 2(14%).

Neuritis (associated with both T1R and T2R) was seen in two patients.

5

2

8

OCCURENCE OF REACTIONS IN STUDY GROUP

type 1 reaction type 2 reaction no reaction

71

Table 10: Time of occurrence of reaction

Time No of patients

Type 1 reaction Type 2 reaction

0 2 1

<3months 1 0

3-6 months 2 1

6-12 months 2 1

Type 1 reaction was present in two patients and type 2 reaction, in one

patient at the time of presentation. 3 patients (2 BB and 1 BL) developed type 1

reaction within 6 months and 2 patients (BL) after 6 months of treatment. Type 2

reaction was seen in two LL patients after 3 months of treatment. All the patients

who developed reaction either type 1 or type 2, had only one episode of reaction.

0

1

2

3

0 <3 3-6M 6-12M

2

1

2 2

1

0

1 1

NO

. OF

PA

TIEN

TS

MONTHS

OCCURENCE OF REACTIONS WITH TIME - STUDY GROUP

TYPE 1 TYPE 2

72

Three patients had grade II deformities at the time of initial presentation.

None of the patients in study group developed any new deformities during the

course of the study.

EFFECTS OF VACCINATION:

All the patients in study group developed an erythematous papule at the

site of BCG vaccination, which progressed to a shallow ulcer, that healed

spontaneously in 3-4 weeks with scar formation. No systemic adverse effects of

vaccination were observed

GROUP B (CONTROL GROUP, MDT ALONE):

Table 11: Clinical scores before, during and after treatment

Group Initial After

3months

After

6 months

After

12 months

Control group 16.40 14.07 11.93 9.93

16.4

14.07

11.93

9.93

0

2

4

6

8

10

12

14

16

18

0 3 6 12

Clin

ical

sco

re

Months

REDUCTION IN CLINICAL SCORE - CONTROL GROUP

73

Table 12: Bacteriological index (BI) before, during and after treatment

Group Initial After 6 months After 12 months

Control group 4.13 3.07 2.20

The mean clinical score of the patients in this group was 16.40; the BI was

4.13. At 3 months after the first vaccination, there was no appreciable fall in

clinical score same as seen in study group. At 6 months, the clinical score fell to

12 and the mean BI was 3.07. At 12 months, the clinical score fell to 10 and the

mean BI was 2.20.

4.13

3.07

2.2

0

1

2

3

4

5

6

0 6 12

Clin

cal s

core

Months

REDUCTION IN BI - CONTROL GROUP

74

Table 13: Granuloma fraction (GF) at baseline and after treatment

Control group Initial After 12 months

Mean GF

(microns) 42.13 12.93

The mean granuloma fraction in study group was 42.13. All patients in

control group also showed reduction in the granuloma fraction except few

patients. Thus, at the end of 12 months, the mean GI was found to be 12.93.

0

20

40

60

0

12

42.13

12.93

Gra

nu

lom

a fr

acti

on

(GF)

Time(months)

REDUCTION IN GF OVER TIME - CONTROL GROUP

75

Table 14: Occurrence of reactions in C ontrol group

Reaction No. of patients

Type 1 reaction 3

Type 2 reaction 5

No reaction 7

During the course of the study, the number of patients who experienced

type 1 reaction were 3 (20%) and type 2 reaction were 5 (33%). Neuritis

(associated with both T1R and T2R) was observed in 4 (50%) patients.

3

5

7

OCCURENCE OF REACTIONS IN CONTROL GROUP

type 1 reaction type 2 reaction no reaction

76

Table 15: Time of occurrence of reaction

Time No of patients

Type 1 reaction Type 2 reaction

0 2 3

<3months 0 1

3-6 months 1 2

6-12 months 2 2

Two patients presented with type 1 reaction and three patients with type 2

reaction at the time of presentation. One patient with BL Hansen developed type 1

reaction within 6 months. One patient with LL and one with BL developed type 1

reaction after 6 months. All 5 patients who developed type 2 reaction were LL.

Out of these five patients, two had recurrent episodes of reaction.

Three patients had grade II deformity at the time of initial presentation and

2 patients developed grade II deformity during the course of study.

0

1

2

3

4

5

0 <3 3-6M 6-12M

2

0

1

2

3

1

2

2

NO

. OF

PA

TIEN

TS

MONTHS

OCCURENCE OF REACTIONS WITH TIME - CONTROL GROUP

TYPE 1 TYPE 2

77

STATISTICAL COMPARISON OF BOTH GROUPS

In this study, statistics was presented by N, Mean and Standard deviation

for quantitative data. For qualitative data, frequency count N and percentage were

used. The data were analyzed using Independent samples T test.

P value < 0.01 – highly significant

P value < 0.05 – Significant

Table 16: Comparison of clinical score (mean+SD) in both groups

Group BASELINE

At 3 months At 6 months At 12 months

Score Reduction Score Reduction Score Reduction

Study

group

16.53

±

3.74

13.93

±

3.28

2.87

±

0.92

10.60

±

3.02

5.93

±

1.79

7.80

±

3.00

8.60

±

2.10

Control

group

16.40

±

4.07

14.07

±

4.01

2.33

±

0.72

11.93

±

3.69

4.47

±

1.06

9.93

±

3.47

6.47

±

1.51

78

A reduction in the values of Ramu's clinical scores was noted in both

groups during therapy. There was no appreciable change of scores at 3 months in

both the groups (P value>0.05), but the change was noticeable from 6 months.

Reduction in the clinical score was more marked in the Study group than in the

Control group both at 6 and 12 months. The differences in the two groups were

statistically significant both at 6 months (P value = 0.01) and 12 months

(P value < 0.01)

16.53

13.93

10.6

7.8

16.4

14.07 11.93

9.93

0

2

4

6

8

10

12

14

16

18

0 3 6 12

Clin

ical

sco

re

Months

MEAN REDUCTION IN CLINICAL SCORE OVER TIME

Study group Control group

79

Table 17: Comparison of bacteriological index (mean+SD) in both groups

There was no significant difference in the baseline BI scores between the

two groups. Both groups showed reduction in the BI at 6 months, but it is not

statistically significant. At 12 months the patients in the study group still had

significantly greater reduction in BI than the control group. The mean reduction in

the study group at 12 months is 2.60, whereas in control group it is 1.93 which is

statistically significant (P value=0.01)

0

1

2

3

4

5

06

12

3.93

2.53

1.33

4.13

3.07

2.2

BI

Months

MEAN VALUE OF BI OVER TIME

Study group Control group

Group

BASELINE

At 6 months At 12 months

Score Reduction Score Reduction

Study

group 3.93±1.28 2.53±0.99 1.40±0.74 1.33±0.82 2.60±0.83

Control

group 4.13±0.99 3.07±0.88 1.07±0.59 2.20±1.08 1.93±0.59

80

Table 18: Comparison of granuloma fraction (mean+SD) between the groups

Group BASELINE

(microns)

AFTER 12 MONTHS(microns)

SCORE REDUCTION

Study group 46.17±8.44 11.07±4.29 35.09±7.73

Control group 42.13±10.84 12.93±4.83 29.20±7.69

Reduction in the granuloma fraction was noted in both the groups at the

end of 12 months. The reduction in the study group was 35.09±7.73 and in the

control group, it was 29.20±7.69. The study group showed significant reduction in

GF (P value < 0.05).

0

10

20

30

40

50

0 12

46.17

11.07

42.13

12.93

Gra

nu

lom

a fr

acti

on

Time(months)

MEAN GF BEFORE AND AFTER TREATMENT IN BOTH GROUPS

Study group Control group

81

Table 19: Incidence of type 1 and type 2 reaction in both groups after

starting therapy

GROUP Type 1 reaction Type 2 reaction

Study Group 5 2

Control Group 3 5

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Type 1 Type 2

5

2

3

5

No

of

pat

ien

ts

Reaction

INCIDENCE OF REACTIONS IN BOTH GROUPS

Study group Control group

82

Type 1 reactions were seen more frequently in the Study group than the

control group. Five (33%) patients of the Study group showed type 1 reaction

compared to three (20%) patients of the control group. Duration of type 1 reaction

in both the groups were between 3-8 months of therapy.

Type 2 reactions occurred more frequently in the Control group. Five

(33%) patients from the Control group had type 2 reaction compared to two (13%)

patients in the Study group.

Clinical Images

CLINICAL IMAGES

Ear nodules in a LL patient Ichthyosis of bilateral lower limbs

in a LL patient

Pre treatment :

Multiple skin colored

nodules over the dosrsum

of the hand in a BCG

vaccinated patient

At 3 months of

treatment

Post-treatment –

at 12 months

Pre treatment

Borderline lepromatous leprosy

showing multiple infiltrated plaques

and few nodules (Study group)

Post treatment

Same patient at 12 months showing,

complete clearance of lesions

Pre-treatment SSS with BI 6+

(BCG Vaccinated patient)

Post treatment SSS

of same patient with BI 2+

10X

40x

Pre-treatment Skin biopsy of a LL patient in BCG vaccinated group

showing diffuse granulomatous infiltrate composed of

foamy macrophages, histiocytes and few lymphocytes

Post Treatment - Skin biopsy of same patient after 1 year,

showing complete clearance of the granuloma

10X

40x

Pre-treatment Skin biopsy of a LL patient in Control group showing diffuse

granulomatous infiltrate, predominantly composed of histiocytes and foamy

macrophages

Post Treatment - Skin biopsy of same patient after 1 year,

showing reduction in the size of granuloma

Discussion

83

DISCUSSION

The present day multidrug therapy (MDT), composed of rifampicin,

clofazimine and dapsone has been very successful in the management of leprosy

and has significantly brought down the prevalence of disease. MDT kills most of

the susceptible live organisms but ―persisters‖/metabolically dormant bacilli do

remain and there are reports of fairly high relapse rate. The incapability to handle

these residual problems is perhaps due to a total or partial lack of effective cell-

mediated immunity against the disease.

Immunotherapeutic agents like vaccines are able to override the

immunological unresponsiveness to bacterial antigens by generation of Th1 type

clones and subsequent amplification of IFN-γ, with concomitant decrease in IL-10

and TNF-α. Therefore, in order to achieve faster killing of viable bacilli and

clearance of dead bacilli, immunotherapeutic agents (vaccines) are being

evaluated as an adjunct to chemotherapy/MDT.

The present study was planned to investigate the immunotherapeutic

efficacy of BCG along with MDT in previously untreated multibacillary patients.

It was analysed using certain parameters like clinical improvement,

bacteriological clearance, histopathologic changes and reaction pattern. After

detailed case history and clinical examination, the patients were randomly

allocated into two groups. The patients in both groups were comparable in all

84

these parameters. All the patients were available for follow up during complete

course of the study.

Acceptability:

In our study it was observed that the BCG vaccine was well tolerated.

Following vaccination, local reactions like erythematous papule and ulceration

developed in all patients. No systemic adverse effects were seen due to

vaccination.

Clinical Score:

Clinical improvement was noted in both groups which is reflected by fall in

the clinical scores associated with reduction in the infiltration and flattening of

papulonodular lesions. At 3 months, there was no significant difference in the

reduction of clinical scores between the groups. But, the reduction was

significantly more marked in the BCG group as compared to controls at 6 months

(P value < 0.05) and 12 months (P value < 0.01). Narang et al. study110

have

showed similar results of significant clinical improvement at 6 months and 12

months in BCG vaccinated patients, which is attributed to faster clearance of

bacilli due to the vaccine.

Bacteriological Index:

The average decline in BI with MDT has been reported to be 0.6 - 1

log/year.122

In our study, bacterial indices declined by 2.60 units/year in patients

receiving BCG and 1.93 units/year in the control group. The difference between

the Bl of the two groups was statistically significant at 12 months (P value =

85

0.003). The results are comparable with prior studies107, 110

which also reported a

significant fall in the BI at 12 months in BCG treated group.

Histopathological changes:

Reduction in the granuloma fraction was noted in all patients receiving

treatment. There was a reduction in the number of foam cells and macrophages

with appearance of epithelioid cells in few patients. BCG vaccinated patients

showed more marked reduction in the size of the granulomas compared to the

control group, which was statistically significant (P value<0.05) by 12 months.

This is in agreement with Narang et al. study110

, where much faster reduction in

the granuloma fraction was observed in the BCG group compared to controls.

Reactions:

The BCG vaccine seems to upgrade the CMI response, which was reflected

by frequent occurrence of type 1 reactions in the vaccinated patients. In our study,

33% patients of the Study group experienced type 1 reactions compared to 20%

patients in the Control group. All of these patients had only one episode of

reaction. Majority of the earlier studies have observed an apparent increase in the

incidence of reversal reactions in patients treated with Mw/BCG vaccines as

compared to the group given MDT alone.110, 116

Type 2 reactions/ENL are immune complex mediated, and they occur in

the presence of M. leprae antigens. Fewer episodes of type 2 reactions were noted

by us in the Study group compared to the Control group (14% versus 33%). Two

86

patients in the control group developed recurrent ENL, despite adequate treatment

with MDT and steroids for reaction.

It was observed that incidence of neuritis (with both type 1 and type 2

reaction) was less in the study group (28%) compared to the control group (50%).

This is in concurrence with the observation by made by Talwar, et al.115

where the

control group patients experienced significantly more episodes of neuritis

compared to the M.w vaccine group. Similar observation was also made in Narang

et al. study which showed significant decrease in the incidence of neuritis in BCG

vaccinated group. The more efficient clearance of bacilli from the nerves may be

responsible for this observation.

New Deformites:

The overall deformity rate, according to the WHO criteria before starting

MDT, was 26.5%. In our study, the overall deformity rate at the time of

presentation was found to be 16.6%. No patients in the vaccine treated groups

developed any new deformity or deterioration of the pre-existing deformity, but

13% of patients in the control group developed grade 2 deformities during

treatment. Similar observations have been made in many of the previous studies

with combined chemotherapy and immunotherapy (Convit et al.123

and Narang

et al.110

).

87

Drug reactions:

One patient (control group) developed dapsone syndrome after one month

of MDT. But the patient didn‘t show classical features of dapsone hypersensitivity

like fever, rash. Instead, presented with features of hepatitis (elevated liver

enzymes and jaundice). Dapsone was stopped in this patient and continued with

other drugs.

LIMITATIONS OF THE STUDY:

1) Small sample size

2) As this study was carried out over a limited period of one and half years,

occurrence of reactions and relapse after RFT (release from treatment)

couldn‘t be assessed.

Conclusion

88

CONCLUSION

In our study, on evaluating the immunomodulatory efficacy of BCG vaccine in

multibacillary leprosy patients, certain parameters like clinical, bacteriological,

histological changes and reaction patterns were compared between the BCG

vaccine treated group (BCG+MB-MDT) and control group (MB-MDT alone).

Based on the above findings the following conclusions were made

Clinical improvement as measured by reduction in the clinical score is

faster in the study group, compared to the control group

Better bacteriological clearance in the study group as shown by reduction

in the BI

Significant histological improvement is noted in the study group than the

control group

Frequent occurrence of Type 1 reaction in the vaccinated patients which

reflects the upgradation of CMI response

Regarding the incidence of type 2 reaction, fewer episodes were seen in

study group compared to the control group

We also observed a decrease in the incidence of new deformities in study

group

89

Hence, based on the previous studies and as observed by our study, it is

seen that BCG proves to be an effective immuno-therapeutic tool in the

management of multibacillary leprosy patients with high smear positivity.

However larger studies with long term follow-up are necessary to confirm the

promising results seen in our patients.

MIP (Mycobacterium indicus pranii) vaccine was successfully introduced

under NLEP owing to its immunotherapeutic and immune-prophylactic effects.

BCG vaccine is cheap and it is freely available in all the health centers in India

(under Universal immunization program of Government of India), and the health

workers are well trained to administer the vaccine. Hence, BCG vaccine can be

considered a better option as it is cheap and easy available.

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Annexure

ABBREVIATIONS

WHO - World Health Organization

NLEP - National Leprosy Eradication Programme

SLAC - SPARSH Leprosy Awareness Campaign

AFB - Acid Fast Bacilli

TT - Tuberculoid leprosy

LL - Lepromatous leprosy

BT - Borderline Tuberculoid leprosy

BB - Mid Borderline leprosy

BL - Borderline Lepromtous leprosy

PCR - polymerase chain reaction

DDS - Dapsone

ILEP - International Federation of Anti-Leprosy Associations

BI - Bacteriological Index

MI - Morphological Index

CMI - Cell Mediated Immunity

MPS - Mononuclear Phagocytic System

GF - Granuloma fraction

SEZ - Subepidermal zone

PGL-1 - Phenolic Glycolipid-1

BCG - Bacillus-Calmette-Guerin

NRAMP - Natural Resistance Associated Macrophage Protein

TLR - Toll-like receptor

PAMP - Pathogen Associated Molecular Pattern

NF-ΚB - Nuclear Factor Kappa B

IFN - Interferon

GM-CSF - Granulocyte Monocyte Colony Stimulating Factor

TNF-α - Tumor Necrosis Factor alpha

DC-SIGN - Dendritic cell-specific intercellular adhesion molecule-3-

grabbing nonintegrin

MIF - Migration Inhibiting Factor

MAF - Macrophage Activating Factor

LTT - Lymphocyte Transformation Test

LMIT - Leukocyte Migration Inhibition Test

DTH/DH - Delayed Type Hypersensitivity

Th - T helper cell

iNOS - Inducible Nitric Oxide Synthase

Treg - T Regulatory cell

FGF - Fibroblast Growth Factor

NGF - Nerve Growth Factor

HLA - Human Leukocyte Antigen

TGF - Transforming Growth Factor

T1R - Type 1 Reaction

T2R - Type 2 Reaction

ENL - Erythema Nodosum Leprosum

NFI - Nerve Function Impairment

MB-MDT - Multi Bacillary Multi Drug Therapy

PB-MDT - Pauci Bacillary Multi Drug Therapy

NSAID - Non Steroid Anti Inflammatory Drug

MIP - Mycobacterium indicus pranii

ICRC - Indian Cancer Research Centre

MAI - Mycobacterium avium intracellulare

Baseline 3 monthReduction -

3 months6 month

Reduction -

6 months12 month

Reduction -

12 monthsBaseline 6 month

Reduction - 6

months12 month

Reduction -

12 months

1 43 M BL 18 16 2 11 7 8 10 5 4 1 2 3

2 37 M LL 20 16 4 10 10 8 12 6 4 2 2 4

3 53 M BL 20 17 3 11 9 8 12 5 3 2 2 3

4 21 F BL 16 13 3 11 5 6 10 2 1 1 0 2

5 21 M BB 14 12 2 9 5 6 8 3 1 2 0 3

6 31 M BL 18 14 4 12 6 9 9 5 2 3 1 4

7 59 M LL 22 18 4 17 5 15 5 6 4 2 3 3

8 28 M BL 8 6 2 4 4 3 5 2 2 0 1 1

9 43 F BB 12 10 2 8 4 5 7 3 2 1 1 2

10 47 M BL 12 10 2 7 5 4 8 3 2 1 1 2

11 61 F LL 16 14 4 11 5 9 7 4 3 1 1 3

12 36 M BB 16 14 4 10 6 6 10 4 3 1 2 2

13 31 F LL 18 16 2 11 7 9 9 4 2 2 1 3

14 24 F BL 20 17 3 13 7 11 9 4 3 1 2 2

15 21 F BL 18 16 2 14 4 10 8 3 2 1 1 2

Baseline 12 monthReduction -

12 monthsType 1 Type 2

Before

starting

MDT

Neuritis

1 43 M 52.6 14 38.6 yes nil nil nil nil

2 37 M 56.4 12 44.4 nil nil nil nil nil

3 53 M 45.2 13.2 32 nil nil nil nil nil

4 21 F 38.8 6.2 32.6 yes nil nil nil nil

5 21 M 27.4 10 17.4 yes nil nil nil G II(claw hand)

6 31 M 48.2 7.4 40.8 yes nil nil yes G II(Trophic ulcer)

7 59 M 57.8 24.2 33.6 nil yes Type 2 nil nil

8 28 M 40.4 11 29.4 nil nil nil nil nil

9 43 F 50.2 11.4 38.8 yes nil Type 1 yes nil

10 47 M 48.2 8.4 39.8 nil nil Type 1 nil nil

11 61 F 52.4 7.3 45.1 nil nil nil nil nil

12 36 M 35 11.2 23.8 nil nil nil nil G II(Trophic ulcer)

13 31 F 52.4 12 40.4 nil yes nil nil nil

14 24 F 39.5 9.6 29.9 nil nil nil nil nil

15 21 F 48 8.2 39.8 nil nil nil nil nil

S.NO AGE SEX

BIOPSY-GF REACTION

DEFORMITY

MASTER CHART - STUDY GROUP

S.

NOAGE SEX SPECTRUM

CLINICAL SCORE SSS

Baseline 3 monthReduction -

3 months6 month

Reduction -

6 months12 month

Reduction -

12 monthsBaseline 6 month

Reduction - 6

months12 month

Reduction -

12 months

1 30 M LL 19 17 2 15 4 12 7 5 4 1 3 2

2 60 M BL 20 18 2 16 4 13 7 4 2 2 2 2

3 29 F BL 8 6 2 5 3 3 5 3 2 1 1 2

4 70 M BB 15 14 1 12 3 10 5 3 2 1 0 3

5 38 M LL 16 13 3 11 5 9 7 5 4 1 3 2

6 62 M LL 14 12 2 10 4 8 6 4 3 1 2 2

7 45 M BL 8 6 2 5 3 4 4 3 3 0 2 1

8 51 M LL 18 16 2 13 5 11 7 4 3 1 2 2

9 43 M BL 16 13 3 10 6 9 7 5 4 1 4 1

10 70 M LL 20 17 3 15 5 11 9 3 3 0 2 1

11 36 F LL 18 16 2 14 4 13 5 5 3 2 3 2

12 23 M LL 20 17 3 14 6 11 9 4 3 1 2 2

13 63 M LL 16 12 4 10 6 8 8 5 3 2 2 3

14 61 M BL 16 14 2 11 5 10 6 3 2 1 1 2

15 29 F LL 22 20 2 18 4 17 5 6 5 1 4 2

Baseline 12 monthReduction -

12 monthsType 1 Type 2

Before

starting

MDT

Neuritis

1 30 M 56 20.4 35.6 nil nil Type 2 nil nil

2 60 M 34.2 8.2 26 yes nil nil yes nil

3 29 F 40.2 13.1 27.1 nil nil nil nil G II(claw hand)

4 70 M 38.1 11.9 26.2 nil nil Type 1 nil nil

5 38 M 42.5 12 30.5 nil yes nil yes G I(resorption)

6 62 M 28.1 8.3 19.8 yes nil Type 2 nil nil

7 45 M 35.3 10 25.3 nil nil Type 2 nil nil

8 51 M 21.5 7.9 13.6 nil yes nil nil nil

9 43 M 38 9.1 28.9 nil nil nil nil G II(Trophic ulcer)

10 70 M 54.1 19.2 34.9 nil nil nil nil nil

11 36 F 51.4 12.9 38.5 nil yes nil nil nil

12 23 M 58 14 44 nil yes nil yes nil

13 63 M 34.2 10.4 23.8 nil nil Type 1 nil nil

14 61 M 48.2 12.3 35.9 yes nil nil yes G II(Trophic ulcer)

15 29 F 52.2 24.3 27.9 nil yes nil nil nil

MASTER CHART - CONTROL GROUP

DEFORMITY

S.NO AGE SPECTRUMSEX

REACTIONBIOPSY-GF

S.NO AGE SEX

CLINICAL SCORE SSS

KEY TO MASTER CHART

SSS - SLIT SKIN SMEAR

GF - GRANULOMA FRACTION

F - FEMALE

M - MALE

BB - BORDERLINE BORDERLINE

BL - BORDERLINE LEPROMATOUS

LL - LEPROMATOUS LEPROSY

G-II - GRADE II

PROFORMA

Case No :

PATIENT DETAILS:

Name : Age : Sex: OP No :

Address : Occupation :

HISTORY:

H/O light coloured skin lesion

Number:

Duration :

Distribution:

H/O decreased sensation

H/O inability to use any part of the body

H/O ulcer

H/O fever

H/O joint pain

H/O visual disturbance, redness of eye

H/O epistaxis

H/O change in voice

H/O deformity

H/O treatment for leprosy in the past

H/O similar illness in the past:

H/O any systemic illness

H/O any drug allergy

CLINICAL EXAMINATION:

GENERAL EXAMINATION:

PR- /min BP- / mm of Hg Temp-

Pallor- Icterus- Cyanosis- Clubbing-

Pedal edema-

Generalised lymphadenopathy-

CVS:

RS:

P/A:

CNS:

Bones and joints:

DERMATOLOGICAL EXAMINATION:

Hypopigmented patches :

Number :

Distribution :

Shape :

Size :

Morphology :

Nodules :

Testing Sensations:

Trophic Changes:

Mucosal examination:

Peripheral Nerves examination:

Musculoskeletal system:

Ocular examination:

Examination of external genitalia:

INVESTIGATIONS:

Slit skin smear -

Biopsy -

Complete blood count -

Renal function test -

Liver function test -

VCTC -

VDRL -

FOLLOW UP:

Clinical score -

Side effects -

INFORMATION SHEET

TITLE: EFFICACY OF BCG AS IMMUNOMODULATOR IN

MULTIBACILLARY LEPROSY

Name of the Investigator:

Name of the Participant :

Purpose of the Research : To study the Immunomodulatory Efficacy of BCG

administered along with MB-MDT in Multibacillary leprosy patients.

Study Design: Interventional study

Study Procedures: In this study, patient’s clinical history noted. Thorough clinical

examination and Slit Skin Smear done. Blood investigations and skin biopsy will be

taken. Patients are then allocated into 2 groups and treated with MB-MDT and MB-

MDT with BCG accordingly.

Possible Risks:

Ulceration at the site of vaccination, regional lymphadenitis, subcutaneous

abscess, keloid scarring, osteitis, disseminated BCG infection.

Possible benefits:

To the Patient:

1) Reduced occurrence and severity of leprosy reactions

2) Increased host immunity against M.leprae so that relapses and reinfection

can be prevented.

To the Doctor:

The results of the study will help to determine the Immunomodulatory Efficacy

of BCG administered along with MB-MDT in Multibacillary leprosy patients. This

may help in providing more effective treatment to leprosy patients in future.

Confidentiality of the information obtained from you : The privacy of the patients in the research will be maintained throughout the study. In

the event of any publication or presentation resulting from the research, no personally

identifiable information will be shared.

Can you decide to stop participating in the study : Taking part in this study is voluntary. You are free to decide whether to participate in

this study or to withdraw at any time.

How will your decision to not participate in the study affect you : Your decision will not result in any loss of benefits to which you are otherwise entitled.

Signature of Investigator: Signature of Participant

Date :

Place :

PATIENT CONSENT FORM

TITLE: EFFICACY OF BCG AS IMMUNOMODULATOR IN

MULTIBACILLARY LEPROSY

Name of the Principal Investigator:

Name of the Institution: Rajiv Gandhi Government General Hospital,Chennai

Patient’s Name : Age/Sex :

Outpatient No. :

Patient may check (☑) these boxes

I confirm that I have understood the purpose of procedure for the above study. I have the

opportunity to ask question and all my questions and doubts have been answered to my

complete satisfaction.

I understand that my/my son’s/daughter’s participation in the study is voluntary and that I

am free to withdraw at any time without giving reason, without my legal rights being

affected.

I understand that sponsor of the clinical study, others working on the sponsor’s behalf, the

ethical committee and the regulatory authorities will not need my permission to look at my

health records, both in respect of current study and any further research that may be

conducted in relation to it, even if I withdraw from the study I agree to this access. However,

I understand that my/ my son’s/ daughter’s identity will not be revealed in any information

released to third parties or published, unless as required under the law. I agree not to restrict

the use of any data or results that arise from this study.

I agree to take part in the above study and to comply with the instructions given during the

study and faithfully cooperate with the study team and to immediately inform the study staff

if I suffer from any deterioration in my health or well being or any unexpected or unusual

symptoms.

I hereby consent to participate in this study

I hereby give permission to undergo complete clinical examination and diagnostic tests

including CBC, RFT, LFT, VCTC, VDRL, Slit skin smear and skin biopsy if required. I

understood that patients will be randomly allocated into 2 groups followed by administration

of MB MDT with 4 doses of 0.1ml of BCG at 3 months interval to one group and MB MDT

alone in other group.

Signature/thumb impression: Signature of the Investigator:

Patient’s Name: Study Investigator’s Name:

Address : DR.R.YAZHINI

Guardian Name : Relation to the patient

CERTIFICATE

This is to certify that this dissertation work titled “EFFICACY OF

BCG AS IMMUNOMODULATOR IN MULTIBACILLARY

LEPROSY” of the candidate Dr.R.YAZHINI with registration number

201730010 for the award of M.D. Degree in the BRANCH XX -

DERMATOLOGY, VENEREOLOGY & LEPROSY. I personally verified the

urkund.com website for the purpose of plagiarism check. I found that the

uploaded thesis file contains from introduction to conclusion pages and result

shows 4 Percentage of plagiarism in the dissertation.

Guide and Supervisor sign with seal