Terri Bianchi, DNP, ARNP

Ormond Beach Dermatology, Ormond Beach, FL

*Resurgence of Leprosy in Florida

2009

2014

*Beau, a Christmas bow

*Disclosure- Power Point

assistance

*Objectives

*Participant will:-Increase awareness leprosy

-Expand differential or Ddx

-Identify national resource

Leprosy Cases Hit FL Counties2/27/15

*ABCnews.com

*http://abcnews.go.com/Health/leprosy-cases-hit-florida-counties/story?id=29258128

*Armadillos cause spike in leprosy

cases in FL 7/21/15

* (Right)Map: CNN.com 7/21/15The Daytona Beach News-

Journal 6/30/15, front page

Emil Kraeplin

1856-1926

* A century ago, Pioneering German psychiatrist 1st suggested the differential approach to diagnosis

* Ddx

*Expand the Ddx

*Important consideration when encountering & treating any chronic skin or rheumatological disorder

*95% humans naturally immune

*Pathogen incubation 9 mo – 20 years

*SSx appearance may follow this time frame

*Reportable federally & in most states, including FL

*Armadillo host, not villain

*Transmission can be fomite, such as soil

Lack of awareness! CDC reported most cases in US delay dx by 3 years (onset SSx to accurate dx)

*Regions of U.S. endemic

*Gulf coast region reported 100-150 cases each year past few years

*Previously FL typically reported 8-10 cases/year

*68% cases male (ages 11-92)

*Human:human transmission, droplets nose & mouth (household contact 25% risk)

*Fortuitously, humans become non-infectious

w/ 1st few doses

appropriate

oral abx tx

*These states account for 70% cases (2010):

*TX 36

*HI 35

*NY 34

*CA 32

*FL 30

*LA 21 and MA 15

Sin & Curse

*Morally suspect, quarantine

Bacterial infection

Transition………………..

*Mycobacterium Leprae 1873bacterial bacillus• Cure 1940 (sulfone drug)

• Out pt treatment 1982• Hansens Disease 1931• Latin ‘lepra’ or scaly

*US Leper Colony

- location: Carville, Louisiana (LA)

- LA Leper Home est. 1894 in an abandoned plantation home built 1859, 350-400 acres

- Nat’l Leprosarium 1894-1999

- voluntary admission 1970

- home to 4,500 victims of dz

- Simultaneously sponsored research & lead to successful tx

- Now called, Gillis W. Long Hansens Disease Center (1982 USDHHS)

- 1992 Carville Historic District > Nat’l Register Historic Places

- 1993 several aged elect to remain > ALF

- 1994 founded Nat’l Hansens Disease Museum > @HRSA , Virtual Tour

- Most suffered inflamed sores, ulcers, lesions eyes, throat & numbness peripherally

(ear lobes, toes/fingers) > disfigured

Pen name, Betty Miller, NY Times Best Seller, 1950 memoir Miracle@Carville& No One Must Ever Know , 1959

Pen name, Stanley SteinPrints newsletter, STAR,mission, spread light& truth of HD (advocateLeprosy > HD)

1899-1967

1928 “pale rose spots on thighs”, debutante, engaged to medical student

*Zoonotic

*Carville/National Hansens Disease Center simultaneous research

*2011 Whole genome resequencing from 1 wild armadillo & 3 humans w/ dz revealed identical strain M. lepare

* Autochthonous cases

* Native born (SE USA), no foreign travel

* No h/o foreign exposure

4/28/11 N Engl J Med; 364: 1626, accessed 7/25/15 www.nejm.org/doi/full/10.1056

Important in research & current vaccine development effort

*Armadilloimmigration

& migration 9 Banded (Dasypus novemcinctus), decendents prehistoric, South America 50 million years ago

Claws & burrowLong tongue &

spit

*Invasive species- Armadillos related to sloths & anteaters- Cannot thrive in very cold, very dry environments- FL is much like the Mother Land: humid, rain, & bugs

galore!

Cannot hear or see well, great sense smell. No bite.

*Exotic, invasive:Colonization10 x

faster than nature

*Texas – state mammal

*Armadillo racing

*People hunt & eat them

*“Hoover hogs” during Depression

*Moved w/ cattle, TX to other states, train cattle cars

*Florida

*Pets, easy to catch

*1936 escaped traveling circus

*1924 released small zoo & escaped Cocoa, FL

* FL Crackers “possum on the half shell”

*FL Dept Health, leprosy reported since 1921

*High, unique reproductive rate

& few predators

The Clinical Advisor April 2015, case 2 = leprosy!

* Journal of Drugs in Dermatology, April 2015

- 27 yod male- Extensor forearm- Scattered ill-defined erythematous nodules & papules- Pain left leg prevented ambulation- Exam evidenced skin colored nodules on earlobes

* September 2013, 58yod male Caucasian CC: “red skin

lesions” x 2mo, no self tx

*73 yod male Ddx rash

unspecified r/o GA (1.3 cm

lesion)

*Leprosy Masquerading as

RA

*Journal of Drugs in Dermatology

*May 2015

*NY Hansen’s Disease Program, Dept Derm, Bellevue Hospital, NY

*“leprosy often presents as rheumatology d/o”:

- Lupus erythematous

- RA

- Anticardiolipin syndrome

(aka antiphospholipid/APS)

*During RA tx for 2 years, cutaneous lesions erupted > referral derm >punch bx w/ fite stain

*dx leprosy

*Caution, age of biologics (immune suppressive) tx in RA, Ps

*Consultant April 2015

*55 yod Caucasian male

*Landscaper, Florida

- Sores hands off/on x 2 years, claw like hand

- Sores > ulcerations

- Pain on ambulation

*Admit to hospital, systemic vasculitis

Ddx: granulomatis w/ polyanglitis, SLE, APS

Accurate Dx, Leprosy

AEB skin bx!

*Accurate diagnosis

*Cutaneously & commonly, early on: pale, reddish skin patch w/ or w/o diminished sensation

*1 or more chronic or recalcitrant maculopapular lesions

*Slight, if any prodromal

*90% have numbness (maybe

years) before skin lesion

- temp goes 1st

- light touch 2nd

- pain last to go(hence injuries hands & feet)

• 4mm punch, full thickness, +/- suture• Fite stain• Dermatopathologist!

Rare, but tragic to miss it

*Leprosy/Hansens Disease

Cool areas of body affected

- Superficial peripheral nerves

- Anterior chamber eyes

- Testes

- Chin

- Malar (cheeks)

- Ear lobes

- Knees, elbows

- Distal BULEs

Thickened superficial peripheral nerve

*Ridley-Jopling Classification

*F/U: Is it recalcitrant?

*Free online course

- Provides all HCPs w/ knowledge to dx & tx the disease- Introduces methods used to prevent disabilities caused by disease- Aids in dx & management, including complications

Add thank you & skin ca ad

- An American’s life time risk melanoma is 1 in 36

- Melanoma #1 cancer adults ages 25-29

- 1 blistering sun burn in youth doubles lifetime risk

US incidence melanoma increased each year x last 30