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Multidrug therapy (MDT), according to the recommendations of a WHO Study Group of 1982, was introduced in the leprosy control program of the All African Leprosy and Rehabilitation Training Center (ALERT), Ethiopia, in January 1983. Paucibacillary (PB) patients are treated with 6 months of MDT. Multibacillary (MB) patients are treated with at least 2 years of MDT and until skin-smear negativity. An analysis was made of the relapses which had been diagnosed among self-reporting patients in four rural districts and Addis Ababa. Among 3065 PB patients, 34 relapses (1.1%) were diagnosed during an average period of 6.1 years after stopping MDT (range 2 1/2 to 7 1/2 years). Among 2379 MB patients, 24 relapses (1.0%) were diagnosed during an average period of 4.7 years after stopping MDT (range 2 1/2 to 6 years). The estimated relapse rate per 1000 patient-years after release from MDT was 2.1 for PB patients and 2.4 for MB patients. From the analysis of the clinical, bacteriological, and histopathological findings, it was concluded that there was strong positive evidence for the diagnosis for 16 of the 34 relapses in the PB patients and for 0 of the 24 relapses in the MB patients. The main cause for overdiagnosis of MB relapses was that too much reliance had been put on skin-smear results, without a careful comparison of the results with those from before, during, and at completion of MDT; the diagnosis was based on the finding of positive smears in one set of smears only; insufficient attention was given to finding solid-staining bacilli; and findings in biopsies, if these were examined, did not confirm the diagnosis. The main cause of overdiagnosis of PB relapses was that too much reliance was put on histological findings, while these are often inconclusive for differentiating between a relapse and late reversal reaction. Recommendations are made on how to limit overdiagnosis of relapses. Operational procedures and criteria for making the diagnosis under conditions where facilities for back-up histological and mouse foot pad investigations are not available are proposed.

This paper reports on reactions in leprosy patients who were treated with multidrug therapy (MDT) in the leprosy control program of the All Africa Leprosy and Rehabilitation Training Center (ALERT) in Ethiopia. Only those reactions which occurred in patients who had not been treated with dapsone before MDT and which required treatment with prednisolone were included. Until the end of the second year of MDT a reversal reaction had been diagnosed in 43.6% of 266 borderline lepromatous (BL) patients and in 19.2% of 109 lepromatous leprosy (LL) patients, and an erythema nodosum leprosum (ENL) reaction in 2.7% and 11.1% of the patients, respectively. The reversal reactions were observed in 4.9% of the BL patients and in 0% of the LL patients at the time of diagnosis of leprosy, in 26.3% and 12.8% of the patients during the first year of MDT, and in 12.4% and 6.4% during the second year of MDT. ENL reactions were seen in 0.8% of BL patients at diagnosis, 1.1% in the first year and 0.8% in the second year and 2.8% at diagnosis, 5.5% in the first year, and 2.8% in the second year for LL patients. During a 3 1/2-year period, a total of 405 reactions were diagnosed among multibacillary (MB) patients on MDT; 365 of these reactions (90.1%) were reversal reactions and only 40 (9.9%) were ENL reactions. The point in time of the reversal reactions showed that the risk of reversal reaction is highest during the first year of MDT. Thereafter there is a gradual decline, although reactions were still observed during the fifth year of MDT. A reversal reaction was diagnosed in 21.0% of 438 BT patients; in 3.4% of the patients the reaction was present at the time of diagnosis of leprosy; in 10.3% it occurred during MDT, and in 7.3% during the first year after release from MDT. During a period of 3 1/2 years a total of 183 reversal reactions were diagnosed among BT patients. The point in time showed a declining trend in the risk of reversal reaction after starting MDT. The risk is highest during MDT, followed by the first 6 months after stopping MDT. However, reactions, although few, still occurred during the fourth year after stopping MDT. The analysis of the results of prednisolone treatment in 161 patients who were treated for nerve function loss in the field showed that 142 patients (88.2%) regained complete or partial recovery of the nerve function(s), while no improvement was observed in 19 patients (11.8%).(ABSTRACT TRUNCATED AT 400 WORDS)

Nasal involvement in lepromatous leprosy is universal and occurs early in the course of the disease. Nasal symptoms include obstruction, crusting, bleeding, and hyposmia. Traditional therapy with dapsone, rifampin, and clofazimine is limited by its cost and toxicity. Minocycline hydrochloride, a tetracycline antibiotic with limited side effects, is promising as a new treatment for leprosy. A case is presented that highlights the clinical presentation, diagnosis, and treatment of lepromatous leprosy.

The paper deals with a topic rarely treated in the bibliography: a carrier of cutaneous and otolaryngologic lesions suspicious of lepromatous leprosy. The AA. made a survey of the typical ENT manifestations of the generalized disease--lepromatous leprosy--and recall the more characteristic diagnostic tests as well as the guide lines of the treatment.

27 leprosy patients (19 adults, 8 children) from Basse Terre (Guadeloupe, FWI) were referred to General Hospital from 1975 to 1989: for diagnostic purpose in half the cases, for starting or modifying treatment regimens, or for complications (ENL). Lepromatous type was predominant (16/27), whereas ENL was the most serious diagnosis and therapeutic problem (7/27). Some epidemiological and psycho-social aspects are discussed.

Leprosy is an infrequent disease in Spain. 4,714 cases of leprosy was registered in the last national census (1979). The disease is still common in certain regions, such as Levant, Andalusia, Extremadura, Canary Island and Galicia. Lepromatous type is more frequent, a typical hallmark of endemies with low activity or characterized by regression. We report a patient affected of borderline lepromatous leprosy with the following characteristics: 1) the only known case in his locality, 2) lack of reaction after the treatment, and 3) due to its clinic, histological, and bacteriological characteristics was quite difficult to determine the leprosy's type. Even though the leprosy is an infrequent disease, it can be seen in everyday's practice, so that the internist and specialist. Have to know the disease in order to make an early diagnosis and to treat the patient effectively.

Isoelectric focusing was used to separate the three components of the antigen 85 complex of Mycobacterium bovis BCG. Antibody responses of leprosy patients against each Mycobacterium bovis BCG. Antibody responses of leprosy patients against each component were quantitated by densitometric analysis of immunoblot assays. The 85A component was recognized by 40% (8/20) of the lepromin positive and negative healthy subjects, by 76% (19/25) of the tuberculoid and by 96% (24/25) of the lepromatous leprosy sera. In contrast, the 85B component was not stained by the control sera, nor by the tuberculoid leprosy sera but by 64% (16/25) of the lepromatous leprosy sera. The results suggest that antigen 85B contains one or several epitopes that are specifically recognized by sera of lepromatous leprosy patients only.

Fingertip blood-flow velocity and its control by vasomotor reflexes were studied in leprosy patients and in healthy controls with a laser Doppler flowmeter. In newly registered patients, the flow was significantly lower than in the healthy controls, and even lower values were recorded in the long-standing patients with lower limb ulcers and/or deformity. The newly registered patients showed substantially impaired vasomotor reflex responses in the fingertips to cold challenge of the opposite hand or deep inspiratory gasp. Low blood flow and impairment of vasomotor reflexes were more prominent in those leprosy patients who showed clinical evidence of neuropathy and/or histological evidence of reaction in a punch biopsy of leprosy skin lesions. This aspect of dysautonomia to cold challenge was particularly prominent in apparently healthy, fully treated ex-patients. There was an unexpectedly high prevalence of impairment of vasomotor reflexes in newly registered and apparently healthy, adequately treated leprosy patients. The method is very sensitive, and it remains to be established whether the lesions it detects are nonprogressive residues, or previous nerve damage, or an indication of on-going nerve damage. A minority of leprosy contacts showed impairment of vasomotor reflexes. Those with two or more affected fingers were more likely to have had a higher level of exposure to Mycobacterium leprae than those with one or no affected fingers. The cause of this unexpected impairment of fingertip vasomotor reflexes in a minority of leprosy control workers has not yet been determined.

The diagnosis of leprosy is made clinically with histologic and cytologic confirmation. The traditional methods for making the cytologic diagnosis of leprosy take time and training, making them unsuitable for rapid office use. We describe a simple, rapid method for cytologic confirmation of the diagnosis of multibacillary leprosy using slit skin scrapings.

An adult man with post-kala-azar dermal leishmaniasis who had lessons distributed in a manner strikingly similar to lepromatous leprosy is described. He was mistakenly treated with multidrug therapy as recommended by the WHO Expert Committee on leprosy. All investigations including slit-skin smears, histopathology, culture for Leishmania donovani and an indirect fluorescent antibody test to confirm post-kala-azar dermal leishmaniasis proved futile. The diagnosis was ultimately based on the previous history of kala-azar, the absence of other disorders which were ruled out by relevant laboratory tests and the good therapeutic response to sodium antimony gluconate. The epidemiological significance of this case and the salient points to distinguish this condition from leprosy are discussed.

Leprosy is an uncommon disease in Saudi population. Lepromatous leprosy is a most contagious form of leprosy. Erythema nodosum leprosum is an unusual complication of leprosy. We report an unusual case of leprosy from the central region of Saudi Arabia presenting as erythema nodosum leprosum.

Comparison of prevalence rates of leprosy as assessed by a rapid survey technique, in which only the exposed parts of the body were examined, with that assessed by a routine total body examination in a population of about 700, showed that most cases of leprosy were detected by the former.

Commercially available polyclonal antibodies raised against strains of mycobacteria were used to detect organisms in tissue sections from 34 cases of tuberculosis, leprosy, and atypical mycobacteria. Thirty-two cases of fungal infections, granulomatous inflammation, and sarcoidosis were used as negative controls. Sections stained with the use of antibodies raised against Bacillus Calmette-Guerin (BCG), Mycobacterium duvalii (MD), and Mycobacterium paratuberculosis (MP) were compared with Kinyoun and Fite-stained tissue sections. In caseating granulomata, clumps of mycobacterial debris, cells, and cell fragments stained. In histiocytic granulomata of mycobacterial infections, histiocyte cytoplasm contained both organisms and debris. The three antibodies showed cross-reactivity against the four groups of mycobacteria tested. Mycobacterial staining using immunoperoxidase was apparent in most cases at low-power (scanning) magnification. Thirty-two of 34 cases of mycobacterial infection, including all 24 Kinyoun-Fite-positive cases, were positive for immunoreactive organisms and debris using anti-MD, anti-BCG, and/or anti-MP. Eight of ten cases of culture-proven mycobacterial infection, in which Kinyoun and Fite stains were negative, had immunoreactive organisms or antigen with anti-BCG, MD, or MP. The antibodies also stained organisms in five cases of sporotrichosis in which the organisms were identified as yeast forms in tissue sections.

Serum samples from 3336 contacts of leprosy patients were tested for antiphenolic glycolipid I antibodies by enzyme-linked immunosorbent assay with the albumin coupled synthetic disaccharide antigen. The overall positivity rate was 9.3%. No significant differences were seen between a group of household contacts of lepromatous patients and those of the other types of the disease. The proportion of ELISA positives was slightly higher in the relatives as compared to workplace contacts and neighbours but significantly different only between the two former (p less than 0.05). Among those contacts with absorbance values higher than 0.100, 5 new leprosy patients were diagnosed, 2 of them with positive skin smears. A sixth contact was detected with a very high absorbance value in whom no single skin lesion was found but whose lepromin reaction was 0 mm and the skin smear showed a bacteriological index of 3+.

Immunoblot assays for the antibodies to Mycobacterium tuberculosis sonic extracts showed that all serum specimens of 40 lepromatous and of 28 tuberculoid leprosy patients reacted in a significant manner to 29/33-kilodalton (kDa) doublet and 64-kDa antigens, respectively. By using an enzyme-linked immunosorbent assay, we observed a significantly high immunoglobulin G antibody titer to the purified M. tuberculosis 29/33-kDa doublet and 64-kDa antigens in lepromatous and tuberculoid leprosy patients, respectively, as compared with normal subjects and tuberculosis patients. This enzyme-linked immunosorbent assay serology may be useful for distinguishing two polar types of leprosy and for diagnosing leprosy in general.

A high incidence of increased plasma level of high density lipoprotein cholesterol (HDL-C) has been reported in cases of lepromatous leprosy. HDL-C levels were estimated in 96 (50 under treatment and 46 untreated) lepromatous leprosy patients and 84 randomly selected matched control patients suffering from other skin diseases attending skin out-patients department. HDL-C estimations were performed for the diagnosis of lepromatous leprosy in patients aged below 60 years, taking plasma HDL-C levels as 28-71 mg./dl. in men and 34-91 mg./dl. in women, as range of normal values. The study revealed that HDL-C levels in lepromatous leprosy group were raised and significantly different when compared with control group (t = 35.1668 and P less than 0.001). The sensitivity of the test was very high, 97.9 per cent (94/96), but specificity was low 80.95 per cent (68/84). False positive and false negative results were 19.04 per cent (16/84) and 2.08 per cent (2/96) respectively. It is opined that a negative test will be mainly useful in excluding diagnosis of lepromatous leprosy.

A technique which reliably demonstrates Mycobacterium leprae, M. tuberculosis and fungi in tissues is described. It is based on the oxidation of cell wall lipid substances by chromic or periodic acid, and the subsequent release of aldehydes which are then capable of reducing ammoniacal silver salt solutions to metallic silver. The organisms so demonstrated appear uniformly solid. The sensitivity of the method and the ease of examination and recognition of bacilli and their products are recommendations for the use of the method in diagnosis and research, disregarding morphological appearances.

The paper describes a case of lepromatous lepra diagnosed from the skin biopsy specimen taken in a 23-year-old male patient. It provides histologic signs that are beneficial for correct diagnosis. Emphasis is placed upon the necessity for staining by the Ziehl-Neelsen method to detect microorganisms in infiltrative and granulomatous skin lesions.

An enzyme immunoassay (EIA) based on sonicate supernatant antigens of a cultivable, atypical bacterium, Mycobacterium w (M. w), for immunodiagnosis of leprosy is described. M. w was selected after screening of sonicate supernatant antigens of seven cultivable mycobacteria in EIA. The results of the assay were compared with that of EIA using phenolic glycolipid-I (PGL-I). The M. w assay was more sensitive than PGL-I based EIA, for detection of leprosy patients of all categories, including long term treated patients with low bacterial load. The M. w assay was highly sensitive (93.49%) for detection of active LL patients, and the difference in the positivity of the two assays for LL patients was statistically significant (p 0.05). The combined positivity of the assays with M. w and PGL-I for LL was higher than that with either antigen alone. M. w assay, in addition, was also highly sensitive for detection of patients with active pulmonary tuberculosis.

A 23-year old male presented for evaluation of skin coloured, non-scaly, asymptomatic papulonodules of sizes varying from 0.5 cm to 2 cm of 4 years duration distributed all over the body including the ears. The plaques present on the face gave the appearance of a 'leonine facies'. Clinically mistaken for lepromatous leprosy in reaction the patient was treated with antileprosy and anti-inflammatory drugs in 3 other centres for months with no improvement. Systemic involvement included painful swelling of both knee joints, pericardial effusion episcleritis and enlarged liver. Negative slit smears for AFB from the nodules repeatedly and the histology of one on the skin nodules clinched the diagnosis of multicentric reticulohistiocytosis. The case is reported not only for its rarity, and varying clinical lesions simulating lepromatous leprosy but also to alert the leprologists to avert unreasonable delay in diagnosis.

The study of leprosy in children has indicated an incidence of 10% amongst leprosy patients attending the clinic. The duration of the disease was usually less than 2 years. The expression of leprosy in this group was either a macule and/or a plaque. Classification was, therefore, different and conforms to indeterminate (I), borderline tuberculoid (BT) and borderline (BB) leprosy. Only occasionally were other clinical variants seen. The bacteriology was largely unproductive by slit-skin smears. The lepromin (Mitsuda) responses were positive in BT and unpredictable in BB patients. Epicutaneous responses to sensitization with dinitrochlorobenzene (DNCB) paralleled responses to lepromin. Microscopic pathology was of very little help. The correlation of these parameters was only 50-60% indicating that the diagnosis of leprosy should primarily be based on clinical features.

Histoid leprosy is a fascinating expression of multibacillary leprosy, the incidence of which was 3.6%. It was seen predominantly in males of the younger age group, who were on inadequate and irregular dosage of diaminodiphenyl sulfone. Papules, cutaneous and/or subcutaneous nodules and plaques appearing over apparently normal skin were its exquisite prospective clinical features. It was invariably supported by enormous, uniformly solid staining discrete bacilli from the lesions, in contrast to their virtual absence from the surrounding normal-appearing skin. Encapsulated tumorous mass, formed primarily by spindle-shaped histocytes, displayed either in intertwining, criss-cross or whorled fashion in haematoxylin-eosin-stained sections, were supplementary. The morphology of acid-fast bacilli was, however, similar to skin-slit smears.