|Year : 2015 | Volume
| Issue : 5 | Page : 609-613
An epidemiological and clinico-histopathological study of leprosy in semi-urban area under Pimpri Chinchwad Municipal Corporation in Pune district of Maharashtra
Alia A Rizvi, Yugal K Sharma, Kedarnath Dash, Neha Tyagi, Ridhima Yadava, Dinkar Sadana
Department of Dermatology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Web Publication||10-Sep-2015|
II-C/31 Ashirwad Colony, Vaishali, Ghaziabad - 411 012, Uttar Pradesh
Source of Support: Nil., Conflict of Interest: None declared.
Background: Despite having been declared eliminated in December 2005 from India as a public health problem, the prevalence of leprosy exceeds 1/10,000 population in certain districts/states of India. A spurt in its prevalence by 60% - from 0.74 to 1.18 within 1-year from 2012 to 2013 in the area under Pimpri Chinchwad Municipal Corporation (PCMC) of Pune district of Maharashtra, wherein our institution is located, motivated us to carry out this study. Aims and Objectives: This prospective study entailed recording of the epidemiological data of cases of leprosy and carrying out correlation of their clinical and histopathological diagnoses as per Ridley–Jopling scale along with inclusion of indeterminate and pure neuritic types. Materials and Methods: Eighty fresh untreated patients hailing from areas under PCMC–in whom leprosy was clinically considered to be either the diagnosis or the differential diagnosis-reporting to the department of dermatology of our tertiary care hospital were enrolled. Their age, sex, and clinical findings were recorded on a proforma. Slit skin and scrape smear were stained by the Ziehl–Neelsen method. Punch biopsies–processed and stained by hematoxylin and eosin and Fite-Faraco method for morphological assessment and identification of the lepra bacilli, respectively–were evaluated histopathologically and a clinico-histopathological correlation, attempted. Results: Male to female ratio of the study patients was 2.3:1; their age ranged from 14 to 74 (mean, 36.67) years. The overall clinico-histopathological concordance observed was 70%. Five cases of indeterminate leprosy (IL) emerged on histopathological examination from among the nine skin biopsies on patients of dermatoses mimicking leprosy (pityriasis alba, postinflammatory hypopigmentation, nevus depigmentosus, etc.). Conclusion: This study enabled us to detect additional cases of IL (from among dermatoses mimicking leprosy) and led to more accurate typing, thereby underscoring the importance of clinico-histopathological correlation as an important diagnostic aid.
Keywords: Clinico-histopathological correlation, indeterminate, India, leprosy, Maharashtra, mimics, prevalence in world
|How to cite this article:|
Rizvi AA, Sharma YK, Dash K, Tyagi N, Yadava R, Sadana D. An epidemiological and clinico-histopathological study of leprosy in semi-urban area under Pimpri Chinchwad Municipal Corporation in Pune district of Maharashtra. Med J DY Patil Univ 2015;8:609-13
|How to cite this URL:|
Rizvi AA, Sharma YK, Dash K, Tyagi N, Yadava R, Sadana D. An epidemiological and clinico-histopathological study of leprosy in semi-urban area under Pimpri Chinchwad Municipal Corporation in Pune district of Maharashtra. Med J DY Patil Univ [serial online] 2015 [cited 2021 Jan 27];8:609-13. Available from: https://www.mjdrdypu.org/text.asp?2015/8/5/609/164979
| Introduction|| |
As per the latest available data from the World Health Organization, 57.8% of the new leprosy cases detected globally in 2012 happened to be from India. Despite having been declared eliminated as a disease of public health importance in India since December 2005, leprosy continues to retain a prevalence rate (PR) higher than 1/10,000 population in parts of the country, namely, Dadar and Nagar Haveli (3.61), Chhattisgarh (2.13), Bihar (1.20), Maharashtra (1.09), and West Bengal (1.05). Pune district-which includes urban areas under Pune city, semi-urban areas under Pimpri Chinchwad Municipal Corporation (PCMC), and rural parts-recorded annual new case detection rate of 8/1 lakh population during 2013; the highest (15.16 per lakh) recorded among the district being in the areas under PCMC with an increase of 35% over that (11.23 per lakh) of the previous year. The PR (1.18) recorded in the same year in areas under PCMC was nearly double of the overall rate (0.60) in the Pune district, having spurted by 60% from the previous year's figure of 0.74.
This resurgence may possibly be ascribed to improved methods of leprosy detection.
The present cornerstone of strategy for leprosy control emphasizes early detection and adequate treatment of cases, so as to break the chain of infection and reduce the load of infection. Health workers at the level of Primary Health Centre are trained to diagnose leprosy based on finding at least one of its three cardinal signs-a skin patch with loss of sensation, enlarged peripheral nerve(s), and lepra bacilli in smears. As these signs may be equivocal-especially in some cases of indeterminate and early tuberculoid leprosy-some of such cases may remain undetected, despite referral to an appropriate center, unless subjected to histopathological examination (HPE). The accurate histopathological response of the tissues correlated with gross clinical morphology increases the diagnostic accuracy not only of the cases suspected clinically but also of a variety of unrelated diseases mimicking the protean manifestations of leprosy.
Hence this study - to assess the concordance between clinical and histopathological diagnosis using Ridley-Jopling scale, with the additional look out for the indeterminate and pure neuritic types - was carried out in patients of leprosy hailing from the predominantly semi-urban area falling under PCMC.
| Materials and Methods|| |
This prospective study was conducted at our tertiary care hospital on 80 fresh untreated patients in whom leprosy was clinically considered to be either the diagnosis or the differential diagnosis. Their age, sex, and clinical findings were recorded on a proforma. In all cases, skin slit and scrape smears were examined with the Ziehl-Neelsen method and punch biopsies were stained by hematoxylin and eosin stain and Fite-Faraco method for morphological assessment and identification of the lepra bacilli respectively, and grouped histopathologically as per the Ridley-Jopling scale with the additional consideration of indeterminate and pure neuritic types. Subsequently, a clinico-histopathological correlation was done.
| Results|| |
The present study on 56 (70%) males and 24 (30%) females had a M:F ratio of 2.3:1. Age of patients in our study ranged from 14 to 74 (mean, 36.67) years; 50 (62.5%), belonged to second to fourth decades. The clinical features in our study were loss of sensation (56; 70%), thickened nerves (54; 67.5%), hypopigmented patches (49; 61.25%), erythematous patches (33; 41.25%), limb deformities (11; 13.75%), and trophic ulcers (6; 7.5%). The most common clinical type, borderline tuberculoid (BT) leprosy, was seen in 29 (36.3%); the remaining types, in descending order, being: lepromatous (LL) (16; 20%), borderline lepromatous (BL) (12; 15%), tuberculoid (TT) (10; 12.5%), indeterminate leprosy (IL) (9; 17.5%), and borderline borderline (BB) (4; 3.75%). Histopathologically, BT (26; 32.5%) leprosy outnumbered the other types: IL (14; 17.5%), LL (14; 17.5%), TT (14; 17.5%), BL (9; 11.3%), and BB (3; 3.75%). Histopathologically proven (14) cases of IL emerged out of three clinical categories;first, those from the other-than-IL (TT-2, BT-4, BB-1, and BL-1; total 8) "clinical" types of leprosy; second, from among the vague, hypopigmented macules with full sensory perception previously treated by practitioners as "miscellaneous" dermatoses (pityriasis alba, postinflammatory hypopigmentation, nevus depigmentosus, etc.) [Figure 1]a and [Figure 1]b in whom IL was considered as one of the clinical differential diagnoses (5) and last, 1, of the 4 cases, "suspected" initially to be IL (the other three were opined TT on HPE) [Figure 2]a and [Figure 2]b.
|Figure 1: Children with histopathologically proven indeterminate leprosy revealing (a) hypopigmented, scaly macule over left cheek, earlier clinically diagnosed as pityriasis alba (b) hypopigmented macule with "geographic" border over left side of neck, earlier clinically diagnosed as nevus depigmentosus|
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|Figure 2: Photomicrograph of skin showing lymphocytic infiltrate around (a) neurovascular bundle and pilosebaceous apparatus (H and E, ×100), (b) sebaceous gland (H and E, ×400)|
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Atrophy, seen in 26 (32.5%) cases - 14 (100%), LL; 7 (77.7%), BL; 3 (11.5%), BT and 2 (66.6%), BB-was the only significant epidermal histopathological finding, epidermis being unremarkable in 42 (52.5%), and ulcerated in the remaining 12 (15%). Grenz zone was present in all 14 cases of LL and 6 (66.66%) of the 9 cases of BL. Epithelioid granulomas were seen in 9 (82%) of the 14 cases of TT and 7 (27%) of the 26 cases of BT leprosy.
The clinico-histopathological correlation ranged from 25% in BB to 80% in TT leprosy, being 75.8% in BT; 75%, LL; 66.6%, IL and 58.3%, BL. The "overall" correlation, irrespective of the type of leprosy, was 70%. We did not observe any case of pure neuritic leprosy [Table 1].
| Discussion|| |
Age of patients ranged from 14 to 74, majority (50; 62.5%) belonged to 21-40 years of age; in the <20 years age group there were a total of four cases, two each of IL and BT leprosy. The majority (48-52.3%) of patients of some previous similar studies from India, too, were from 21 to 40 years of age. Some previous similar studies from India also observed majority (48-52.3%) of their study patients to belong to 21-40 years of age.,, The male preponderance (M:F2.3:1) in our study has also been reported in many previous studies.,,, As per Noorden, this preponderance could result not only from greater likelihood of males acquiring infection due to their lifestyle but also inhibition of many females from reporting for treatment due to the social taboos and customs.
Loss of sensation, nerve thickening, hypopigmented macules, and erythematous patches were detected in 56 (70%), 54 (67.5%), 49 (61.25%), and 33(41.25%) of our cases, respectively. Limb deformities were seen in 11 (13.75%) and trophic ulcers, in 6 (7.5%) cases. Moorthy et al. found hypopigmented lesions (80.91%) to be the most common clinical finding. BT leprosy, the most common clinical type seen in 29 (36.3%) of our study patients, was also recorded to be the most common in the studies by Bijjaragi et al. (47.9%) and Moorthy et al. (54.5%). However, Pandya and Tailor (30%), Manandhar et al. (25.3%), and Thakkar and Patel (23.3%) recorded the most common clinical type to be TT [Table 2].
|Table 2: Comparison of clinical and histological subtypes among various study groups|
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BT leprosy, seen in 26 (32.5%) cases, was the most common histopathological type among the 38 (47.55%) cases of the borderline spectrum; remaining being BL, 9 (11.25%) and BB, 3 (3.75%). This predominance of the borderline group on HPE has also been observed in the previous studies from India., 11, ,, The two polar types of leprosy, as also IL, had the identical prevalence of 14 (17.5%) on HPE in our study; their prevalence in other Indian studies is listed [Table 2].
The hypopigmented patches on the face in children have a high risk of misdiagnosis, especially so in cases of IL in whom sensory deficit may either be absent or difficult to elicit. The evident importance of biopsy as an aid in diagnosis of such cases was highlighted by the detection of five cases of IL out of the nine skin biopsies from patients presenting with hypopigmented macule(s) with intact sensory perception over head and neck area.
We observed the clinico-histopathological correlation of 80% in TT leprosy, which in the earlier Indian studies had ranged from 24% to 75%., 11, ,, The correlation observed in other types of leprosy was: 75.8%, BT; 75%, LL and 25%, the minimum among our study, in BB leprosy. Previous Indian studies have also reported this concordance to be minimum among BB leprosy [Table 3].,
|Table 3: Comparative study of clinico-pathological correlation by different authors|
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The overall clinico-histopathological parity of 70% seen in our cases was more than that of 45.3-62.6% recorded in some other previous studies from India [Table 3].,,,
| Conclusion|| |
Cardinal signs of leprosy entail only clinical judgement and skin smear examination. As the present cornerstone of leprosy control hinges on reducing the load of infection in society by breaking the chain of infection, detection of its cases and ensuring their adequate treatment at the earliest become paramount. As some early/indeterminate/borderline cases of leprosy may bemuse clinically, may overlap and lack cardinal sign(s), clinico-histopathological corroboration could improve diagnostic yield as seen in our study wherein five cases of IL emerged on HPE from among the nine cases having fully sensate hypopigmented macules which had been variously treated previously by practitioners. As the small size, short duration, and restricted case selection of our study limit the extrapolation of its results, larger studies are imperative to finetune further strategies to prevent the resurgence of leprosy.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]