Leprosy

Screening of family contacts should be performed.

BCG vaccine - see section on Immunisation

* but not less than 150 mg of rifampicin

Duration of therapy is now reduced to 12 months, with adequate education and follow up.

• At the time of stopping treatment, it is important to educate the patients about the signs and symptoms or relapse and reaction and request them to come back immediately.
• Lepromatous or borderline lepromatous patients who return not showing any improvement or with evidence of deterioration will need an additional 12 months of MDT for multibacillary leprosy.
• Review patients regularly for 12months to diagnose deterioration as early as possible.

Treat with:

*Not less than 150 mg of rifampicin.

MDT should be supplied in 28-day blister packs for ease of ordering and to avoid medicine wastage. Specific blister packs are available for children.

This is a cell-mediated immune reaction to mycobacterium leprae. It is characterised by swelling of skin lesions that become oedematous, red and tender. New lesions may appear. Peripheral nerves may become swollen and tender, with loss of sensation and paralysis in the distribution of the nerves involved. The reactions can occur before MDT is commenced or after completion of MDT, but they are commonest during the first 3 months of MDT. The full dose of anti-leprosy medicines must be continued in addition to treatment of the reaction.

Mild Reversal Reaction

A reaction in which only the skin, not the nerves, are involved:

If there is no improvement, consider treatment with corticosteroids. If there is evidence of neuritis (tender nerves, nerve deficit) use corticosteroids as below. Do not wait for nerve damage to appear as it may be too late for function to return.

Severe Reversal Reaction

A reaction in which there is also new nerve damage with loss of sensation and /or motor function in hands, feet or eyes.

'New' implies additional to what the patient already had at registration or developed within the last 6 months.

Admit to hospital. Treat with corticosteroid: 

Patients can be discharged at the dosage of 20 mg daily for subsequent outpatient review.

In this reaction immune complex formation and deposition occurs with the activation of complement. This type of reaction is characterised by crops of tender subcutaneous nodules on the face, trunk and extensor surfaces of the limbs. It may include systemic features such as fever, lymphadenitis, orchitis, arthritis, nephritis, iridocyclitis and peripheral neuritis. Severe ENL may also present with ulcerating and pustular lesions. The full dose of anti­-leprosy medicines should be continued in addition to the treatment of the reaction.

Mild Type II Reaction

If there is no improvement or the patient develops nerve damage, corticosteroids are indicated.

Severe Type II Reaction

Admit for corticosteroid therapy and refer to specialist urgently:

Recurrent Type II Reaction

Use clofazimine in anti-inflammatory dosage in addition to prednisolone. Attempt to taper prednisolone while maintaining clofazimine as below:

Refer all patients developing abdominal complaints (pain, constipation, distension).

It may take 4 to 6 weeks for clofazimine to take effect in controlling ENL.

• Be on the alert for new onset of diabetes or exacerbation of known diabetes. Diabetes will need careful monitoring - ideally as an inpatient.
• Blood pressure should also be monitored.
• Also watch for tuberculosis or gastrointestinal parasitic infections that might be revealed by the use of steroids.
• If difficulties arise in balancing treatment of reactions and side effects, refer for specialist care.

All patients should be managed at primary care level under the guidance of District and Provincial TB/Leprosy Co-ordinators. Complicated cases should be referred to the Tropical Diseases Unit at Harare Central Hospital. Advice can be obtained from the Leprosy Mission on telephone Harare +263( 4) 251647.