Multibacillary Leprosy in a Child

Arridha Hutami Putri

, Mila Darmi

, Ramona Dumasari Lubis

Department of Dermatology and Venereology, Faculty of Medicine Universitas Sumatera Utara, Jln. Dr. Mansur No. 66,

Medan, Sumatera Utara

Department of Dermatology and Venereology, General Hospital of H. Adam Malik, Jln. Bunga Lau No. 17, Medan,

Sumatera Utara

Corresponding author

Keywords: Leprosy, Children, Multibacillary, M leprae

Abstract: This manuscript aims to review the cutting-edge developments regarding the diagnosis, management, and

prevention of leprosy in children. Where leprosy in children is a robust indicator of the active source of

infection in the community, we reported a case of borderline lepromatous leprosy in a 14-year-old boy. He

came with the chief complaint of swelling of left little finger since one month ago. The patient also

complaint blackish patch with loss of sensations on the left hand since two years ago. After one year, there

was an appearance of papules on the ears and sparse eyebrows followed by swelling of left little finger one

month ago. His father was already diagnosed as multibacillary leprosy eight years ago and had completed

the treatment. There is no history of BCG vaccination. Physical examination revealed sparse eyebrows

(madarosis), dermatological examination revealed diffuse hyperpigmentation macular with anesthesia on the

left hand, papules and infiltrate on the ear lobes. Sensibility examination revealed anesthesia on the left

hand, which is innervated by the ulnar and median nerve. Thickened and tenderness found on the ulnar

nerve and muscle weakness grade 3 was found on the left hand, which is innervated by the ulnar nerve.

Ziehl-Neelsen staining of slit skin smear revealed acid-fast bacilli with Bacteriological Index 4+. The

patient was diagnosed as multibacillary leprosy then prescribed with multi-drug therapy and advice on daily

care routinely. The prognosis of the patient is good since no disabilities. Early diagnosis and treatment is a

fundamental strategy to prevent leprosy transmission.

1 INTRODUCTION

Leprosy has been a major public health problem in

many developing countries for centuries. Children

are believed to be the most vulnerable group to

infection with Mycobacterium leprae given their

nascent immunity and possible intrafamilial contact

(Singal et al, 2010). Leprosy in children has a

significantly unique aspect because of its potential to

cause progressive physical deformity with serious

consequent psychosocial impact on both the child

and the family. Epidemiologically, childhood

leprosy is an index of transmission of disease in the

population (Kaur et al, 1991). In the post-elimination

era, the incidence of leprosy amongst young children

indicates active foci of transmission in the

community, making it a robust epidemiological

indicator to assess the progress of leprosy control

programs (Singal et al, 2010).

Amongst children, the

disease tends to occur with the highest frequency in

children of 5–14 years age group and only 5.8–6%

cases are below five years of age. This may be due

to the relatively long incubation period of leprosy

and delayed diagnosis of indeterminate lesions in

children. Among children, boys are more commonly

affected than girls. This may be due to greater

mobility and increased opportunities for contact in a

male child (Shetty et al, 2013).

Familial contacts are

known to have a significant role in the development

of childhood leprosy.The risk of developing leprosy

in a person is four times when there is a

neighborhood contact. However, this risk increases

to nine times when the contact is intra-familial.

Further, the risk gets higher if a contact has a

multibacillary (MB) form. The attack rate reportedly

increases when the index case is mother (Singal et

al, 2010; Jain et al, 2002).

The mode of transmission of leprosy is still not

conclusively proven although infection can occur

Putri, A., Darmi, M. and Lubis, R.

Multibacillary Leprosy in a Child.

DOI: 10.5220/0009990304070410

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 407-410

ISBN: 978-989-758-469-5

407

through very long and close contact. Another

presumption is by nasal droplets inhalation (Singal

et al, 2010; Wisnu et al, 2016). There is also

epidemiologic evidence to suggest that leprosy may

be transmissible from mothers to offsprings via the

placenta. The report of a child developing leprosy at

the age of 3 weeks is an example where the infection

could have been intrauterine. Although M. leprae are

known to be present in the breast milk of mothers

suffering from lepromatous leprosy, the risk of

acquiring leprosy infection in the breastfed infant via

the gastrointestinal tract remains uncertain (Singal et

al, 2010).

Leprosy in children can be challenging to

identify, mainly because of the peripheral nerve

function evaluation. The younger the child, the more

difficult the changes in sensitivity are to evaluate.

Leprosy diagnosis is based on clinical signs and loss

of sensation, associated or not with thickened

nerves. Although there are no laboratory exams that

can detect all cases of leprosy, the presence of acid-

fast bacilli (AFB) in skin smears is conclusive for

leprosy diagnosis (Singal et al, 2010; Wisnu et al,

2016).

Given that one of the main targets of the

global leprosy strategy is zero disabilities among

new pediatric patients (children below the age of 15)

by 2020, this case report aims to review the cutting-

edge developments regarding the diagnosis,

management, and prevention of leprosy in children.

2 CASE

A 14-year-old boy came for treatment in polyclinic

Dermatology and Venereology H.Adam Malik

General Hospital presented He came with the chief

complaint of swelling of left little finger since one

month ago. The patient also complaint blackish

patch with loss of sensations on the left hand since

two years ago. After one year, there was an

appearance of papules on the ears and sparse

eyebrows followed by swelling of left little finger

one month ago. No report of fever, joint pain or

urinary problem and the same compliance before.

His father was already diagnosed as multibacillary

leprosy eight years ago and had completed the

treatment. There is no history of BCG vaccination,

and the patient did not complete his vaccination. In

physical examination, the vital signs were within

normal limits, and nutritional status was normal, but

we found sparse eyebrows (madarosis) (see figure

1a). Dermatological examination revealed diffuse

hyperpigmentation macular with anesthesia on the

left hand (figure 1b and 1c). There were papules and

infiltrates on the ear lobes (figure 1d). The sensory

examination revealed anesthesia to touch and pain

stimulus in the skin lesions and area, which is

innervated by ulnar nerve and median nerve. On

palpation of the peripheral nerves, thickening and

tenderness found on the ulnar nerve. The motoric

examination revealed grade 3 weakness in abduction

movement, which is innervated by the ulnar nerve.

We also noted a decrease in sweat production in the

area with skin lesion during activities.

Figure 1. (a) Madarosis in eyebrows. (b) (c) a diffuse

hyperpigmentation macular, the size of a placard

accompanied by anesthesia on the left hand. (d) infiltrate

on the ear lobes.

The differential diagnosis in these patients is

multibacillary type leprosy, postinflammatory

hyperpigmentation, and tinea manus. Then in the

patient carried out a bacteriological examination of

acid-resistant bacteria with a skin smear slit on ear

lobes, bacteriological index results of the left ear

lobe (+) 4 and right ear lobe (+) 4 were obtained

(figure 2). A diagnosis of multibacillary leprosy as

defined by the World Health Organization (WHO)

was made. The patients, without a clear history of

exposure to infectious diseases, were subsequently

treated with multidrug therapy, consisting of

monthly doses of rifampicin 450 mg and clofazimine

150 mg, plus daily doses of dapsone 50 mg and

clofazimine 50 mg. The patient was educated to rest

enough and to control routinely every month,

besides doing daily care routinely. The prognosis of

the patient is quo ad vitam bonam, quo ad

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

408

functionam dubia ad malam, and quo ad sanationam

malam.

Figure 2. The results of slit skin smear examination in

patients showed (+) 4.

3 DISCUSSION

Leprosy in children under the age of 15 is a

significant epidemiological indicator. This is related

to the active transmission of disease in the

community, recalling that the leprosy control

program carried out is not

efficient.(WHO,2015;WHO,2016) In children, this

disease most often occurs at the age of 5-14 years

and only 5.8-6% of cases in children under five

years old. This is due to the relatively long

incubation period and delayed diagnosis of

indeterminate lesions. More common in boys,

possibly due to greater mobility and increasing

opportunities for contact.(Shetty et al,2013) Family

contacts are known to play an important role in the

development of leprosy in children. The risk of

developing leprosy in a person increases nine-fold if

the contact is between families. Furthermore, the

risk increases if contact with an MB patient, and the

incidence increases if the source of contact is his

mother (Singal et al, 2010; Jain et al, 2002).

In this patient, the source of contact was his father

who diagnosed with a multibacillary type of leprosy

since eight years ago. So that patients are at risk of

leprosy from birth because of the long incubation

period of leprosy with an average of 2-5 years but

can also be up to 40 years. (Kementrian Kesehatan

RI,2014) Risks are increasing because patients are in

contact with multibacillary leprosy patients, and

there is not BCG immunization history. In the study

of Richardus and Oskam, someone who had

received a BCG vaccine in his childhood received

protection by 57%.(Richardus et al,2019)

Leprosy in children is very difficult to detect,

usually due to errors in examining peripheral nerve

function. In a much younger child, it is more

difficult to check for changes in sensibility.(Barreto

et al,2017;Romero-Montoya et al,2014). The

diagnosis in this patient based on history, physical

and dermatological examination, and investigations.

Based on WHO Expert Committee on Leprosy, the

enforcement of the diagnosis of leprosy in children

is the same as that of adult patients, namely if there

is at least one of the followings cardinal signs:

hypopigmented or erythematous skin lesions with

loss or disturbance sensation, peripheral nerve

involvement characterized by thickened or enlarged

peripheral nerve with nerve disorders and presence

of acid-fast bacilli in a slit-skin smear.(Lee et

al,2012) The patient complaint blackish patch with

loss of sensations on the left hand since two years

ago. After one year, there was an appearance of

papules on the ears and sparse eyebrows followed by

swelling of left little finger one month ago. Physical

examination revealed sparse eyebrows (madarosis),

and dermatological examination revealed diffuse

hyperpigmentation macular with anesthesia on the

left hand. There were papules and infiltrates on the

ear lobes. The sensory examination revealed

anesthesia to touch and pain stimulus in the skin

lesions and area, which is innervated by ulnar nerve

and median nerve. Thickened and tenderness found

on the ulnar nerve and muscle weakness grade 3 was

found on the left hand, which is innervated by the

ulnar nerve. We also noted a decrease in sweat

production in the area with skin lesion during

activities. Ziehl-Neelsen staining of slit skin smear

revealed acid-fast bacilli with Bacteriological Index

4+. Positive skin smears have been reported in less

than 10% cases. The skin smear positivity has been

shown to increase with age. (Singal et al, 2010)

Ridley and Jopling classification based on

clinical, histopathological, and immunological

criteria can be used for classifying leprosy in adults

and children as well. In most children, the most

leprosy spectrum is borderline tuberculoid (BT)

types with a prevalence of 42-78%. However, a

large proportion of early cases of childhood leprosy

remain AFB negative because most of them are TT,

BT, or indeterminate

(Singal et al, 2010)

simplified classification based on the number of

lesions and total peripheral nerve involvement was

given by WHO in 1998; paucibacillary-PB) and

multibacillary-MB. (Wisnu et al,2016;WHO,2016;

Kementrian Kesehatan RI,2014). School children

lesions are very preliminary, and the present

challenge is to diagnose them with very mild

Multibacillary Leprosy in a Child

409

symptoms, with no reactions nor disabilities, still on

PB form. (Barreto et al,2017) Multibacillary leprosy

presents as more than five skin lesions with

hypoesthesia or anesthesia, symmetrical nerve

thickening, and nerve function deficits, madarosis,

leonine facies, and deformities in an advanced

stage.(Bryceson et al,1990). The patient was

diagnosed as multibacillary leprosy due to having

madarosis and slit skin smear revealed acid-fast

bacilli with Bacteriological Index 4+. The

differential diagnosis of tinea manus can be ruled

out because the lesions in tinea are usually well-

defined with elevated or more active edges even

though they are accompanied by dry skin and affect

only one part of the body. However, KOH

verification was negative. Postinflammatory

hyperpigmentation can be excluded because there is

no history of injury or infection that occurred in the

patient's left hand before.

The patient then prescribed with multi-drug

therapy for children with MB leprosy and advice on

daily care routinely. In Indonesia, MDT for Children

is divided into under five years, 5-9 years, 10-15

years, and more than 15 years. In patients treated

with MDT MB children, which consists of

rifampicin 450 mg every month, clofazimine 150 mg

at the beginning of the month and 50 mg per day,

and dapsone 50 mg per day. The prognosis of the

patient is good due to no disabilities and deformities

were seen.

4 CONCLUSION

Early diagnosis and treatment is a fundamental

strategy to prevent leprosy transmission. Leprosy in

children below 15 years old is a robust indicator of

the active source of infection in the community

where they live. Subclinical infection among

children is considered a sentinel for hidden

prevalence in the general population, as well. Early

diagnosis in children can be hard, even for those

with experience in dealing with this disease, because

of the full range of clinical aspects of the skin

lesions and mainly due to the difficulty of

performing the clinical peripheral nerve evaluation.

The younger the child, the more difficult the changes

in sensitivity are to evaluate. Ongoing research is

trying to develop better diagnostic tests and to

advance chemoprophylaxis and immunoprophylaxis

approaches. However, for now, we must maintain

leprosy expertise and improve the health

professionals training for leprosy diagnosis

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