About the Book

The book covers all aspects of leprosy, including its history, epidemiology, immunogenetics, bacteriology, immunology, pathology of Mycobacterium leprae, mechanisms of nerve damage, disease classification, clinical and laboratory diagnosis, differential diagnosis, chemotherapy, lepra reactions and their management and National Leprosy Eradication Programme.
Includes chapters related to basics of history taking and clinical examination, techniques of nerve examination, ocular leprosy, vaccines (immunoprophylaxis and immunotherapy), chemoprophylaxis, deformities and their management, recording and assessment of nerve involvement and experimental leprosy.
Covers special situations, viz. leprosy in children, leprosy and pregnancy, leprosy associated with HIV and issues related to community-based rehabilitation, psychosocial aspects, stigma, and migration in leprosy.
Presents clear and comprehensive information that help in diagnosing leprosy in low endemic situations.
Discusses problems of drug resistance, challenges and scenario beyond 2020.
Highlights the role of NGOs in the eradication program, and the case histories for achieving the control over leprosy.
Contains the most up-to-date and comprehensive material from 84 acclaimed experts of national and international repute based on the wealth of their expertise.
Gives an idea of how the disease looks in different shades of skin color through photo gallery.
Improves the diagnostic accuracy with the help of nearly 450 figures that capture the presentation of leprosy in practice.
Enhances clinical and therapeutic knowledge with the latest guidance on diagnosis and other rapidly changing research areas in leprosy.
Ideal book for dermatologists, leprologists, internists, epidemiologists, social scientists, laboratory and research persons, teachers and students, national and international NGOs and the Health Ministers.

About the Author

Bhushan Kumar MD FRCP (Edin) FRCP (London) Hemanta Kumar Kar MD MAMS

Table of Contents:
Contents Section 1: The Disease History and Epidemiology 1. History of Leprosy in India: A Historical Overview from Antiquity to the Introduction of Mdt 3 KV Desikan, Shubhada S Pandya Historic Authentication of Leprosy in India 3; The Evolution of Modern Leprology 3; Pathology 8 The Era of Chaulmoogra/Hydnocarpus Oil Therapy in India 9; Leprosy as A Public Health Problem 11 Icbelra in Madras Province 13; The Bhore Committee 14; Legislation 15; The Era of New Drugs 17 Developments at Independence 17; Indian Social Initiatives and Gandhiji’s Support 19 The Indian Association of Leprologists 24; Surgeons as Trail Blazers 29 2. Epidemiology of Leprosy 33 PL Joshi Leprosy and International Disease Classification 34; Definition of Leprosy 34 Geographical Distribution and Prevalence 34; Agent 37; Host Factors 37 Environmental Factors 39; Disability 39; Transmission 39; Incubation Period 40 Diagnosis 40; Classification of Leprosy 41; Epidemiological Indicators for Monitoring 41 Relapses 43 3. Global Leprosy Situation: Historical Perspective, Achievements, Challenges and Future Steps 45 Sumana Barua Leprosy: A brief overview 45; History of the Disease 46 History of Treatment of Leprosy 46; Global Leprosy Situation 48 Evolution of Global Leprosy Strategies: To Ensure Relevant Technical Assistance from WHO 50 Measure for Disease Burden due to Leprosy 51 Remaining Challenges in Further Reducing the Disease Burden 51; International Leprosy Summit 52 Need to Change the Image of Leprosy in the Community 53 Policy Guidance by WHO for Member States National Leprosy Programs 53 Key Messages on Leprosy 54; Further Steps in Defining Global Leprosy Strategy 2016–2020 55 List of Publications on Leprosy by WHO Global Leprosy Programme 55 Technical Report Series: WHO Expert Committee on Leprosy 55 WHO Technical Advisory Group on Leprosy Control: Meeting Reports 55 Global Program Managers’ Meeting Reports 55 Sentinel Surveillance for Drug Resistance in Leprosy: Meeting Reports 55; Training Manuals 55 Weekly Epidemiological Record (WER) 56 4. Changing National Scenario, National Leprosy Control Programme, National Leprosy Eradication Programme, and New Paradigms of Leprosy Control 59 CM Agrawal, BN Barkakaty Preface 59; Vision 59; Mission 59; Progress Through Different Stages 59 Editors’ Views 68 Section 2: Basic Scientific Considerations and Pathology 5. Immunogenetics of Leprosy 73 Rajni Rani Genes and Proteins of the Major Histocompatibility Complex 74 Nomenclature of the Human Leukocyte Antigen 76; Human Leukocyte Antigen and Leprosy 77 Other Genes Involved in Susceptibility to Leprosy 78; Genome Wide Association Studies 81 xviii Ial Textbook of Leprosy 6. Bacteriology of Leprosy 90 B Sekar Mycobacteria 90; Pyridine Extraction 93; Clinical Spectrum of Leprosy 94 Immunological Properties of M. leprae 94: Pathogenesis of M. leprae 94 Metabolism of M. leprae 94; Biological Properties of M. leprae 95 Experimental Animal Models for M. leprae 97; Other Experimental Animals 98 Drug Resistance 98; Laboratory Diagnosis of Leprosy 99 7. Immunological Aspects 105 Indira Nath, Mehervani Chaduvula General Immune Responses 105; Immunological Features of leprosy 106 Leprosy Reactions 111; Immunopathology of Dermal Lesions 112 Nerve Damage in Leprosy: The Immune Mechanisms 113; Immunogenetics of Leprosy 115 8. Biochemical Aspects of Leprosy 119 Krishnamurthy Venkatesan, Nirmala Deo Mycobacterium leprae 119; Host-M. leprae Interactions 122 Hematological, Serological and Biochemical Changes in Patients with Leprosy 123 Serum Enzymes 127 9. Pathological Aspects of Leprosy 132 Dullobho Porichha, Mohan Natrajan Need for Histopathology 132; Histology of Various Types of Leprosy 133 Regressing Lesions 141; Reactions in Leprosy 142; Relapse in Leprosy 145 Involvement of Other Organs 145 10. Structure, Electrophysiological and Ultrasonographic Studies of Peripheral Nerve 152 Sujai K Suneetha, P Narasimha Rao, Suman Jain Structure and Function of Peripheral Nerve 152; Structure of Nerve 153 Types of Nerves 154; Nerve Supply to the Skin 155; Nerve Endings 155 Damage to Peripheral Nerves 156; Mycobacterium leprae and Neural Predilection 156 Electrophysiological Studies on Peripheral Nerves in Leprosy 157 Electrophysiological Study by Emg 157; Application of Electrophysiological Studies in Leprosy 159 High Resolution Ultrasonography as an Imaging Tool in Leprosy 160 High Resolution Ultrasonography 161 11. Pathomechanisms of Nerve Damage 170 Vanaja Prabhakar Shetty General Features of Nerve Damage in Leprosy 170; Entry of M. leprae into the Nerves 172 Infection of Schwann Cells by M. leprae 173 Type of Degeneration and Regeneration Seen in Leprous Nerves 174 Immunological Aspects of Nerve Damage 174; Autoimmune Type of Damage 176 Role of Mycobacterial Antigens in Nerve Damage 176 Role of Inflammatory Cytokines in Nerve Damage 176; Insidious Nerve Damage 177 Neuropathic Pain 177; Leprosy Reactions and Nerve Damage 177 12. Naturally Occurring Leprosy: Mycobacterium leprae and Other Environmental Mycobacteria in Nature 182 UD Gupta, Partha Sarathi Mohanty Molecular Biology of Mycobacterium leprae 182; Transmission 183 13. Experimental Leprosy: Contributions of Animal Models to Leprosy Research 186 Linda B Adams, Maria T Pena, Rahul Sharma, Ramanuj Lahiri, Richard W Truman Mouse Model 186; Armadillo Model 192 Section 3: Clinical, Laboratory Diagnosis and Differential Diagnosis 14. History Taking and Clinical Examination 207 Aparna Palit, Ragunatha S, Arun C Inamadar History Taking 207; Clinical Examination 211 Contents xix 15. Case Definition and Clinical Types of Leprosy 236 Bhushan Kumar, Sunil Dogra Case Definition 236; Classification of Disease 238; Clinical Features 239; Rare Variants of Leprosy 248 Nerve Involvement 252; Systemic Involvement 252 16. Classification 254 Radhey Shyam Misra, Joginder Kumar Kataria Need for Classification 255; Classification Criteria 255 Madrid Classification 256; Indian Classification 256; New Ial Classification 257 Ridley-Jopling Classification 257 World Health Organization Classification (1988) for Leprosy Control Programs 258 World Health Organization Classification (1998) 259 Classification Presently used in India for Treatment Purposes (who Classification as Modified Under Nlep) 259 Miscellaneous Criteria in use for Classification into Pb and Mb 259 Classification: Present Global Perspective 260; Correlation among Various Classifications 260 17. Methods of Nerve Examination 263 BK Girdhar Nerve Examination 263; Palpation of Nerve Trunks 264; Palpation of Cutaneous Nerves 265 18. Histoid Leprosy 268 Virendra N Sehgal Historical Landmarks 268; Definition 268; Epidemiology 268; Clinical Features 269 Bacteriology 269; Histopathology 271; Tuberculoid Contamination 272; Ultrastructure 272 Immunoprofile 273; Diagnosis 273; Differential Diagnosis 273; Treatment 274 Significance of Histoid Lepromas 275 19. Laboratory Diagnosis 278 Joyce Ponnaiya Slit-Skin Smear Examination 278; Slit-Skin Smear—its Role and Indications 278 Bacterial Index 280; Morphological Index 281; Nasal Mucosal Smears 281 Skin Biopsy 282; Fixatives 283; Hematoxylin-Eosin Stain 283 Job-Chacko Modification of Fite-Faraco Stain for M. leprae 284 Gomori-Grocott Methenamine Silver Stain 284; Fluorescent Microscopy to Detect M. leprae 285 Immunochemical Staining to Demonstrate Mycobacterial Antigens 285; S-100 Stain for Schwann Cells 285 Nerve Biopsy 285; Histamine Test 286; The Sweat Test 286; Cytological Diagnosis of Leprosy 287 Fine Needle Aspiration Cytology for Cutaneous Lesions of Leprosy 287 20. Serological and Molecular Diagnosis of Leprosy 290 U Sengupta, VM Katoch Serodiagnosis 290; Future Scope for Immunoassays 292 Genome of M. leprae 292; Detection of Drug Resistance 294; Future Perspective 294 21. Differential Diagnosis of Dermatological Disorders in Relation to Leprosy 298 NL Sharma, Vikram Mahajan Pityriasis Alba 299; Polymorphic Light Eruption 299; Vitiligo 299 Nevus Achromicus/Nevus Anemicus 308; Acquired Hypomelanosis 308 Contact Leukoderma 308; Pityriasis Versicolor 308; Psoriasis 308; Cutaneous Sarcoidosis 310 Granuloma Annulare 310; Leishmaniasis 310; Cutaneous Tuberculosis 312 Lupus Miliaris Disseminative Faciei 312; Discoid Lupus Erythematosus 312 Malignancies 312; Miscellaneous Rare Conditions 313; Some General Points to Remember 313 22. Differential Diagnosis of Neurological Disorders in Relation to Leprosy 316 Bela J Shah Patterns of Neuropathy 316; Epidemiology 317; Basic Anatomy 317; Pathophysiology 317 Basic Terminology 318; Diagnostic Approach 318; History 318 Physical Examination 320; Laboratory Testing 321 Various Neuropathic Disorders 321; Hereditary Neuropathy 326 xx Ial Textbook of Leprosy Section 4: Systemic Involvement and Special Situations of Leprosy 23. Systemic Involvement in Leprosy 331 V Ramesh, Joginder Kumar Kataria Bacillemia in Leprosy 331; Bones, Joints and Muscles 332; Nail Involvement 335 Eyes 335; Upper Respiratory Tract (Nose, Paranasal Sinuses, Oral Cavity, Oropharynx, and Larynx) 336 Lower Respiratory Tract 337; Gastrointestinal Tract 337; Reproductive System 337 Kidneys 337; Endocrine Glands 338; Lymph Nodes, Bone Marrow, and Spleen 338 Central Nervous System 339; Cardiovascular System 339; Hematology and Serology 339 24. Leprosy and Human Immunodeficiency Virus Coinfection 344 Archana Singal Prevalence and Diagnosis 344 Predominance of Multibacillary or Paucibacillary Type and Clinical Features 345 Complications, Reactions, Relapse and Outcomes 345; Response to Treatment 346 Impact of Leprosy on Hiv Progression and Antiretroviral Therapy 346 Immunology and Histology in Leprosy-Hiv Coinfection 347 Immune Reconstitution Inflammatory Syndrome 348 25. Leprosy and Pregnancy 352 Neena Khanna Effect of Leprosy on Female Reproductive System 352; Effect of Pregnancy on Leprosy 353 Presentation of Leprosy in Pregnant Women 354; Effect of Leprosy on Pregnancy 356 Postpartum Period 356; Impacts on Infant and Lactating Mother 357; Practical Tips 358 26. Childhood Leprosy 360 Archana Singal, Namrata Chhabra Epidemiology 360; Transmission 361; Classification 361; Clinical Presentation 362 Diagnosis 366; Treatment 367; Prevention 367 27. Ocular Leprosy 370 Daniel Ebenezer Ocular Involvement 371; Clinical Examination of the Eye in Leprosy 371 Lagophthalmos and Other Lid Deformities 378; Corneal Involvement 382; Ocular Inflammations 385 Cataract 387; Intraocular Pressure 389; Ocular Deformity Classification in Leprosy 390 Section 5: Disease Complications (Nerve Involvement, Neuritis and Reactions) 28. Neuritis: Definition, Clinicopathological Manifestations and Proforma to Record Nerve Impairment in Leprosy 397 P Narasimha Rao, Sujai K Suneetha, Gigi J Ebenezer Definitions 397; Pathological Basis of Neuritis 398 Mechanisms of Neuritis Across the Spectrum of Leprosy 399 Mechanism of Neuritis during Reactions 400; Clinical Presentations of Neuritis 400 Neuritis Associated with the Disease 401; Neuritis Associated with Reactions 401 Silent Neuritis or Quiet Nerve Paralysis 402; Clinical Manifestations of Neuritis 402 Methodology to Record Nerve Involvement 404; Clinical Grading of Nerve Thickening, Tenderness and Pain 404 Tools to Assess Sensory and Motor Nfi and Integrity of Peripheral Nerves 405 Tools to Assess Motor Nfi 409; Tools to Assess Autonomic Nfi 409; Examination of Eyes in Leprosy 410 Disability in Leprosy and its Grading 410; Proforma to Record Nerve Function Impairment 411 Motor Function Assessment of Important Nerves by Voluntary Muscle Testing 412 Proforma as for Recording Nfi in the Eye 412 Proforma to Record Clinical Grading of Nerve Involvement in Leprosy 413 Proforma to Record Disability, Deformities and Ulcers 413 xxi 29. Leprosy Reactions: Pathogenesis and Clinical Features 416 Hemanta Kumar Kar, Amrita Chauhan Types of Leprosy Reactions 416; Epidemiology 417; Type 1 Reaction (Reversal Reaction) 418 Type 2 Reactions 424; Lucio Phenomenon 434 Section 6: Therapeutics (Medical and Surgical), Prophylaxis and Vaccines 30. Chemotherapy of Leprosy 441 Paul R Saunderson Dapsone 442; Rifampicin 442; Clofazimine 443; Ethionamide/Prothionamide 444 Fluoroquinolones 444; Minocycline 444; Clarithromycin 445; Bedaquiline 445; Persisters 445; Relapse 445; Future Regimens 446 31. Chemotherapy: Development and Evolution of WHO-MDT and Newer Treatment Regimens 448 VV Pai, RR Rao, V Halwai Some Significant Landmarks in the Treatment of Leprosy and the Evolution of Mdt 448 Who Study Group on Chemotherapy of Leprosy 450; History of Mdt 450 Post-treatment Surveillance 452; Chemotherapy of Leprosy: Further Challenges 454 Chemotherapy and Related Clinical Issues 455; Recommendations for Research Trials 458 32. Management of Leprosy Reactions 465 Hemanta Kumar Kar, Ruchi Gupta Early Diagnosis of Reaction 465; Management of Type 1 Reaction or Reversal Reaction 465 Treatment of Late Reversal Reaction 468; Management of Type 2 Reaction 468 Management of Lucio Phenomenon 475 33. Management of Neuritis and Neuropathic Pain 478 Bhushan Kumar, Sunil Dogra Diagnosis and Monitoring 479; Management 480; Corticosteroids 481 Other Anti-inflammatory Agents 483; Clofazimine 483; Thalidomide 483 Azathioprine 483; Cyclosporine 484; Intraneural Administration of Drugs 484 Chronic Neuropathic Pain 484; Surgery 485; General Measures 486 Prevention 486; Newer Approaches of Treatment 487 Human Immunodeficiency Virus and Leprous Neuritis 487 34. Chemoprophylaxis in Leprosy 490 BK Girdhar Who Needs Chemoprophylaxis? 490; Dapsone Chemoprophylaxis 491 Rifampicin for Protection Against Leprosy 493; Application of Chemoprophylaxis 494 35. Leprosy Vaccines: Immunoprophylaxis and Immunotherapy 496 Kiran Katoch Immunoprophylaxis 496; Chemoprophylaxis 498; Immunotherapy 499 36. Nursing Care in Leprosy Patients 506 Vineet Kaur, Gurmohan Singh Nursing Assessment of a Leprosy Patient 506; Assessment During Repeat Visits 509 Assessment of “Risk” Status 509; Assessment of Activities of Daily Living 509 Role in the Care of Anesthetic Limbs 510; Intervention in Deformity due to Leprosy 512 Intervention for Care of the Eyes in Leprosy 515; Role in the Care of Women with Leprosy 515 Role in the Care of Indoor Patients 516 37. Deformities of Face, Hands, Feet and Ulcers and their Management 517 Atul Shah, Neela Shah Clinical Manifestations 517; Disabilities and Deformities in Leprosy: Terminology 518 Nerve Involvement 519; Testing for Nerve Damage 519; Deformities of Hands 522 Deformities of Feet 526; Deformities of Face 528 Contents xxii Ial Textbook of Leprosy Reconstructive Surgery (in Disability Prevention and Medical Rehabilitation)—A Government of India Initiative 529 Economic Rehabilitation 530; Health Education to a Person Affected with Leprosy 531 Numbness? No Sensation in your Hands or Feet? 536 Section 7: Miscellaneous 38. Deformity and Disability Prevention 541 GN Malaviya Types of Deformities 541; Grading of Disabilities and Deformities 542 Factors Affecting the Onset and Progression of Disabilities 543 Causation of Deformities 544; Effects of Infiltration of Tissues by M. Leprae 544 Effects of Motor Paralysis 547; Effects of Anesthesia and Analgesia 547 Prevention of Disabilities 547; Anticipating Nerve Function Impairment 548 Role of Steroids 548; Role of Nerve Trunk Decompression 548 Care of the Eyes 548; Management of Reactions 548; Monitoring and Self-reporting 548 Evaluation of the Patient and Assessment of Disability 549; Role of Physiotherapy 549 Techniques of Physiotherapy as Applied to Leprosy Affected Persons 550 Prevention of Progression of Disabilities 556 Disabilities in Leprosy in the Context of Newer Concepts 558 39. Relapse in Leprosy 562 Devinder Mohan Thappa, Sowmya Kaimal, Divya Gupta Definition 562; Relapse Rate 563; Microbiological Aspects 564 Immunological Tests for Relapse 564; Histopathology 565; Relapse Interval 565; Classification of Relapse 566; Predisposing Factors for Relapse 566; Clinical Features 567 Differential Diagnosis 567; Diagnosis 569; Treatment 570; Failure to Respond to Therapy 570 40. Drug Resistance in Leprosy 573 Masanori Matsuoka Chemotherapy 573; Method for Susceptibility Assay 576 Sentinel Surveillance by WHO 578; Relapse and Persisters 578 Viability in Various Conditions 579 41. Morbidity and Mortality in Leprosy 583 Ben Naafs, S Noto, PAM Schreuder Morbidity 583; Mortality 584 42. Recording-Reporting and Monitoring MDT Services 587 Pratap Rai Manglani Terms Used 587; Records 591; Reports 591 Validation Mechanism at Different Level 593; Performance Assessment 594 Section 8: Rehabilitation and Social Issues 43. Rehabilitation 619 D Kamaraj Leprosy Rehabilitation 619; Community Based Rehabilitation 620; Sample Referral Format 626 Rehabilitation Services for Disabled Persons under the Ministry of Social Justice and Empowerment 626 Vocational and Employment Services/Opportunities for People with Disabilities under the Ministry of Labor 628 Services for Disabled Persons under the Ministry of Rural Development 628 44. Community-based Initiatives in Comprehensive Leprosy Work 630 PV Ranganadha Rao Leprosy Program 631 Rationale and Purpose of Community-based Initiatives for Comprehensive Leprosy Work 632 xxiii Community Participation in Primary Health Care 632; Opportunities for Community-based Initiatives 634 Scope of Community-based Initiatives in Leprosy 635 Experiences of Community-based Initiatives in Comprehensive Leprosy Work 635 45. Psychosocial Aspects in Leprosy 641 PK Gopal Stigma 641; Rehabilitation 643; Categorization of Leprosy Affected Persons 644 Empowerment 645 46. Human Rights and Stigma in Leprosy 646 VV Dongre In the Footsteps of Time... 646; Social Aspects 646; Medical Implications 647 Aspects of Discrimination: Human Rights Violations 647 Parsi Marriage Act of 1936 (No Divorce Granted on the Ground of Leprosy) 648 Employment Rules 649; Winds of Change 650; Voice of Awakening 650 47. Migration and Leprosy 652 Mohammad Aleem Arif Effects of Migration on Leprosy Control 653 Migration, Stigma and Human Rights in Leprosy 655 48. Health Promotion, Education and Counseling 657 Manimozhi Natarajan Perspectives 657; Health Promotion 658; Health Education 658 Information, Education and Communication 659; Interpersonal Communication 663 Case Study 666; Communication Skills 666; Programme Focus in Relation to Leprosy 668 Key Issues in Communication for Leprosy Programme 669 Activity Planning Versus Strategic Planning 670 49. Role of NGOs in National Leprosy Eradication Programme 672 Thomas Abraham, Pankaj Sharma, Atul Shah, VV Pai, Mohammad Aleem Arif Major Ngos Working in Partnership with Nlep 672; Local Voluntary Organizations 684 Section 9: Future Prospects 50. Leprosy: Future Challenges 687 Diana NJ Lockwood Immunoprophylaxis 687; Diagnosis 688; Immunotherapy 689; Immunosuppression 690 Erythema Nodosum Leprosum 690; Neuropathic Pain 690 51. Leprosy Scenario Beyond 2020 694 PS Sundar Rao The Journey So Far 694; The Current Scenario 695; The Future 696 52. Leprosy Scenario Beyond its Elimination 704 Marcos Virmond The Elimination Strategy 705; Leprosy Beyond Elimination 706; Clinical Expertise 708 Transmission and Vaccine 709; Research 710 53. Leprosy Recognition and Treatment in a Low Endemic Setting 713 David M Scollard Background 713; What is Low Endemic? 713 Integration of Leprosy Services into General Health Care 714 Goals and Requirements of Leprosy Services in Low Endemic Situations 714 The United States Experience as a Model for Management of Leprosy in a Low Endemic Situation: Carville 2.0 714 Contents xxiv Ial Textbook of Leprosy 54. Case Studies 718 Pankaj Sharma, Hemanta Kumar Kar, Ruchi Gupta Childhood and Disease Detection 722; Public Pressure for Isolation 722 Shift Away from the Native Land 723; Choice of Profession 723 The Social Mobilization of LAPs 724; Family and the Children 724; Embracing Christianity 724 Social Implications of Disease 726; No Family, Alone in the World 727; The Children 727 The Mission Factor 727; The Religion 728; Indirect Pressure for Extradition 728 Treatment and Long Stays at Various Missionary Hospitals 729 Move to Delhi (and No to Begging) 730; Marriage and Children 731 A Social Server by Heart and a Philanthropist 731; The Changing Scenario 733; Message 734 Photo Gallery 735 Index 743