Journal of Clinical Dermatology & Therapy Category: Clinical Type: Review Article
Recent Advances in Diagnostic Techniques and New Hope towards Leprosy Elimination in the Post Elimination Era
- Prasad PVS1*, Kaviarasan PK1, Kannambal K1, Poorana B1, Abinaya R1
- 1 Department Of Dermatology Venereology And Leprosy, Annamalai University, Tamil Nadu, India
*Corresponding Author:Prasad PVS
Department Of Dermatology Venereology And Leprosy, Annamalai University, Tamil Nadu, India
Received Date: Apr 16, 2017 Accepted Date: Nov 01, 2017 Published Date: Nov 15, 2017
Leprosy has been known since 1500BC, but the early diagnosis of leprosy still remains a challenge. Many newer techniques have been developed to diagnose leprosy at the field level so that surveillance of contacts can be done in a better way. Early diagnosis of leprosy helps to block the transmission and also in preventing the deformity. As there is increasing incidence of resistance to rifampicin, clofazimine and dapsone, we are in a need of newer combination therapy for leprosy. This article reviews about the recent techniques for early diagnosis of leprosy and the newer combination therapy for drug resistance cases.
Leprosy becomes an ever challenging disease to entire medical fraternity, by the existence of fresh untreated cases, treated but relapsed cases, multi drug resistant cases in every continent in spite of global approach with Multibacillary drugs. Leprosy has left behind a terrifying image in the history as well as in human memories as a result of mutilation, rejection and exclusion from the society .
Leprosy control measures and elimination strategies are very effective in bringing down the global leprosy prevalence which has dropped down from 4.2 per ten thousand in 2002 to 0.69 in 2015. The leprosy control program has been a successful one but for few hurdles. In India the National Leprosy Control Program (NLCP) has been in vogue since 1955. The annual new case detection rate in India was estimated as 9.73 per 100,000 population in 2015 . With continuous implementation of elimination strategies in India almost thirty-three states/ union territories have achieved the level of leprosy elimination i.e., Prevalence Rate (PR) less than one case per ten thousand population. However, some rural areas at district level, still form the pockets of endemic regions with higher prevalence rates . India alone accounted for 58.85% of the global leprosy burden . According to September 2016 statistics, there are 102,178 cases in India. However, there is still an occurrence of considerable number of new cases in India, indicating an ongoing transmission, with an Annual New Case Detection Rate (ANCDR) of 9.98/100,000 population .
The diagnosis of leprosy is a challenge as there are no gold standard methods to differentiate between infection and disease. Leprosy is also an endemic disease in developing countries, where detection rates show only a slight trend toward a decrease in the disease prevalence. It is accepted that transmission occurs from human to human through the upper airways, although intermediate hosts like armadillos may play a role in certain countries like United States. Multibacillary leprosy patients harbour millions of bacilli that can potentially contaminate their close relatives of house hold contacts. Surveillance of these contacts would be an easy control strategy to block transmission, as suggested by the World Health Organization (WHO). As we are not able to bring down the new case detection rate further as expected, recent studies focus on early diagnosis . This article reviews various emerging advanced techniques in the diagnosis of leprosy. Treatment of leprosy has revolutionized the disease since the introduction of Multi Drug Therapy (MDT) in 1981. However, as there is an increasing incidence of resistance among commonly used drugs like rifampicin, dapsone and clofazimine, there is a necessity for newer effective combinations with bactericidal drugs. This article also reviews various newer drugs effective against leprosy and their combinations to improve the patient compliance and treatment outcome.
ADVANCES IN DIAGNOSIS OF LEPROSY
Diagnosis of leprosy is based on slit skin smear for demonstration of Acid Fast Bacilli (AFB) for a long time. It is understood that there are many disadvantages of this procedure like AFB is not demonstrable in all patients especially paucibacillary group like True Tuberculoid (TT) and Borderline Tuberculoid (BT) types . Demonstration of AFB needs trained technicians and referral laboratories and hence this procedure is followed at present only in the teaching institutions and not in the field level [7,8].
Histopathological examination of biopsy specimens from skin or nerve is another procedure in the diagnosis of leprosy which gives more information on the type of infiltrate and nerve involvement .
Immunological tests like ‘Lepromin’ which indicates the immune status in the patients is also outdated as both lepromin and Dharmendra antigens are not available freely at present. Hence we have to depend on alternate and newer techniques to make early diagnosis of leprosy.
Polymerase Chain Reaction (PCR) based diagnosis of leprosy
Early diagnosis of leprosy poses problems in certain patients who are infected, harbour the organism but lack classical signs and symptoms. In such cases, good surveillance of patients’ close contacts has increased the detection rate at a very early stage as they have less severe clinical presentations and lower Bacteriological Indices (BI) [16-18]. Immuno diagnostics or immunological diagnosis of leprosy plays an essential role both in the diagnosis as well as the confirmation of leprosy at the early stage of infection. Most of the immunological tools, to detect M. leprae are based on their ability to detect major unique components like Phenolic Glycolipid-I (PGL-I) specific proteins by means of mono clonal and poly clonal antibodies or T cell immune response as measured by IFN-γ production. Apart from the lack of availability of good diagnostic techniques in all centres, there are also variations in the immunity among various spectra of leprosy patients. For example, most of the Pauci Bacillary (PB) patients, may not have detectable antibodies at an early stage of the disease and most of the Multi Bacillary (MB) patients do not produce IFN-γ in spite of their high bacillary load which can be picked up by either PCR or anti PGL-I detection .
Lack of a gold standard diagnostic test for leprosy and the inability to distinguish infected individuals from those exhibiting active disease makes leprosy diagnosis essentially based on clinical features. This is the reason for late diagnosis and hence spread of infection in the population and difficulties encountered to interrupt the disease in the population. In this context, detection of M. leprae DNA by PCR in difficult to diagnose cases favours early identification and correct diagnosis. By this method, pure neural leprosy is more commonly diagnosed, indeterminate leprosy is detected more frequently, and early detection in household contacts is made possible. PCR confirms the disease even in cases of clinical and histopathological dispute [16-18].
Real-time PCR measure total DNA content estimated by molecular levels and could be correlated to bacterial load, corroborating the clinical data, which can be useful to determine a Molecular Bacteriological Index (MBI) [15,20].
Since PCR assays are based on DNA detection and did not reflect live bacilli, to overcome this problem, studies were conducted on Reverse Transcriptase PCR (RT-PCR) based assays for M. leprae viability estimation. RNA based tests only reflect nucleic acids from living organisms .
PCR is used in contacts of leprosy patients and if found positive the risk of progression to active disease increases. Genome studies also proved that wild armadillos transmitted leprosy to patients in the southern United States. DNA based PCR assays can be 100% specific while the sensitivity ranges from 34-80% in PB patients and 90% in MB patients .
Quantitative PCR (qPCR) is a useful tool for the diagnosis of infectious diseases, and has been used to detect several pathogens including M. leprae . Skin biopsy specimens or slit skin smears can be subjected for qPCR assessment in leprosy. Studies on qPCR from skin biopsy and slit skin smear of leprosy patients from Brazil showed 85% sensitivity with 85% positive predictive value and 61% negative predictive values respectively . Currently qPCR is considered as a rapid, sensitive and specific method for diagnosing M. leprae from tissue specimens. The use of Repetitive Element Regions (RLEP) has the advantage of being more sensitive. In one study from Brazil, qPCR method detected M. leprae in the peripheral blood samples in 200 untreated leprosy cases and 826 household contacts . This study revealed that if PCR was positive in blood samples from index cases at the time of detection they were at a greater risk of developing leprosy at a later date . Recently M. leprae DNA was amplified from oral mucosal samples. This technique detected bacilli even when they are undetectable by routine examination .
Comparison of various types of PCR is presented in table 1.
|Conventional PCR||Real Time Quantitative PCR||RT-PCR|
|Advantages||Collects data at the end of reaction More sensitive than serological methods||Collects data at the exponential phaseHigh resolution Less time consuming Automated||Able to detect viable bacilli Helpful in assessing response to chemotherapy|
|Disadvantages||Poor resolutisonTime consuming||Expensive||ExpensiveOnly available at research centres|
Table 1: Comparison of various PCR methods.
IMMUNOLOGICAL TESTS FOR LEPROSY
Antibody based tests
a. As a confirmatory marker
b. As a predictor of disease outcome
c. An indicator of nerve damage and exacerbation
d. As a tool for preclinical intervention
Protein based serology in the micro array format adds to diagnostic resolution and may aid in early clinical detection once reduced to a ‘field-friendly format’.
Assays based on cellular immune responses, and the facile detection of gamma interferon, may assist in pre-clinical detection allowing for early diagnosis and appropriate treatment .
Diagnosis of leprosy among contacts with sub clinical infection warrants immunological intervention. Various immunological tests which detect leprosy antibodies were compared for their efficacy. The native and synthetic PGL-1 ELISA assays detected antibodies in 22% and 31% in PB patients and the ML flow test failed to detect antibodies in this group. The study concluded that all three tests showed sensitivity ranging from 60-68%. The use of PGL-1 ELISA and ML flow tests are thus recommended as additional tools in the diagnosis and classification of clinical forms, aiding in prescribing the correct treatment regimen to prevent subsequent nerve damage and disability . PGL-1 ELISA may also be used to detect sub clinical infection in leprosy . PGL-1 recognizes the trisaccharide portion of the molecule whereas the ML flow test is a lateral immune chromatographic flow test which detects the anti PGL-1 antibodies. Both these tests are useful in the assessment of the host immune response to M. leprae .
Slit skin smear is the most widely used complementary examination in leprosy patients which has been in vogue for many years. It has disadvantages like lack of infra structure like laboratory, specially trained personal and validity of test reading. ML flow test is an immune-chromatographic assay which detects M. leprae specific anti PGL-1 IgM antibodies. It is easy to perform and can be used at primary health care centres because the test does not require a specific infrastructure. ML flow test results are recorded as 0 (sero negative), 1+, 2+, 3+ or 4+ according to colour intensity of antigen band . ML flow test is positive in 97.8% of MB patients with BI >2+. It is also positive in 93.5% of all patients with positive skin smears. Interestingly it shows positive in 37.8% of patients with negative skin smears. These patients would have been started on MDT-PB regimen in the absence of these test reports which could lead to relapse after many years .
Two fusion proteins ML0405 and ML2331 (LID-1 designated leprosy IDRI diagnostic) have been tested for their antibody reactivity and was found to be more sensitive than PGL-1 .
Antigen based tests
2. Another new antigen MMPII (bacterio ferritin) which is also reactive in PB sera has been tested.
3. Glycolipids like PDIM (phthiocerol dimycocerosate), Glycopeptidolipids, and mycolic acids like Trehalose mono mycolate and Trehalose dimycolate form the cell wall components of M. leprae and are assessed by using thin layer chromatography. Antigen detection like antigen 18 is another new area of research identified instead of antibody detection.
4. ESAT-6 (Early Secretory Antigen Target) ML0049 was found to be 100% specific and sensitivity was 82.4% in MB and 19.4% in PB cases.
The major disadvantages of all these tests are the cost effectiveness and hence out of reach of people [29,30].
M. leprae genome
One current approach is to use bioinformatics and comparative genomics to identify potentially antigenic proteins for diagnostic purposes and future vaccine developments. There are three classes of proteins in M. leprae, those restricted to M. leprae, those present in M. leprae with orthologs in other organisms and those exported or surface exposed proteins. After the completion of genomic sequencing of M. leprae, genes that are unique to M. leprae and no homologues to M. tuberculosis are looked into .
Cytokine profiles in leprosy
High-Resolution Ultrasonography (HRUS) in leprosy
Most modern sonographic machines use pulsed colour Doppler to assess whether structures, usually blood, are moving towards or away from the probe and its relative velocity. Colour Doppler imaging of each nerve can be performed to look for presence or absence of blood flow signals in the epineural plexus and infra fascicular vessels of nerve trunk. Normally there is hypo-vascularity of nerve trunks. Increased blood flow signals seen in colour Doppler in thick and tender peripheral nerves of leprosy denotes oedematous and hyperaemic changes secondary to inflammation leading to alteration of an effective blood nerve barrier during reactions .
Non-invasive tests like HRUS, MRI (Magnetic Resonance Imaging) and nuclear magnetic resonance are available in a few centres only. They have shown arterial and venous flow is altered in damaged nerves and in active ENL and are patient friendly.
TREATMENT AND DRUG RESISTANCE
Current treatment regimen 
|Multidrug Therapy for Paucibacillary Disease (MDT-PB)|
|Adult 50-70 kg||600mg/month Supervised||100mg Daily unsupervised|
|Child 10-14 year||450mg/month Supervised||50mg Daily unsupervised|
|Child <10 year||300mg/month Supervised||25mg Daily unsupervised|
|Multidrug Therapy for Multibacillary Disease (MDT-MB)|
|Adult 50-70 kg||600mg/month supervised||100mg daily unsupervised||300mg/month supervised &50mg daily unsupervised|
|Child 10-14 year||450mg/month supervised||50mg daily unsupervised||150mg/month supervised &50mg on alternate day unsupervised|
|Child <10 year||300mg/month supervised||25mg daily unsupervised||
100mg/month supervised &50mg twice weekly unsupervised
Problems of current MDT regimen 
2. Duration of MDT is relatively too long.
3. Emergence of drug resistance is virtually unavoidable in any large scale treatment of an infectious disease with microbial agents. Some patients with rifampicin resistance and multidrug-resistant leprosy have already been reported. A safe and effective alternative regimen should be developed for patients with rifampicin resistance or who cannot tolerate rifampicin .
New MDT regimens
|Drugs||Class||Bactericidal Activity Mice||Bactericidal in Activity Humans||Unit Cost in|
|R207910||Diarylquinoline||+++||Not done||Not yet available|
1. Rifapentine 900 mg (or Rifampicin 600mg) + Moxifloxacin 400 mg + Clarithromycin 1000mg (or Minocycline 200 mg) administered once monthly under supervision for 12 months.
2. For rifampicin resistant leprosy:
a. Intensive phase: Moxifloxacin 400 mg + Clarithromycin 500mg + Minocycline 100mg + Clofazamine 50 mg daily for six months.
b. Continuation phase: Moxifloxacin 400 mg + Clarithromycin 1000 mg + Minocycline 200 mg once monthly for addition of 18 months.
3. ROM (Rifampicin + Ofloxacin + Minocycline) therapy: A review on meta-analysis comparing 6 studies on comparing ROM therapy with MDT and 8 studies that evaluated only ROM therapy was done. It showed that in PB patients ROM therapy as a single dose was less effective. However, ROM therapy as multiple doses showed equal efficacy that of MDT MB in MB patients. Multiple doses can be considered as another alternative for PB patients .
4. Gatifloxacin is a FDA approved fluoroquinolone antibiotic that inhibits the bacterial enzymes DNA gyrase and topoisomerase IV. The dose ranges from 100-400 mg/day.
5. Linezolid is a synthetic oxazolidine drug approved by FDA to treat infections by gram positive organisms. It acts as an inhibitor of protein synthesis of bacteria. The dose ranges from 600 mg per day. It can cause bone marrow suppression or optic atrophy. More than 36% of that group discontinued linezolid due to adverse effects .
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Citation:Prasad PVS, Kaviarasan PK, Kannambal K, Poorana B, Abinaya R (2017) Recent Advances in Diagnostic Techniques and New Hope Towards Leprosy Elimination in the Post Elimination Era. J Clin Dermatol Ther 4: 027.
Copyright: © 2017 Prasad PVS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.