DR [page 40] [Dermatology Reports 2011; 3:e18] Epidemiologic and clinicopathologic aspects of Leprosy in Dakar; evaluation of 73 new cases Suzanne Oumou Niang,1 Moussa Diallo,1 Maodo Ndiaye,1 Assane Diop,1 Boubacar Ahy Diatta,1 Mohamed Wadih,1 Assane Kane,1 Mame Thierno Dieng,1 Charles Insa Badiane2 1Centre Hospitalier Universitaire Aristide Le Dantec, Dakar, Senegal; 2Institut de Léprologie Appliquée de Dakar, Senegal Abstract Hundreds of new leprosy cases are still diag- nosed in Dakar despite all the efforts in the struggle by the national program for elimina- tion of leprosy by the Institute of Applied Lep- rosy in Dakar. The aim of our study was to eval- uate the epidemiological, clinicopathological and outcome of new cases of leprosy. A prospective study was conducted over a period of one year listing all new cases of leprosy based on clinical diagnosis, bacteriology and histology. 73 new cases were recorded. The sex ratio was 1.5 and the mean age of 39.5 years. Children aged from 0 to 15 years old repre- sented 12%. The clinical forms were rated in order of decreasing frequency Borderline 47.94%, 30.13% lepromatous lepromatous, in- determinate 8.21, borderline lepromatous 6.84, TT: 5.47%, 1.36 and neurological bb%. Neuro- logical signs were enlarged nerve in 50 cases, a neurological deficit in 16 cases and a sensi- tive deficit in 16 cases. The complications were burns and ulcerations in 10 cases, a claw in 7 cases, a reversal reaction in 7 cases, erythema nodosum in 4 cases and neuritis in 8 cases. The number of new cases mutilated was 24.65%. The smear was positive in 42% and histology contribution in 91.37% of cases. Our study highlights the significant number of pa- tients with multibacillary contagious, affected children, the high proportion of disability grade 2/OMS reflecting the delay in diagnosis. This delay is due to ignorance, to traditional treatments and low socio-economic status and lack of trained diagnostic teams in different areas apart from referral centres. Introduction Although leprosy does not constitute a public health problem in Senegal since 1995, it still persists. Each year, hundreds of pa- tients are diagnosed by the staff of the Na- tional Program for Elimination of Leprosy (NPEL) and the Institute of Applied Leprology of Dakar (IALD). In 2006, there were 353 new cases of leprosy and 282 in 20071 in the whole territory of Senegal. The aim of our study was to evaluate the epidemiological and clinico- pathological profile and the outcome of new cases of leprosy in Dakar, the capital of Senegal. Materials and Methods We undertook this prospective study in- cluding patients diagnosed with new cases of leprosy during 2008 and being treated at the IALD. The diagnosis was based on clinical, bac- teriological (slit skin smear (SSS) of at least 3 sites, accounting for the Bacteriological and morphological index, BI, MI) and pathology cri- teria (the skin biopsy or the musculocuta- neous nerve of the elbow). Riedley & Jopling classification was used and added to the Pure Neurological Leprosy (PNL). A thorough neu- rological exam allowed us to classify the pa- tients following the disability criteria of the WHO (World Health Organization). The WHO treatment protocol was used: the standard multidrug therapy (MDT) for 12 months if Multi-bacillary (MB) leprosy when the IB was positive and multidrug therapy (MDT) for 6 months if Pauci-bacillary (PB) leprosy when the IB was negative. The sys- temic corticosteroids were prescribed for a pe- riod of 6 months in case of severe reactions or recent neuropathy. A secondary prevention of disabilities, with information, education and communication and physical therapy, proper footwear and measures of self protection was set up. Restorative Surgery like nerve decom- pression, palliative surgery or wound debride- ment, when necessary completed this global care. A dermatological and neurological exam was done every month during their regular follow up visits. Results Epidemiology During the study period, 73 new leprosy pa- tients were registered,they were referred from different centers (Table 1). Thirty-three pa- tients (45.2%) initially used traditional medi- cine. Patients comprised 44 men and 29 women with a sex ratio of 1.5. Distribution by age is shown in Figure 1. The mean age of pa- tients was 39.5 and ranged from 4 (Figure 2) to 75 years (Figure 3) (mean 39.5). 38 patients (52.05%) were single versus 35 patients (47.94%) were married. 38 patients (52.05%) worked in the informal sector, 8 pa- tients (10.95) in the formal sector. Thirteen patients (17.80%) were students or pupils and 14 patients (19.80%) were unemployed. Forty patients (56.16%) were from Dakar and its suburbs, 32 patients (43.83%) from other re- gions of Senegal and 3 patients (4.10%) from neighboring countries. Clinicopathological data Present complaints were dermatological and neurological symptoms. Seventy-two patients (98.63%) presented dermatological complains; with spots in 64 patients (84.67%) and sores in 16 patients (21.91%); 23 patients (31.5%) had neurological symptoms with painless burn in 9 patients (12.32%), ulnar claw in 4 patients (5.47), nerve pain in one patient and pares- thesis in 9 patients (12.32%). The time of the first visit in relation to ap- pearance of symptoms or signs was variable from less than a year to more than 10 years (Table 2). In 14 patients (19.18%) there had been a close contact with a leprosy family member. The different clinical presentations are shown on Table 3, 41 patients (56.16%) had Borderline leprosy, immunologically un- stable, while 33 patients (45.05%) had the polar leprosy form which is stable. Sixty-three patients (86.30%) had normal sensory or hy- poesthesic hypochromic macular lesions, 21 patients (28.73%) had papulo-nodular lesions and 5 patients (6.84%) had hypo or anesthetic plaques. Fifty patients (68.49%) had nerve hyper- trophy, cubital nerve in 37 patients (50.68%); superficial cervical plexus in 7 cases (9.58%)and superficial peroneal nerve in 6 cases (8.21%), 16 patients had motor deficit (21.91%), and 14 patients(19.17%) had a sen- sitive deficit. Twenty patients (28.76%) had nasal obstruction with or without crusted Dermatology Reports 2011; volume 3:e18 Correspondence: Suzanne Oumou Niang, Centre Hospitalier Universitaire Aristide Le Dantec, 30 Avenue Pasteur B.P. 3001 Dakar, Senegal. E-mail: suzeoumou@yahoo.com Key words: leprosy, Senegal. Received for publication: 7 June 2011. Revision received: 3 August 2011. Accepted for publication: 6 August 2011. This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY- NC 3.0). ©Copyright S.O. Niang et al., 2011 Licensee PAGEPress, Italy Dermatology Reports 2011; 3:e18 doi:10.4081/dr.2011.e18 No n- co mm er cia l u se on ly [Dermatology Reports 2011; 3:e18] [page 41] rhinitis, and 13 of them (17.80%) had epis- taxis. Thirty-seven patients (50.68%) were hospi- talized because of complications (Table 4), claw fingers and reversal reactions (Figure 5) were noted in 7 patients each.18 patients (24.65%) had WHO disability grade 2 at his ini- tial visit. Forty-two(58%) patients had a nega- tive SSS, and 31 patients (42%) had a positive one with the BI equal or superior to 4 + in 5 pa- tients. Biopsies were done in 58 patients (Figure 6) and were conclusive in 53 patients (91.37%). At the end, 37 patients (50.6%) had pauci- bacillary (PB) leprosy, 30 patients (41.09%) had multi-bacillary (MB) leprosy. WHO thera- peutic standard recommendations were ap- plied to all the patients, except in 5 cases were the BI equal or superior a 4+, the treatment were conducted for a period of 24 months. Corticotherapy was given to 29 patients (39.72%) who had either neuritis or reac- tion.40 patients (55%) suffered from a psy- chosocial impact, 37 patients (51%) had some functional impairment and 22 patients (30%) had some professional impact. Regression of the skin lesions was noted in all the cases after the first month of therapy. Discussion We report 73 new cases of leprosy during a period of one year, this number does not re- flect the real situation in the country, be- cause ILAD is a referral center, staffed by Doctors and equipped with a laboratory, while at the NPEL, the diagnosis is done by Leprosy Nurses Specialist LNS, who used the WHO Case Report Table 4. Distribution of cases per complications. Complication Number of cases % Ulcers or burns of the extremities 10 13.69 Motor deficit 11 15.06 Reversal reaction 07 9.58 Erythema nodusum leprosum 04 5.47 Pure neuritis 04 5.47 Lagophtalmia 01 1.36 Table 3. Distribution of different leprosy forms. Forms of leprosy BT LL I BL TT PNL BB Number of cases 35 22 6 5 4 1 0 Percentage 47.94 30.13 8.21 6.84 5.47 1.36 0 BT, borderline tuberculoid; LL, lepromatous leprosy; I, Indeterminate leprosy; BL, borderline lepromatous; TT, tuberculoid leprosy; PNL, pure neurological leprosy; BB, borderline borderline. Figure 3. Lepromatous leprosy form in a 70-years- old woman. Figure 4. A post burn digital ulcer in LL patient. Table 2. Distribution of cases per timeline of the first visit. Timeline of Number % the first visit of cases <1 year 39 53.42 1-5 years 25 34.24 5-10 years 07 9.58 >10 years 02 2.73 Table 1. Distribution of cases per referring centers. Referring Number % center of cases Hospitals 40 54.78 Health centers 13 17.8 IALD 12 16.43 Private practice 08 10.95 Total 73 100 Figure 1. Age distribution of new leprosy cases. Figure 2. A BT form in a 4-years-old kid. Figure 5. Reverse reaction in a borderline tuberculoid form. Figure 6. Granulomatous peri-annexial infiltrate in a tuberculoid leprosy.No n- co mm er cia l u se on ly [page 42] [Dermatology Reports 2011; 3:e18] clinical classification. The particularities of our study were the relatively large number of Multi-bacillary (MB) leprosy patients, poten- tially contagious and the number of affected kids, the high proportion of WHO disability grade 2, reflecting late diagnosis and con- tinued transmission of the disease. The limi- tations of our study were, its short duration, which did not allow a long term outcome. The number of recruited patients represents a quarter of the total new cases of leprosy ob- served in 2007, in the whole territory of Senegal. Male predominance observed in our study was noted by many other authors2,3,4 and the percentage of affected females (39.73%) matches the one reported by the NPEL, it is less than the 60% seen in Uganda and far superior to the 8.5% reported in the Democratic Republic of Congo.1 The mean age of 32 years is higher than the one (32 years) reported at the Marchoux Institute in Mali.5 The time of the first visit was long, more than 1 year in almost half the cases. this delay is certainly due to ignorance, low economic status, but most importantly due to Diagnostic error induced by the use of tradi- tional medicine as we found in 45% of the cases. the same factors that delayed the diag- nosis were also noted by Keita at the Mar- choux Institute in Mali, Muller in Guade- loupe.5,6 The predominance of interpolar forms (54.75%) is similar to the one reported in the literature, while the indeterminate leprosy (8.22%) stays inferior to that as re- ported by Bobin and Flageul evaluated be- tween 20 and 80%,2,3 and can translate also the lack of early diagnosis. The positive SSS in 42% underline the significant presence of the bacteria as reported in other studies.2,7,8 The pathology was very contributory be- cause it confirmed the diagnosis in 91.37% of the cases. In the case where the histological study was unavailable or non contributory and the SSS negative (27.39%), the diagnosis was based only on clinical arguments (27.39%). The number of disabilities reported in our study (24.65%) reflects the severity of the neu- rological involvement that is 2 times higher than the NPEL (11.3%) and the WHO (12.46%). Conclusions The diagnosis of hundreds of new annual cases of leprosy, and the severity of the neuro- logical impairment justify more vigilance in the primary prevention of the disease. It makes it essential to early diagnosis in order to pre- vent disabilities. Such struggle includes training highly competent health staff in both Hospitals and community clinics. References 1. OMS. Comité Régional de L’Afrique. Elimi- nation de la lèpre. Rapport de situation. AFR/RC57/INF.Doc/2 :5 avril 2007. 2. Bobin P. Lèpre. Encycl Méd. Chir. Maladies infectieuses 8-038-F-10,2007. 3. Flageul B. Maladie de Hansen. Lèpre. Encycl Méd Chir. Dermatologie 98-370-A-10,2001. 4. Keita S, Faye O, Konare HD, Sow SO, Ndiaye HT, Traore I. Evaluation de la classification clinique des nouveaux cas. Etude réalisée à l’Institut Marchoux (Bamako, Mali). Ann Dermatol Venereol 2003;130:184-6. 5. Keita S, Tiendrebeogo A, Berthé D, Faye O, Ndiaye HT. Valeur prédictive des motifs de consultation pour le diagnostic de lèpre à Bamako (Mali). Ann Dermatol Venereol 2002;129:1009-11. 6. Muller P, Frederic M, Salzer B, Strobel M. Lèpre en Guadeloupe: maladie en decline, délai diagnostic en hausse. Ann Dermatol Venereol 2003;130:619-21. 7. Bobin P. Peut-on envisager l’élimination de la lèpre dans le monde? Ann Dermatol Venereol 2001;128:205-6. 8. Kadji F, Lucht F, Helenon R, Leoture A. Epi- demiologie de la lèpre en Martinique. Bull ALLF 2001;8:19-23. Case Report No n- co mm er cia l u se on ly