Original article

Annales de dermatologie et de v?n?r?ologie 2001; 128: 217-219
? Masson, Paris, 2001

New cases of leprosy at Marchoux Institute: a comparative study 1988-1997

S.?Keita?⁽¹⁾, A.?Tiendrebeogo?⁽¹⁾, H.?Konare?⁽²⁾, B.-S.?Cisse?⁽²⁾, O.?Faye?<sup>(2)

(1)</sup>Observatoire de la L?pre en Afrique (OLA), BP 2759, Bamako, Mali.
⁽²⁾Unit? de Dermato-L?prologie, Institut Marchoux, BP 251, Bamako, Mali.

Tir?s ? part : S.?KEITA , at above address. E-mail: sbsow@malinet.ml

SUMMARY

Background

The prevalence of leprosy had declined greatly over the last decade. The purpose of this work was to determine whether changes in the epidemiology, clinical and bacteriological patterns occurred among patients with leprosy treated at the Marchoux Institute in 1988 and in 1997.

Patients and methods

We conducted a descriptive cross-sectional study, reviewing retrospectively all files of patients with leprosy seen in 1988 in comparison with a prospective series of leprosy patients seen in 1997. Only new cases of leprosy, prior to treatment and with skin and/or nervous lesions irrespective of the bacilloscopy results, were included in the two series.

Results

We included 93 patients among 246 patient files in 1988. There were 119 new cases in 1997. The following variables showed changes: mean delay to consultation (41.2 months in 1988 versus 26.1 months in 1997; patient's suspicion of having leprosy (93 patients in 1988 versus 22 in 1997); notion of contact (35 cases in 1988 versus 45 in 1997). Multibacilli leprosy predominated over paucibacilli leprosy in 1988 (51 versus 42 cases). This trend was inverted in 1997 (44 versus 75) (p<0.009). Patients with grade 2 handicap were more numerous in 1988 (20 cases versus 2 cases, p<0.001).

Conclusion

These findings demonstrate a change in the epidemiology, clinical and bacilloscopic pattern of patients with leprosy from 1988 to 1997.

R?SUM?

Nouveaux cas de l?pre ? l'Institut Marchoux (Bamako, Mali). Etude comparative 1988-1997.

S.?Keita, A.?Tiendrebeogo, H.?Konare, B.-S.?Cisse, O.?Faye

Introduction

La pr?valence de la l?pre a beaucoup diminu? au cours de la derni?re d?cennie. Le but de ce travail ?tait de rapporter les ?ventuelles modifications dans les profils ?pid?miologique, clinique et bact?riologique chez les malades atteints de l?pre vus ? l'Institut Marchoux en 1988 et en 1997.

Malades et m?thodes

Une ?tude transversale descriptive a ?t? men?e sur une s?rie r?trospective concernant l'ensemble des dossiers de malades atteints de l?pre vus en 1988, et sur une s?rie prospective de malades l?preux vus en 1997. L'inclusion dans les deux s?ries ne concernait que les nouveaux cas de l?pre, jamais trait?s et ayant des l?sions cutan?es et/ou nerveuses de l?pre quel que soit le r?sultat de la bacilloscopie.

R?sultats

Nous avons inclus 93 dossiers sur 246 collig?s en 1988, et les dossiers des 119 nouveaux malades vus en 1997. Nous avons observ? les modifications des variables suivantes?: le d?lai moyen de consultation (41,2 mois en 1988?; 26,1 mois en 1997)?; la suspicion de l?pre par le malade (93 fois en 1988?; 22 fois en 1997)?; la notion de contage (35 fois en 1988?; 45 fois en 1997). La l?pre multibacillaire ?tait pr?dominante en 1988 par rapport ? la l?pre paucibacillaire (51/42)?; cette tendance ?tait invers?e en 1997 (44/75) (p?vs 2 cas, p?

Conclusion

Ces r?sultats r?v?lent l'existence d'un changement des profils ?pid?miologique, clinique et bacilloscopique des malades au cours de la d?cennie 1988-1997.

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The prevalence of leprosy has decreased considerably over the last decade, from ten million cases in 1988 to 828,000 cases reported in 1998 [1]. This suggests that a change in epidemiological, clinical, and bacteriological profile may have occurred. The aim of this study was to search for modifications in profile observed in patients suffering from leprosy seen at the Marchoux Institute in 1988 and 1997.

Patients and methods

We conducted a descriptive study on two series of patients with leprosy. A retrospective series was comprised of all case reports registered in 1997. We included only new cases of leprosy, i.e.: patients who had never been treated and who presented skin and/or nerve lepromatous lesions whether the results of bacilloscopy were positive or negative.

Specific data was determined for each case of leprosy in the retrospective and the prospective studies. This questionnaire included: patient's identity, presentation, geographic origin, reason for consultation, duration of symptoms before consulting the Marchoux Institute, notion of contamination, complete clinical examination data with particular attention to the skin and mucosa, neurological and muscular data, and degree of infirmity according to the World Health Organization (WHO) scale (table?I) [2].

Supplementary examinations (bacilloscopy and skin biopsy) together with clinical data guided the clinical, bacteriological, and histological classification of the leprosy cases. Data were analyzed using Epi-Info software, and the chi² test permitted comparison of the two series.

Results

Two hundred forty six cases of leprosy were seen in 1988. Among these, 93 cases conformed to our definition (new case, never treated) and were included. In 1997 all the files of 119 case reports were included (table?II). The mean age of the patients in 1988 was younger than that of the patients in the 1997 group (25.9 (12.2 years vs. 33.8 (16.7 years). In both studies, the majority of patients were male and adult (19.5 p. 100 children vs. 80.5 p. 100 adults in the retrospective study, and 10.9 p. 100 children vs. 89.1 p. 100 adults in the prospective study). The majority of patients lived in rural settings. The mean interval between onset of symptoms and consultation was longer in 1988. A possible source of contagion was recalled 35 times in the retrospective study and 45 times in the prospective study. The clinical results are presented in table?III and IV.

Discussion

In view of the spectacular worldwide decrease in the prevalence of leprosy, particularly in Mali, we inquired whether this decrease was accompanied by any change in epidemiological, clinical, or physiologic response profiles of these patients. We conducted a descriptive study of two series of patients: a retrospective series from case reports of patients seen in 1988 and a prospective series of patients seen in 1997.

The results revealed a significant change in patient profile. Patients diagnosed in 1997 were older, with a high proportion of male patients, a shorter interval to consultation, and a predominance of paucisymptomatic and paucibacillary cases. In both studies children were less often affected than adults, consistent with recent data [1] that only 10.3 p. 100 of new cases diagnosed in 1988 were children aged less than 15. Early signs of disease in children may be overlooked or misinterpreted; however, the predominance of leprosy among adults may suggest that in endemic areas leprosy is contracted in childhood and is manifested during adulthood.

There was a male preponderance in both studies, but the gender ratio was not statistically significant. The risk of contracting the disease, however, appears greater in males and may vary with sociological diversity, such as greater participation in socio-professional life and therefore greater risk of contagion. The majority of patients lived in rural areas, but this trend decreased from 73.3 p. 100 in 1988 to 60.5 p. 100 in 1997. However, the incidence of cases among Bamako residents increased, from 17.4 p. 100 in 1988 to 22.7 p. 100 in 1997. Increased contacts in the urban population might explain this increased incidence. The mean delay before consultation was lesser in 1997, allowing earlier diagnosis and treatment. In the prospective study only 22 patients (18.5 p. 100) suspected their disease. The majority ignored the relationship between their symptoms and leprosy. The atypical nature of the lesions and the difficulty in diagnosis, even for medical staff, appear to be the basis for this. A notion of contamination could not be established in the majority of patients during these two studies, and it is difficult to identify the source of contagion. The same proportion of patients in 1988 and in 1997 confirmed having had contact with a person known to have leprosy. Clearly, knowledge of a contagious contact is not a requisite condition for infection.

Comparison of the two groups demonstrated a significant change in the clinical profile of patients with leprosy. The increased prevalence of macular lesions (48.4 p. 100 in 1988 and 71.4 p. 100 in 1997) may be explained by early screening. Moreover, the number of cases with more than 5 skin lesions decreased from the retrospective group to the prospective group (52.7 p. 100 versus 34.5 p. 100). This may be explained by the application of polychemotherapy to the whole population and by early screening strategies. Nerve hypertrophy associated with pain was noted in the principle nerves, with a greater frequency in ulnar and radial nerves. Neuritis, one of the principle signs of leprosy, was reported as the most important element in the diagnosis of leprosy [3].

We noted a decrease in degree 2 infirmity between 1988 and 1997 (21.5 p. 100 vs. 1.7 p. 100). Early diagnosis and treatment are the only means of reducing the risk of infirmity in these patients. Clinical results show that the incidence of severe forms is diminishing. This decrease in severity was confirmed by supplementary examinations. The number of patients with negative smears was greater in 1997 (63 p. 100) than in 1988 (46.23 p. 100). Leprosy was more often paucibacillary and classified as tuberculoid or borderline in 1997 than in 1988.

In conclusion, the early clinical diagnosis of leprosy is increasingly difficult due to atypical presentations. The decrease in incidence of leprosy is related to the recognition of its clinical manifestations.

To cite the present paper, use exclusively following reference: Keita S, Tiendrebeogo A, Konare H, Cisse BS, Faye O. Nouveaux cas de l?pre ? l'Institut Marchoux (Bamako, Mali). Etude comparative 1988-1997 (full text in english on e2med.com/ad). Ann Dermatol Venereol 2001; 128: 217-9.

REFERENCES

[1] D?tection des cas de l?pre. Relev?s Epid?miologiques Hebdomadaires. OMS 1998;73:153-60.

[2] Guide de la lutte antil?preuse, Organisation Mondiale de la Sant? (OMS). Gen?ve: 2^e??dition, 1989;112.

[3] Saylan T, Sutlas M, Yuksel A, Cakiner T, Aytekin H. The characteristics and mode of detection of the new patient encountered in the leprosy endemic province of Van within the last live years. Indian J Lepr 1989;61:225-8.

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