|Year : 2011 | Volume
| Issue : 2 | Page : 207-210
A very common case become rare: Anesthetic considerations of lepromatous leprosy
Sandeep Sahu, Vipin Goyal, Sanjay Dhiraaj, Kamal Kishore, PK Singh
Department of Anaesthesiology and Intensive Care, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||9-Apr-2012|
Assistant Professor, Department of Anaesthesiology and Intensive Care, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh - 226 014
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Leprosy or Hansen's disease is very uncommon in developed countries. More than 80% of the world's cases occurs and still reported from developing countries. But nowadays due to increase in international affairs, medical tourism, globalization and immigration, there is increasing possibility to find patients anywhere, which require anesthesia for surgical interventions. Leprosy is a chronic infectious disease caused by Mycobacterium leprae and involves mainly skin, peripheral nervous system, upper respiratory tract, eyes and testes. Anesthetic consideration is focused mainly on complications related to leprosy like cardiac or respiratory dysautonomia, autonomic dysfunctions and side effects which are related to drug therapy and are challenging. There can be drug-related hepatitis and renal insufficiency in these patients. We report the anesthetic management of a patient with lepromatous leprosy who had undergone laparoscopic radical nephrectomy for renal cell carcinoma under general anesthesia.
Keywords: Complications, dysautonomia, lap-radical nephrectomy, lepromatous leprosy
|How to cite this article:|
Sahu S, Goyal V, Dhiraaj S, Kishore K, Singh P K. A very common case become rare: Anesthetic considerations of lepromatous leprosy. Anesth Essays Res 2011;5:207-10
|How to cite this URL:|
Sahu S, Goyal V, Dhiraaj S, Kishore K, Singh P K. A very common case become rare: Anesthetic considerations of lepromatous leprosy. Anesth Essays Res [serial online] 2011 [cited 2019 Aug 20];5:207-10. Available from: http://www.aeronline.org/text.asp?2011/5/2/207/94783
| Introduction|| |
Leprosy was recognized in the ancient civilizations of China, Egypt and India. The first known written mention of leprosy is dated back to 600 B.C. According to recent key facts released about leprosy by WHO in 2010, based on official reports received during 2010 from 141 countries and territories, the global prevalence of leprosy registered at the beginning of 2010 stood at 211,903 cases, while the number of new cases detected during 2009 was 244,796 (excluding the small number of cases in Europe). Most previously highly endemic countries have now reached elimination. However, pockets of high endemicity still remain in some areas of Angola, Brazil, Central African Republic, Democratic Republic of Congo, India, Madagascar, Mozambique, Nepal and the United Republic of Tanzania. These countries remain highly committed in eliminating the disease, and hence continue to intensify their leprosy control activities. ,
All South-eastern Asian region countries have now eliminated leprosy as a public health problem, which is defined as a registered prevalence rate lower than 1 case per 10,000 population at the national level. Till 2007, five countries including India contributed more than 80% of the newly detected cases worldwide. Multidrug therapy (MDT) was included in the National Leprosy Eradication Program (NLEP) of India in 1982 that decreases the prevalence rate (PR) from 5.7 cases per 10,000 populations (1983) to 0.74 (2008). As of 31 st March 2009, 32 States in India have achieved the level of elimination and but still some states like Bihar and Chhattisgarh have PR between 2 and 3 per 10,000 population.  So still one can encounter leprosy patient as us, from nearby states or country, because India and some other Asian country was just about to declared leprosy free.
Leprosy is disease of developing countries and more prevalent in the people of lower socio-economic status. From the old world it is considered as social stigma. The causative agent for this disease is Mycobacterium leprae, an acid-fast bacilli. The routes of transmission of leprosy are mainly through nasal droplet infection, contact with infected soil or insect vectors. The Ridley-Jopling or the WHO classifications are often used to characterize the patient's disease.  The spectrum of clinical presentation varies widely depending on the type of leprosy. A very important clinical setting is the presence of any leprous reactions, which are very serious complications consequence of dynamic changes in the immune status of the patient.  Clinical, bacteriological, pathological and immunological spectrum of leprosy varies between tuberculoid and lepromatous leprosy. In India around 90%, of cases are tuberculoid leprosy. In tuberculoid forms of leprosy clinical manifestations remain confined to the skin and peripheral nerves. The skin lesions consist of anhidrotic, hyperaesthetic, hypopigmented macules or plaques. Clinical manifestations of leprosy vary in accordance with the immune response of the host. Peripheral nerve involvement leads to their enlargement in thickness and neuropathy and commonly involves the ulnar, posterior auricular, peroneal and posterior tibial nerves. While lepromatous leprosy patient have clinical manifestations like skin nodule and plaque, they may also have peripheral neuropathy and involvement of other organs. Neuropathy leads to insensitivity and myopathy which in turn leads to planter ulceration, foot drop and joint deformities. In eyes there may be corneal ulceration and opacities, uveitis, cataract or glaucoma. , Other complications are orchitis, nerve abscess, amyloidosis, etc. Early diagnosis and treatment with MDT dapsone, rifampicin and clofazimine and this drug combination kills the pathogen and cures and remains the key elements in eliminating the disease as a public health concern. Chronic nature of disease and longer duration of treatment may lead to side effects and organs toxicity that complicates anesthetic management. 
| Case Report|| |
We discuss a case of 65-year-old, ASA II, 63-kg male posted for left-sided laparoscopic radical nephrectomy due to renal cell carcinoma. Patient was a known case of lepromatous leprosy and was on medications rifampicin, dapsone and clofazimine since 7 months. At first preanesthetic check-up (PAC) visit he was found to be a known case of chronic obstructive pulmonary disease on derriphyline and inhalers of budesonide and ipatropium bromide. Patient was also chronic smoker since 20 years. He was having bilateral basal coarse crepitations for which advised incentive spirometry, steam inhalation and prescribed antibiotics and nebulization with bronchodilator. He was examined to rule out cardiac dysautonomia (by normal 2D-Echo, Valsalva response, ECG changes to respiration and blood pressure changes related to posture and hyperventilation, all were within normal limits) and respiratory dysautonomia [by breath holding time 30 sec, pulmonary function test (PFT); values was showing obstructive pattern and sleep study were acceptable as per age]. Rest of his general examination and biochemical (liver and kidney functions test) investigations were within normal limits. On PAC review patient clinically improved and chest X-ray and PFT were acceptable. On night before surgery patient was given tablet rantidine 150 mg and lorazepam 1 mg perorally and advised to continue with respiratory medications.
In operation theatre monitoring was applied and large bore IV line was secured after local anesthetic application. Anesthesia was induced with propofol 150 mg after midazolam 2 mg and fentanyl 120 mcg and was intubated with size 8.5 cuffed endotracheal tube after administration of muscle relaxant; atracurium 50 mg. Anesthesia was maintained with oxygen, air (50:50) with sevoflurane, fentanyl, atracurium and propofol infusion. Central venous catheter was placed in right IJV for CVP monitoring and fluid management. Radial artery was cannulised to know beat to beat variability, invasive blood pressure monitoring and serial ABG analysis. Standard monitoring like ECG, SPO 2 , ETCO 2 , temperature, urine output were done. While making left sided kidney positioning nerve and joints injury protection by adequate padding were done. All the universsal principals of anesthesia for laparoscopic surgery were followed. Patient remained hemodynamically stable intraoperatively. At the end of surgery anesthesia was reversed with neostigmine 2.5 mg and glycopyrrolate 0.4 mg. Extubation was smooth done after giving xylocard 60 mg. Post operative analgesia was maintained with IV paracetamol 1 gm\6 hrly and vitals monitored in postoperative care unit.
| Discussion|| |
On review of literature not much references has been found regarding anesthetic management of leprosy patient in pubmed. Management of present case is important pearl to revisit leprosy patient in view of anesthetic considerations. Leprosy is a multisystem disease so anesthetic implication of leprosy needs particular attention toward the organs involved and a thorough PAC of patient is required. Patient may be posted for surgery either related to the complication of leprosy like cataract, joint deformities, planter ulceration or elective and emergency surgical procedure related to systemic diseases. 
These are important anesthetic considerations that should be followed during laparoscopic urology surgery. Laparoscopic procedures in renal surgical patients are having similarity with abdominal surgical procedures. These include effects on the cardiovascular system, mechanical consequences due to pneumoperitoneum (raised intra-abdominal pressure), systemic absorption of carbon dioxide, neurohumoral responses and physiological changes associated with the positioning (near full lateral position, renal position) during surgery. , During laproscopic cholecystectomy renal cortex and medullary blood flow, glomerular filtration and creatinine clearance fall and urine production decreases. Handling the kidney increases plasma renin and antidiuretic hormone release. All these changes are more concerned in renal function deranged or damage patient undergoing renal laparascopic procedures.  Other important concerns in laparoscopic urology are these patients having renal dysfunction, due to diseases process leading impairment of drug metabolism and its variable systemic effects, fluid management, monitoring, complication of surgery and conversion to open procedure in these patients. 
Cardiovascular system involvement in leprosy characterized by cardiac dysautonomia leading bradycardia, hypotension, cardiac arrest, various arrhythmias and other ECG changes or absence of response to various perioperative manipulations such as intubation, extubation or anticholinergic drugs that need careful intraoperatively vigilance. All of these are more pronounced in patients with longer duration of leprosy. , Respiratory dysautonomia lead to decreased breath holding time, depressed cough reflex and alteration in PFT and risk of aspiration that may increase the incidence of postoperative complication or need for postoperative ventilation. Nasal obstruction and vocal cord involvement may occur in late stage of lepromatous leprosy, may leads to difficult airway. , Autonomic neuropathy may present and manifested as orthostatic hypotension, altered baroreceptor reflex and impaired response to valsalva manoeuvre. Luckily our patient PAC ruled out cardiac and respiratory dysautonomia and autonomic involvement but we were prepared with proper monitoring for possible complications and its management.
The effects of leprosy on haematological are as anemia, thrombocytopenia and agranulocytosis leading decrease in O 2 -carrying capacity, impaired coagulation and increase chances of postoperative infection. Increase bone resoption and osteomyelitis due to leprosy imposes for pathological fracture meanwhile positioning during surgery. Hepatitis due to leprae reaction or drug-related side effects may cause abnormal liver function tests (particularly increased aminotransferase level). The specific granulomatous lesions suggestive of leprous hepatitis are mainly seen in lepromatous leprosy (40%), whereas, granulomata in the liver could be present in all types of leprosy (70%). Some of the hepatic lesions progressed to stellate fibrosis and early cirrhotic changes (40%).  Renal involvement in lepromatous leprosy may be manifested as glomerulonephritis and amyloidosis that causes renal failure. Hepatorenal derangements may cause delayed recovery from anesthesia due to impairment of drug metabolism and delayed clearance. Rifampicine is an inducer of hepatic cytochrome P 450 , so requirement of anesthetic drugs can be increased that are metabolized by it. Rifampicine may produce intermittent toxic syndromes (e.g., flu syndrome, shock syndrome, and rarely, thrombocytopenic purpura and acute renal failure) and hepatitis. Dapsone can produce haemolytic anemia, methaemoglobinaemia, agranulocytosis, hepatitis, peripheral neuropathy, psychosis and lepra reaction.  Spinal and epidural anesthesia should be used cautiously in patients with long-standing disease because hypotension and urinary retention are frequent problems. Neurological deficit can also follow after nerve blocks or regional anesthesia. As present case having normal biochemical parameters and was taking drugs for only one year still we chose atracurium as muscle relaxant and minimal doses of anesthetics due to all above issues.
As these patients are prone to nerve damage and neuropathies, that should be considered during regional blocks. These all above facts were considered while managing present case.
As leprosy patients may have cardiac, respiratory dysautonomia and autonomic involvement. Due to drugs side effects and dysautonomia they are prone to multiple organ failure. Proper PAC assessment and optimisation with intraoperative period adequate monitoring and preparation is essential while managing leprosy patients.
WHO strategy for leprosy elimination (Key Facts report, 2010)
The following actions are part of the ongoing leprosy elimination campaign, which should be strictly followed to eliminate and eradicate leprosy from universe. 
- Ensuring accessible and uninterrupted MDT services available to all patients through flexible and patient-friendly drug delivery systems;
- Ensuring the sustainability of MDT services by integrating leprosy services into the general health services and building the ability of general health workers to treat leprosy;
- Encouraging self-reporting and early treatment by promoting community awareness and changing the image of leprosy;
- Monitoring the performance of MDT services, the quality of patients' care and the progress being made toward elimination through national disease surveillance systems.
| References|| |
|1.||WHO Leprosy forum report. Available from: http://www.WHO.int/lep/en. [Last accessed on May 2006]. |
|2.||WHO fact sheet about leprosy elimination. Available from: http://www.WHO.int/lep/en. [Last accessed on Feb 2010]. |
|3.||Gautam VP. Treatment of leprosy in India. J Postgrad Med 2009;55:220-4. |
|4.||Yens DA, Asters DJ, Teitel A. Subcutaneous nodules and joint deformity in leprosy: Case report and review. J Clin Rheumatol 2003;9:181-6. |
|5.||Concha M, Cossio ML, Salazar I, Fich F, Perez C, Gonzalez S. Hansen's disease: Case report and review of literature. Rev Chil Infect 2008;25:64-9. |
|6.||Hernandez S, Jose Raman Ortiz-Gomez, Miguel Salvador, Julio Barrena, Ana Carla Loban. Anesthesia implication of lepromatous leprosy in Europe, case report rare European experience. Anesthesiology and Rescue 2009;3:288-91. |
|7.||Hempenstall K, Holland R. Regional anaesthesia for emergency caesarean section in a patient with lepromatous leprosy. Anaesth Intensive Care 1997;25:168-70. |
|8.||Mitra S, Gombar KK, Gombar S. Anaesthetic considerations in a patient with lepromatous leprosy. Can J Anaesth 1998;45:1103-5. |
|9.||Mitra S, Gombar KK. Leprosy and the anaesthesiologist. Can J Anaesth 2000:47;1001-7. |
|10.||Leonard IE, Cunningham AJ. Anaesthetic considerations for laparoscopic cholecystectomy. Best Pract Res Clin Anaesthesiol 2002;16:1-20. |
|11.||Lund C. Anaesthesia for minimally invasive gastric and bowel surgery. Best Pract Res Clin Anaesthesiol 2002;16:21-33. |
|12.||Yokoyama M, Ueda W, Hirakawa M. Haemodynamic effects of the lateral decubitus position and the kidney rest lateral decubitus position during anaesthesia. Br J Anaesth 2000;84:753-7. |
|13.||Conacher ID, Soomro NA, Rix D. Anaesthesia for laparoscopic urological surgery. Br J Anaesth 2004;93:859-64. |
|14.||Kale HD, Zawar PC, Chawhan RN, Kulkarni GR. Cardiac dysautonomia in lepromatous leprosy. Indian J Lepr 1984;56:563-8. |
|15.||Shah PK, Malhotra YK, Lakhotia M, Kothari A, Jain SK, Mehta S. Cardiovascular dysautonomia in patients with lepromatous leprosy. Indian J Lepr 1990;62:91-7. |
|16.||Gupta OP, Jain AP, Jajoo UN, Kumar K, Parvez K. Respiratory dysautonomia in leprosy. Indian J Lepr 1984;56:844-6. |
|17.||Grover S, Bobhate SK, Chaubey BS. Renal abnormality in leprosy. Lepr India 1983;55:286-91. |
|18.||Cartel JL, Millan J, Guelpa-Lauras CC, Grosset JH. Hepatitis in leprosy patients treated by a daily combination of dapsone, rifampin, and a thioamide. Int J Lepr Other Mycobact Dis 1983;51:461-5. |
|19.||Jacobson RR. Treatment of leprosy. In: Hastings RC, editor. Leprosy. 2 nd ed. Edinburgh: Churchill Livingstone; 1994:328-98. |