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ABSTRACT: Objectives: Drug resistance in leprosy is an emerging concern, leading to treatment failures, recurrences, and potential spread of resistant Mycobacterium leprae in the community. In this study, we aimed to assess drug resistance prevalence and patterns amongst leprosy patients at a tertiary care referral hospital in India. Methods: Mutations in drug resistance determining regions for dapsone, rifampicin, and ofloxacin of the M. leprae genome in DNA extracted from skin biopsies of 136 leprosy patients (treatment-naive = 67, with persistent skin lesions = 35, with recurrence = 34) were analysed by polymerase chain reaction followed by Sanger sequencing. Wild-type strain (Thai-53) was used as a reference strain. Results: Resistance mutations were identified in a total of 23 patients, constituting 16.9% of the cohort. Within this subset of 23 cases, resistance to ofloxacin was observed in 17 individuals (12.5%), while resistance to both dapsone and rifampicin was detected in three patients each (2.2% for both). The occurrence of ofloxacin resistance showed minimal disparity between recurrent and treatment-naive cases, at 17.6% and 16.4%, respectively. Dapsone resistance emerged in two treatment-naive cases and one case with persistent skin lesions. Notably, none of the treatment-naive cases or those with recurrence/relapse exhibited rifampicin resistance. Subsequently, no statistically significant correlation was identified between other clinical variables and the presence of antimicrobial resistance. Conclusions: The occurrence of resistance to the current multidrug therapy regimen (specifically dapsone and rifampicin) and to ofloxacin, a secondary antileprosy medication in M. leprae, represents a concerning scenario. This calls for an expansion towards bactericidal drug options and the establishment of robust surveillance for drug resistance in countries burdened with high leprosy rates. Moreover, the introduction of stringent antimicrobial stewardship initiatives is imperative. As a single centre study, it represents a limited, cross-sectional view of the real situation in the field.

Leprosy is a disease with spectral clinical manifestations along with two types of reactions, type 1 reaction (T1R) and type 2 reaction (T2R). T1R especially occurs because of the defensive upgradation of cell-mediated immunity (CMI) to M. leprae antigens. T1R is the main cause of disability in leprosy. The role of conventional adaptive T cells has been well studied to understand T1R. A comprehensive understanding of the role of unconventional T cells in the manifestation of inflammation during T1R is crucial and has not been studied. In our study, we found significantly higher plasma levels of TNFα, IL1β, IL17, and IP10 in T1R when compared to non-reaction (NR). Gene expression for cytokines in blood circulation by qPCR showed significantly higher expression of IFNγ, IP10, TNFα, IL6, IL17A and chemokines CCL3, CCR1, CCR5, and CXCR3 in T1R as compared to NR. Frequencies of NKT-like cells (48.7 %) and NK cells (22.3 %) were found significantly higher in T1R in comparison to NR (36.9 %, 18.3 %, respectively) (p = 0.0001). Significantly lower levels of γδT cells (3.32 %) were observed in T1R in comparison to NR (5.16 %). The present study has provided evidence for the first time on the role of plausible unconventional T cells in the immunopathogenesis of T1R in leprosy.

Resistance to antileprosy drugs is one of the main contributors for the persistence of leprosy in the present era. In the absence of universal antimicrobial resistance (AMR) surveillance through the national program, the indications for resistance testing remain a important dilemma to clinicians. WHO recommendations mainly focus on clinical relapse, which could be picked up late with continued transmission and repeated leprosy reactions in the patient. We report here a series of eighteen leprosy cases who were tested for AMR in view of the positive morphological index after completion of multidrug therapy, chronic Erythema nodosum leprosum, and clinical relapse.

ABSTRACT: Objectives: Purulia is one of the high-endemic districts for leprosy in West Bengal (the eastern part of India). The annual new case detection rate (ANCDR) of leprosy in West Bengal is 6.04/100000 (DGHS 2019–20). Our earlier report provided evidence of secondary drug resistance in relapse cases of leprosy. The aim of the current study was to observe primary drug resistance patterns for dapsone, rifampicin, and ofloxacin amongst new leprosy patients from Purulia, West Bengal in order to better understand the emergence of primary resistance to these drugs. Methods: In the present study, slit-skin smear samples were collected from 145 newly diagnosed leprosy cases from The Leprosy Mission (TLM) Purulia hospital between 2017 and 2018. DNA was extracted from these samples and the Mycobacterium leprae genome was analyzed for genes associated with drug resistance by polymerase chain reaction (PCR), followed by Sanger sequencing. Wild-type strain (Thai-53) and mouse footpad-derived drug-resistant strain (Z-4) were used as reference strains. Results: Of 145 cases, 25 cases showed mutations in genes associated with resistance to rifampicin, dapsone, and ofloxacin (as described by the World Health Organization, rpoB, folP, and gyrA, respectively) through Sanger sequencing. Of these 25 cases, 16 cases showed mutations in ofloxacin, two cases showed mutations in combinations of ofloxacin and rifampicin, four cases showed a mutation only in rifampicin, one case showed mutations in combinations of rifampicin and dapsone, and two cases showed mutations only in dapsone. Conclusion: Results from this study indicated the emergence of resistance to antileprosy drugs in new cases of leprosy. As ofloxacin is the alternate drug for the treatment of rifampicin-resistant cases, the emergence of new cases with resistance to ofloxacin indicates that ofloxacin-resistant M. leprae strains are actively circulating in this endemic region (i.e., Purulia, West Bengal), posing challenges for the effective treatment of rifampicin-resistant cases.

Rationale: Leprosy, a chronic granulomatous disease often present clinically as erythema nodosum leprosum, a type 2 reaction. The involvement of cochlear part of audiovestibular system is a rarity. Patient concerns: A 26-year-old male patient with lepromatous leprosy developed bilateral sensorineural hearing loss (SNHL) during type 2 reactional episode. Diagnosis: Recurrent erythema nodosum leprosum in rifampicin-resistant lepromatous leprosy. Interventions: Corticosteroids and second-line multidrug therapy. Outcomes: The patient improved significantly and was further referred for management of psychosocial impact due to sensorineural hearing loss. Lessons: The hearing impairment is a rare complication of type 2 reaction. Any patient with suspected cranial nerve involvement should essentially be screened by tuning fork tests for early detection of hearing impairment and offer timely intervention as required. All high bacteriological index cases should be investigated for antimicrobial resistance in high endemic areas.

Abstract Several Mycobacterial infections including leprosy and tuberculosis are known to evoke autoimmune responses by modulating homeostatic mechanism of the host. Presence of autoantibodies like, rheumatoid factor, anti-nuclear factor and antibodies to host, collagen, keratin, myelin basic protein (MBP) and myosin, have been earlier reported in leprosy patients. In the present study, we detected the role of mimicking epitopes between Mycobacterium leprae and host components in the induction of autoimmune response in leprosy. Based on our previous findings, we predicted and synthesized a total of 15 mimicking linear B cell epitopes (BCE) and 9 mimicking linear T cell epitopes (TCE) of keratin and MBP. Humoral and cell-mediated immune responses against these epitopes were investigated in Non-reaction (NR), Type 1 reaction (T1R) leprosy patients, and healthy controls. We observed significantly higher levels of antibodies against 8 BCE in T1R in comparison to NR leprosy patients. Further, we also found 5 TCE significantly associated with lymphocyte proliferation in the T1R group. Our results indicated that these epitopes play a key role in the induction of autoimmune response in leprosy and are also strongly associated with the inflammatory episodes of T1R. Conclusively, these molecules may be employed as a biomarker to predict the inflammatory episodes of T1R.

IntroductionImmunological reactions are frequent complications that may occur either before, during, or after treatment and affect 30–50% of leprosy patients. The presence of autoantibodies like rheumatoid factor, antinuclear factor, and antibodies to host collagen, keratin, actin, myosin, endothelial cells, and myelin basic protein (MBP) has been earlier reported in leprosy patients. The purpose of this study was to identify cross-reactive proteins in clinical samples such as saliva and slit skin scrapings (SSS) of leprosy patients which could be utilised as prognostic biomarkers for Type 1 Reaction (T1R) in leprosy.MethodA total of 10 leprosy patients in T1R and 5 healthy volunteers were recruited. The protein was extracted from their SSS and saliva samples, thereafter, isoelectric focusing (IEF) and two-dimensional PAGE were performed to analyse the proteins. Furthermore, the cross-reactivity was identified by western blotting host proteins in gel against purified IgG from Mycobacterium leprae soluble antigen (MLSA)- hyperimmunized rabbit sera, thereafter, cross-reactive proteins were identified by MS/MS. The cross-reactive host proteins were analysed for homologous bacterial proteins and B cell epitopes (BCEs) were predicted by using bioinformatic tools.ResultsA total of five spots of salivary proteins namely S100-A9, 35.3 kDa, and 41.5 kDa proteins, Serpin peptidase inhibitor (clade A), Cystatin SA-III, and four spots of SSS namely 41.4 kDa protein, Alpha-1 antitrypsin, vimentin, and keratin 1, were identified as cross-reactive. Further, a total of 22 BCEs of cross-reactive host proteins were predicted and visualised.DiscussionThis data provides strong evidence of cross-reactivity/molecular mimicry between host and pathogen in leprosy patients with reaction. These BCEs of cross-reactive proteins could be further studied to predict reactions and may be utilised as an early diagnostic biomarker for T1R in leprosy.