Mann‐Whitney U test results of the differences in the expression of Rab5, Rab7, tryptophan aspartate‐containing coat protein (TACO), leprae lipoarabinomannan (Lep‐LAM), and phenolic glycolipid‐1 (PGL‐1) based on positive and negative viability with
In Indonesia, leprosy remains a health problem because its elimination has not achieved. This shows the high Mycobacterium leprae transmission as a result of difficulties in the early detection, termination of the transmission chain, and management evaluation. Integrated translational research has been carried out as a solution for the problem. Dissemination of the various results of the research is conducted by the educational aspects tiered with a variety of learning methods including a textbook based on research findings, scientific papers at various scientific meetings, and published journals, as well as aspects of community service through electronic media, newspapers, and management and counseling with leprosy patients and their contact person, especially in endemic pockets area.
- Mycobacterium leprae
- translational research
Leprosy (Morbus Hansen) is a chronic infectious disease caused by bacteria
In Indonesia, leprosy remains a health problem. Indonesia has the third‐highest number of leprosy patients in the world after India and Brazil, the discovery of new cases is relatively stable from year to year, the dominance of the type of MB (potentially infectious) causes disability (9.9%) and can strike children (7.8%) thus affecting the future of the nation buds. This shows ongoing leprosy transmissions as a result of difficulties in the
1.1. Methods featured achievement
The data of leprosy problems in community studies were obtained from Department of Health. In addition, the process of medical education with a unique learning method, not only through lectures but also plunge the management of patients in the clinic (bed side teaching), provides an opportunity to discover a wide range of issues that require to handle leprosy patients.
Research that has been carried out involving all of the Members of the Division of Leprosy, Dermatology and Venereology Department, Faculty of Medicine, Airlangga University—Dr. Soetomo Teaching Hospital Surabaya along with the Leprosy Study Group—Institute of Tropical Disease Airlangga University, students of the Faculty of Medicine, Universitas Airlangga, residents of Dermatology and Venereology Department, Faculty of Medicine, Airlangga University—Dr. Soetomo Teaching Hospital, and postgraduate students, Airlangga University. In addition not only involving the faculty and students of Airlangga University, but also wide range universities such as Indonesia University, Padjadjaran University, Diponegoro University, Hassanudin University, and Sam Ratulangi University to conduct collaboration researches. The cooperation is also carried out by various local and foreign communities, among others Leprosy Research Centre of Tokyo, the Netherlands Leprosy Relief, and the Royal Tropical Institute, Amsterdam.
Working closely with various communities and doing some research setting requires a good strategy. The success of team work was supported by the dedication, discipline, and clear job description. At the time of this research, education and community service aspects are not left behind. By involving medical students, the educational process can still take the time to do some research studies, and to perform community service through health services and counseling.
Broadly speaking, research of
2. Review of Research Collaboration by Faculty of Medicine Universitas Airlangga, Dr. Soetomo Teaching Hospital, and Leprosy Study Group, Institute of Tropical Disease, Universitas Airlangga
2.1. Diagnosis of leprosy
Diagnosis of leprosy using cardinal sign only detects the clinical leprosy due to the limitation of this method. Acid‐fast bacilli test for detection of
2.1.1. Detection of DNA
M. leprae using PCR
The presence of
In those 122 patients with leprosy contact, we found 29 people who had >600 U/ml antiPGL‐1 IgM antibody refer to subclinical leprosy (Figure 1). From 29 subclinical leprosy patients, we collected 2 ml of venous blood and extracted
The result of this study is expected to be important for the management of patients with subclinical leprosy. Considering the potential to manifest into leprosy and become a source of transmission, therefore, we suggest that using new preventive measures such as chemoprophylaxis for high risk groups is important to control the spread of leprosy.
2.1.2. Detection of RNA
M. leprae (viable) using RT‐PCR and quantification of DNA M. leprae using real‐time PCR
In skin biopsy and blood from both MB and PB leprosy, 16S rRNA
2.1.3. The failure of phagolysosome process as a marker viability
Phagolysosome process in macrophage of leprosy patients is important in the early phase of eliminating
Membrane trafficking in phagolysosome failure is deemed as an important discovery in the study and it is represented by two compounds derived from the host (Rab5 and Rab7) and from the agent (Lep‐LAM). PGL‐1 role in the inhibition of lysosomes activation pathway in phagolysosome failure was also found from the study. Hence, the expression profiles of Rab5, Rab7, Lep‐LAM, and PGL‐1 can be used as markers of
Based on the three studies above, early diagnostic method for leprosy can be performed suited to the condition of the facility involved. In a highly qualified laboratorium with skilled analysts, DNA and RNA tests can be performed whereas in a laboratorium with limited facility and analysts, Immunohistochemistry (IHC) test may be used instead based on the phagolysosome failure process.
2.2. Management of leprosy
There has been a decrease in the number of new leprosy patient after MDTL era. However, the number of new cases found is still relatively stable. This means that interventions are still needed to evaluate, and measures to be taken to manage leprosy cases.
2.2.1. Dapsone and rifampicin resistance
Drug resistant cases can be tested by using the biomolecular method as an alternate solution as it is relatively simpler and less time consuming . Based on the detection of mutation in
All isolates showed positive PCR results by Lp1–Lp4. From 59 isolates, 50 isolates showed positive PCR results by folP1–folPR (Figure 12A) and the same result goes by rpoBF‐rpoBR from 77 out of 94 isolates (Figure 12B). In
Surprisingly, from three cases that show mutations in the
2.2.2. Methylsulfonylmethane treatment in erythema nodosum leprosum
Erythema nodosum leprosum (ENL) is a complex reaction found in the immune system . It causes antibody‐antigen complexes to be deposited within various tissues and may cause vasculitis. This condition may occur in MB leprosy patients. While the immunopathology of this disease is not fully understood, the reaction is known as a tumor necrosis factor‐α (TNF‐α)‐mediated process. The severity of the condition, possible complications, limited treatment choices, and recurrent nature of the disease makes it complicated to manage. Research studies to find choices of treatment options for ENL are imperative as the current treatment options are limited with high level of morbidity and chronicity. Previous study showed that methylsulfonylmethane (MSM) has strong capability as antiTNF‐α properties in vitro. This means that MSM might be useful for treating TNF‐α‐mediated conditions, such as ENL reaction. Hence, the objective of this study is to establish a correlation whether MSM is effective to treat the clinical signs and symptoms of recurrent ENL reaction in MB leprosy patients.
In this study, patients eligible for the study were all those with MB and admitted for at least a second episode of severe ENL reaction. A total of 10 patients who were eligible for the inclusion and exclusion criteria were enrolled for the study. A standardized history taking using a checklist was recorded from all of the patients chosen for the study. Thorough physical examination was done to look for skin signs, motoric or sensory neuropathy signs, and other possible complications of ENL. After each examination, ENL reaction severity scale was performed and included the basic neurological examination.
Nerve function assessment includes sensory nerve function using the Semmes‐Weinstein monofilament test (MFT) and motor nerve function using voluntary muscle tests (VMTs) and all impairments will be recorded. Blood (10 ml) was taken for laboratory assessments on day 1, 7, and 63 for TNF‐α examination and routine blood assessment on day 1, 7, 14, 56, and 112. MSM was given to the patients in the study with a dose of 0.1 g/kg bodyweight daily in two divided doses in addition to the World Health Organization’s (WHO) multidrug treatment (MDT) and/or additional clofazimine, if a patient has already taken it when the new reaction occurred. If the patient shows clinically significant improvement, the dose would be tapered off by 1 g every 2 weeks, starting from 1 week from the start of MSM treatment. Treatment will be stopped completely in 2 weeks after reaching 1 g/day level.
Graphic of TNF‐α in 10 patients is shown in Figure 14. Two out of 10 patients showed improvement from ENL reaction. These patients revealed high level of TNF‐α, and this value decreased along with lessening of ENL severity scale. First, patient showed increased ENL severity scale within MSM tapering off (full dose of MSM repeatedly and tapered off). The second patient was still in a good condition during follow‐up. Eight other patients were dropped on day 3 and 5. In those eight patients, the value of TNF‐α showed to be normal and was excluded from the study due to the increase of ENL severity scale. MFT and VMT examinations showed no changes during the study.
This finding proves that MSM treatment modality is possible as drug of choice for ENL patients with high level of TNF‐α in concordance to its mechanism of action as an antiTNF‐α.
2.2.3. Chemoprophylaxis in subclinical leprosy
Subclinical leprosy is a person who has high titer of IgM antiPGL‐1 without clinical manifestation of leprosy that manifests after several years . Preventive treatment of this leprosy is required especially in children in order to prevent manifest toward leprosy and prevent it from spreading. We evaluate the result of 2 years preventive treatment to subclinical leprosy in elementary school children using special regiment rifampicin and clarithromycin in Raas Island and Nguling, East Java, Indonesia.
Serological surveys for leprosy were conducted and involved a total of 5066 school children, who were screened in 2 leprosy endemic locations in East Java. About 302 elementary school children [109 from Nguling (Figure 15) and 193 from Raas Island (Figure 16)] were positive for sero (+++) with high IgM antiPGL‐1 antibody titer (>3000 U/ml ELISA). Rifampicin 300 mg daily with 250 mg clarithromycin daily for 10 days was given as a preventive treatment, continued with the same drugs administered intermittently every 2 weeks for 3 months. Every year, clinical and serological examination was evaluated.
After 2 years evaluation, none of the children showed any manifestation of leprosy clinically. IgM antiPGL‐1 antibody level showed to decrease between these 2 years of evaluation (Raas Island and Nguling:
Chemoprophylaxis for subclinical leprosy in children showed a promising good result after 2 years of evaluation. Further evaluation will be conducted for the next 3 years ahead. Our research about subclinical leprosy in children may support the clinical importance of it in exploring the disease transmission and how we can prevent it.
From these three studies, evaluation of resistance for suspected cases, MSM administration for refractory cases to steroid and administration of chemoprophylaxis for subclinical leprosy, can be implemented on routine leprosy management. Ongoing research is expected to prevent the onset of leprosy. Study on the impact of chemoprophylaxis in household and neighbor contact person with a grant from the Netherlands Leprosy Relief is also being carried out in collaboration with the Ministry of Health and local government.
2.3. Mode of the transmission
During this time, it is believed that the only source of transmission is leprosy MB type, but as we have not achieved elimination, we begin to think about another source of the transmission.
2.3.1. Strain local study in endemic area using PCR sequencing
Multiple locus variable number of tandem repeat (VNTR) analysis has been proposed as a mean of genotyping for tracking leprosy transmission . Many tandem repeats have been reported to be polymorphic with the potential as genetic markers to differentiate strains of
As shown in Table 3, there were five samples showing the same copy number of four genetic marker: TTC = 15; AC 8a = 10; AC 9 = 10, and 6–7 = 6. Two samples showing the same copy number of four genetic marker: TTC = 16; AC 8a = 10; AC 9 = 11, and 6–7 = 6. The multiple locus VNTR analysis shows two identical
|Table of VNTR analysis|
|No||TTC||AC 8a||AC 9||6–7|
2.3.2. Environment study and multicase family study using PCR sequencing
East Java is a province in Indonesia that has few endemic areas for leprosy . In order to comprehend this increasing incidence of leprosy, molecular typing will make it feasible to study geographical distributions of
The copy number of TTC repeats in Talango Island varied from 9 to 60 copies (Table 4). The 11‐copy TTC genotype was the most frequent in all samples.
|No. of repeats||Slit‐skin specimens||Nasal swabs||Water sources|
|Total||100% (24 cases)||100%(26 cases)||100% (24 cases)|
The copy number of TTC repeats in Talango Island varied from 10 to 11 copies (Table 5). The 11‐copy TTC genotype was the most frequent in all samples. There were no differences were found statistically in the pattern distribution of TTC repeats between nasal swab of households contacts and skin tissues of patients (
|Location||Family member||Relationship||TTC repeat|
|Nasal swab||Slit‐skin spec.|
|House 1||MB patient||Husband||10||10|
|Family contact||Child||‐ |
|Family contact||Sister in law||11|
|Family contact||Mother in law||10|
|Family contact||Father in law||‐|
|House 2 (Neighborhood)||MB patient||Child||11||11|
2.3.3. Mother‐baby transmission in leprosy
Lucio phenomenon is a rare type of reaction in untreated lepromatous leprosy type with diffuse infiltrative form, characterized with ulcerative type of skin lesions . In this study, a case of 29‐year‐old Indonesian female, 7th month primigravida with lucio leprosy, without prior treatment using WHO‐multidrug therapy (MDT). Laboratory examinations reported bacterial index 6+ and morphological index 7% from slit‐skin smear; histopathology revealed lucio phenomenon; PCR examination found
In Table 6, patient’s antiPGL‐1 IgM and IgG titers collected during caesarian section were way over the cutoff limit, whereas the antiPGL‐1 IgM and IgG titers from the umbilical cord blood were below the limit. Hence, placenta is regarded as a protective barrier against fetomaternal transmission of
|Subject||ELISA anti PGL‐1 (U/mL)||Cut off (U/mL)|
|Patient during the caesarian section||4854||1061|
|Umbilical cord blood during the caesarian section||0||516|
|Patient (after 7 months of therapy)||l912||1505||605||630|
|Baby (5 month‐old)||5||1724|
|Baby (1 year‐old)||0||3|
Studies in genotyping of patients and contact person proved that genotyping is not always appropriate; there is still the possibility of environmental transmission source. From these three studies above, there can be further potential research on transmission of leprosy from nonhuman sources. In the transmission pattern from mother to baby, it shows the importance of the role of placenta as a barrier, therefore, the health of the expecting mother needs to be optimized so as to prevent fetomaternal transmission and to treat the mother as early as possible and closely monitored the baby during incubation phase.
Dissemination of an integrated translational research above is done through aspects: education: lectures, case discussions, bed side teaching, and writing research‐based textbook for medical students, undergraduates, postgraduates, and dermatology and venereology residency program. Besides, presentations are done at local and international scientific meetings as well as publication of journals. Research: an integrated translational research is a continuous activity with the ultimate goal to eliminate leprosy in Indonesia. Community services: improving services and counseling at social events as well as when we are doing research in endemic pockets area. Besides, counseling is also done through electronic media. Community services can be done in practice of the research results of what they learned through lectures and case discussions in accordance with the level of competence they need to accomplish.
Various educational activities, research, and community service above increase knowledge about leprosy with the ultimate goal of achieving elimination through improvements in the field of preventive, curative, promotive, and rehabilitative. Here, the role of educational institutions is very important in helping to resolve the national problem. In the future, we hope more collaboration research of diagnosis, management, and mode of transmission will be conducted to overcome the problem of leprosy include early detection, management evaluation, and termination of the transmission chain. Integrated translational research is important to be done to resolve leprosy problems both in the community and clinics during the process of medical education.
Prakoeswa CRS, Agusni I, Izumi S. Detection of DNA Mycobacterium lepraein blood of the subclinical leprosy. Folia Medica Indonesiana. 2007; 42(2):64-67. ISSN 0303-7932
Prakoeswa CRS, Agusni I, Izumi S. Detection of viable mycobacterium lepraein skin biopsy and peripheral blood mononuclear cells (molecular biology study of 16s rRNA M. leprae). Media Dermato Venereologica Indonesiana. 2011; 38(3):6-13. ISSN 0216-0773
Prakoeswa CRS, Adriaty D, Wahyuni R, Iswahyudi, Yusuf I, Sutjipto, Agusni I, Izumi S. Expression profile of Rab5, Rab7, TACO, Lep‐Lam and PGL‐1 on the failure of phagolysosome process in macrophage of leprosy patients as a viability marker of Mycobacterium lepra.International Journal of Mycobacteriology. 2016; 5:155-163
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Prakoeswa CRS, Astari L, Citrashanty I, Listiawan MY, Agusni I, Brakel W. Pilot trial: Treatment methyl sulphonyl methane for erythema nodusum leprosum. In: Proceedings of the 18th International Congress of Leprosy; 16-20 September 2013; Brussel. Belgium: International Congress of Leprosy; 2013. pp. 267-278
Prakoeswa CRS, Adriaty D, Wahyuni R, Kusnartedjo, Astari L, Listiawan MY, Agusni I, Izumi S. Three years of evaluation in preventive treatment of subclinical leprosy in elementary school children with subclinical leprosy. In: Proceedings of the World Congress of Dermatology; 8-13 June 2015; Vancouver. Canada: WCD; 2015. p. 60
Prakoeswa CRS, Adriaty D, Wahyuni R, Iswahyudi, Damayanti L Sasmojo M, Agusni I, Izumi S. Genotyping Mycobacterium lepraeBandung clinical isolates by multiple locus VNTR analysis. In: Proceedings of the Konas Perdoski XII; 20-22 Juni 2008; Palembang. Indonesia: Konas Perdoski; 2008. pp. 219-220
Adriaty D, Wahyuni R, Iswahyudi, Mudatsir, Prakoeswa CRS, Agusni I, Izumi S. Genotyping analysis by TTC repeat variation of M. lepraeisolates in leprosy endemic area in East Java (Epidemiology Molecular Study in Poteran Island, Sumenep, East Java Province). In: Proceedings of the 4th Indonesia Biotechnology Conference (International Forum for Biotechnology); 15-17 February 2008; Bogor. Indonesia: International Forum for Biotechnology; 2008. p. 55
Prakoeswa CRS, Herwanto N, Agusni RI, Rismauli F, Adriaty D, Wahyuni R, Iswahyudi, Listiawan MY, Agusni I, Izumi S. Lucio Phenomenon of leprosy LL type on pregnancy: A rare case. Leprosy Review. 2016; 78:1-6