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Sunday, May 31, 2015

Team South India: Leprosy in Hyderabad, India

by Lucy Sung, c/o 2018

Team South India: Lucy, Nancy, Jason, and Melanie
Resilience one of the most important qualities of a physician. As medical students, we are constantly put under the pressure to succeed, answer questions correctly, be polite and courteous to all people, even if they are yelling at you in rage or in pain. On top of it all, we get lectures from the people upstairs that we need to take care of ourselves and remember to exercise.

It can be a lot to juggle.

But the best way to continue your day while you rub your sore shoulders and resist snacking on more Cheez-its, is to remind yourself that medical school is training. We are training for the best job (IMHO) in the world. We are always told that becoming a physician is a privilege. We are reminded so much that sometimes, the word - privilege - ceases to hold meaning.

This is why I love traveling. It is always about discovering and challenging yourself to adapt to any environment. In other words, increasing your resiliency.

There are two parts that I always look forward to when traveling:

Part 1. Going to the new place.
Part 2. After being at the new place for some time, going back home.

Outside Omani General Hospital, the oldest hospital in India. 
There are lessons learned in every step.

In the first part - Going to the new place - the experience of plucking yourself out of your environment and being plopped into a new one is a privilege in itself. Not everyone has the courage, the finances, and the time, to leave their responsibilities behind at home, and go forth and do something just for themselves. When I leave the airplane at my new destination, I feel nothing but relief. Relief because I have a slight fear of planes, but also because now it is time where I can focus on myself and prepare to learn something new about the people around me and about myself.

This is why I believe that traveling is a great and useful tool for medical students. We will learn by experience during our clinical years how to adapt to the hospital, but that is limited to bedside manners and how to bite your tongue at bully attendings. For our own personal development, traveling teaches you resilience by demonstration of the people that you meet and putting you in stressful situations that cannot be escaped by closing the door. You learn to confront, culturally appropriately of course, and how to share ideas and communicate without words. One of the fondest pastimes when I was a Peace Corps Volunteer in Rwanda was sitting with my neighbors in the late afternoon chatting about life, cows, and the future. But often, we sat in silence and enjoyed each other company while we watched the cows graze. When I was at a market place in Zanzibar, a Muslim grandma slapped my face and walked away because I was showing my shoulders. Did I want to yell and show my anger? Of course. But is that really going to solve anything? Probably not. Although it is not a fond memory, it reminds me that I am still a guest in another person's home, their country, their culture.

Lesson from Traveling #1: Increase your ability to walk in other people's shoes and learn empathy.

After the devastating earthquake in Nepal, the team was disbanded on grounds of safety. Melanie, through some kind of magic, established contact with the oldest hospital in India and invited classmates to join her and her family in Hyderabad, India. In the middle of finals, myself and 2 other students quickly decided to join Melanie and we soon found ourselves with tickets and visas to India.

The team with Dr. Ramesh in surgery 
At Osmania General Hospital, we were greeted by our preceptor, Dr. Ramesh. He loves to laugh and pimped us a lot on anatomy. From one of his residents, we got a tour of the hospital, a 100 year old colonial building that could rival the Buckingham Palace in its esthetic. However, the inside also smelled like it was 100 years old as well. Pigeons flew in the rafters in the four story tall alcove, dark corners were stained with urine, and patients beds were lined side by side like army beds in bunkers. Despite the sharp contrast against the Western hospital whose air is tinged with antiseptic, everything and anything was treated here.

Tuberculosis is very common!
Jason examining a patient with upper lobar pneumonia
The magnificent alcove of Osmania General Hospital
Medical Ward, patients either waiting or recovering from surgery

Our days consisted of either surgeries, receiving lessons and being pimped by doctors in general surgery or medicine, but with special permission and a few phone calls, we had the opportunity to exam three patients with leprosy.


In a slightly offensive and stereotypical way, I had imagined leprosy to be like the images I had been exposed to of leper colonies. Bandages and isolation, is what the unknowing person like myself imagined. We had a short lesson on leprosy during our immunology course -- TH1 and TH2 imbalances, tuberculoid, lepromatous, and other words that had become a scramble in our brains.

From Princess Mononoke, how I thought leprosy looked like

After getting lost a few times, getting turned away twice, and then eventually talking our way into meeting some patients, we finally had permission to learn about this disease that is not found in the USA.

In immunology, we learned that there are two types of leprosy: tuberculoid (non contagious) and lepromatous (contagious). There are actually FIVE types of leprosy that is along the spectrum of the disease. In order of increasing severity:

  • Tuberculoid leprosy (TL) -- strong immune response
  • Borderline tuberculoid (BT)
  • Borderline borderling (BB)
  • Borderline lepromatous (BL)
  • Lepromatous leprosy (LL) -- poor immune response
Patients who live in endemic regions and presenting with hypopigmentation patches and loss of sensory dermatones at the patches should be considered for leprosy. 

A and her father with the team

We first met A and her father. A is 13 years old and the cutest, nicest teenager I have ever met. Why can't the teenagers in my life be as polite as her? Last year, she fell down while playing and banged her elbow into the ground. She noticed that the wound turned black and she could not feel any touch, pain, or temperature at the site of the healing lesion. Soon, she noticed patches of lighter skin spreading with the same characteristics of loss of touch and pain. 

Note hypopimentation

New hypopigmentation on the dorsum of her right hand.
Her nails are orange because of henna, a common way to get colored nails in cultures that use it.
A is a typical teenager :)
She and her father visited the local doctor, who then sent them to Osmania General Hospital for treatment for Borderline tuberculoid leprosy. Her treatment includes going to her village's health center to take rifampin under supervision and documented and taking a dose of dapsone daily for 1 year. WHO provides medicine sachets free of charge.

Free of charge by the WHO
Leprosy treatment sachets, one per month. Rifampin once a month and dapsone daily x 24 months.
MDT = multidrug therapy

A and her father must take a 3 hour bus ride to Osmania General Hospital for follow up and laboratory, every 2 months, for the past year. It is a great time commitment, but A and her father were sweet and answered every question we had, even encouraging us to exam her patches. 

Dr. Aradya B. also demonstrated how to conduct a physical exam with a new patient with a possible leprosy diagnosis. In the video below, our patient also has a non-healing ulcer on his foot, a common occurrence because the lack of sensation on the plantar side of feet does not alert the person to sharp objects, burns, or other kinds of trauma. 

Key aspects for the physical exam:
  • Note the number and distribution of skin lesions, the borders, and hypopigmentations. 
  • Assess neuropathies -- test areas for hypoesthesia such as touch, pinprick, vibrations, temperature, and anhidrosis. This was a great review of the main nerves of the body. 
  • Sensory loss is most common, but motor loss and and tenderness can also be found. It is essential to do detect all possible nerve damage. 
Note edema, non-healing ulcer, and adenopathy  

Lesson from Traveling #2: Talk to people, especially the locals. You'l learn so much more. 

The second part -- After some time in a new place, going back home -- is also a welcomed relief. Ready to escape the devastating India summer heat that resulted in over 2000 heat wave related deaths in our region. Ready to go back home and see family and friends. Ready to get a pedicure because my heels are just plain nasty. Our next stop is Nepal where we will be meeting with our community partners to conduct health camps, and where I plan on helping to rejuvenate Nepal's tourism economy by buying all the souvenirs. 

It was over 115F every day...

STEP 1 Recall:
  • Leprosy is an infection caused by bacteria Mycobacterium leprae and Mycobacterium lepromatosis
    • Acid fast, obligate intracellular bacteria, thin rods
  • Transmission is from nasal discharge contact
  • Two types that we must know: 
    • Tuberculoid leprosy: strong immune response that causes a granuloma formation. Characterized by a TH1-type immune response
    • Lepromatous leprosy: the immune system is weak and diffuse inflammatory damage occurs. There is low cell-mediated immunity, characterized by a TH2-type immune response.
    • Dx: PCR or skin/nerve biopsy
    • Tx: TL type: dapsone and rifampin x 6mo. LL type: dapsone, rifampin, and clofazimine x24 mons.

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