CASE PROTOCOL

Maria Reyna Hospital

DEPARTMENT OF INTERNAL MEDICINE

November 27, 2008

Collera, Joanne M.
Encong, Aubrey A.
Gullim, Carryll Lynne M.
Hassannoor, Adlee W.
OBJECTIVES
1. To present a case of erythema nodosum leprosum presenting as acute sinusitis
2. To discuss its diagnosis, pathophysiology and management

GENERAL DATA
A case of LR, 44-year-old, male, Filipino, Roman Catholic, married,
businessman; currently residing at Ebarle-Corrales Streets, Cagayan de Oro City; and
admitted for the first time last November 6, 2008 at 4:35 pm.

Informant: Patient
Reliability: 80%

CHIEF COMPLAINT
Nasal congestion

HISTORY OF PRESENT ILLNESS

9 days prior to admission (PTA), patient claimed to have noted on and off fever
with temperature ranging from 37.6°C to 37.8°C. There were no other associated
symptoms at this time. Patient self-medicated with Phenylpropanolamine +
Chlorphenamine maleate + Paracetamol (Nafarin-A), 1 tab every 4 hours for 5 doses
which afforded relief.
4 days PTA, patient was very busy preparing for an incoming family event. He
was exposed under the heat of the sun for many hours, lifting and arranging heavy
materials in order to build a tent. Few hours after, he noted nasal stuffiness associated
with feverish feeling. There were no associated chills, headache, nausea and vomiting.
Non-pruritic, non-painful, erythematous nodule was also noted on his right lower
infraorbital area. He just continued taking Paracetamol + Phenylpropanolamine HCl +
Phenyltoloxamine Citrate (Sinutab) 1 tablet every 4 hours with no relief. No consult was
done.
3 days PTA, patient noted recurrence of fever, especially noted in the afternoon,
with highest temperature recorded at 39.9°C. This time it was associated with chills, nasal
congestion, diaphoresis, loss of appetite and frontal headache, tearing in quality, non-
radiating, 7/10 in severity. Still, no consult was done. Instead, he just continued taking
Sinutab every 4 hours. However, no relief was noted.
1 day PTA, the right lower infraorbital nodule gradually increased in size. He also
noted onset of similar lesion on the opposite side, with no other associated symptoms.
Morning PTA, fever, chills, and headache still persisted. However, there was now
associated difficulty of breathing brought about by the increasing severity of his nasal
congestion. This prompted him to seek consult at Maria Reyna Hospital as an out-patient.
CBC was done revealing WBC of 16.9, Neutrophils of 80.4% and Lymphocytes of 6.3%.
X-ray of the paranasal sinuses showed that his sinuses are of normal lucency and that his
nasal septum is in the midline. There were no localizing signs. He was then seen by an
ENT specialist and was given Oxymetazoline HCl (Drixine) nasal spray without relief.

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Due to lack of response to the drug and the weakness noted by the ENT specialist, he was
advised admission to which he complied.
PAST MEDICAL HISTORY
Last December 2005, patient had multiple non-pruritic, erythematous and
hypopigmented patches first noted on his forehead which gradually progressed to involve
his upper and lower extremities and torso. He also noted hyperpigmented, non-pruritic,
brownish-black macules on his lower extremities and right flank that were associated
with numbness, decreased sensation to pain, weakness and slight discomfort on affected
areas. He sought consult at Provincial Health Office and was diagnosed to have leprosy
without work-up being done. He was prescribed with Multidrug Therapy (Rifampicin,
Clofazipime, Dapsone) 4 tablets on first dose and 2 tablets daily for 1 month and the
cycle is again repeated every month for 1 year, with good compliance.
Two months after completion of treatment, he noted recurrence of multiple
brownish macules and hyperpigmented brownish-black patches, non-pruritic, non-painful
on upper and lower extremities, and torso associated with numbness, pinprick and
decrease sensation to pain. He sought consult at Provincial Health Office. Prednisone was
prescribed with unrecalled tapered dosages which he took for one week with good
compliance. Noted regression of brownish macules.
Patient is a known hypertensive for 3 years, highest BP 160/110, usual BP
140/100. No maintenance medications but was advised to exercise.
Patient is nondiabetic, non asthmatic with no history of previous hospitalizations
and operations.

FAMILY HISTORY
Patient claimed to have family history of hypertension and diabetes mellitus on
his paternal side. He denied any other heredo-familial diseases like asthma and cancer.

PERSONAL AND SOCIAL HISTORY

He was a chronic smoker for about 42 pack years and stopped just recently. He
was also an occasional alcoholic beverage drinker. He has no known allergy to drugs.
However, he claimed to have an allergy to chicken meat.
He finished Bachelor of Science in Marine Transportation. He was once an
official in their barangay. He currently works with his wife in dry goods business.
He denied any exposure to or even contact with persons known to have any form
of skin disease. Patient loves outdoor activities like biking, hiking and jogging.

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REVIEW OF SYSTEMS

GENERAL:
(-) weight loss, fatigue
SKIN
(-) pallor, lumps, itching, rashes, sores, jaundice
NAILS
(-) clubbing, color change
HEAD
(-) lightheadedness, dizziness
NECK
(-) pain, swollen glands, lumps
EYES
(-) pain, redness, itchiness
EARS
(-) hear loss, tinnitus, pain
NOSE & SINUSES
(-) epistaxis, tenderness, discharges
MOUTH & THROAT
(-) dry lips, gumbleeding
RESPIRATORY
(-) dyspnea, chest pain
CARDIOVASCULAR
(-) palpitations, chest pain
GASTROINTESTINAL
(-) abdominal pain, constipation, obstipation
URINARY
(-) frequency, hematuria, dysuria
MUSCULOSKELETAL
(-) stiffness, limitation of movement, joint pains
NEUROLOGIC
(-) tremors, memory deficits, seizures
HEMATOLOGIC

(-) anemia, easy bruising, bleeding

ENDOCRINE

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 (-) weight change, heat intolerance, cold intolerance
PSYCHIATRIC
(-) mood changes, suicidal ideation
PHYSICAL EXAMINATION

Examined patient awake, conscious, cooperative, ambulatory and not in

respiratory distress with the following vital signs:
BP: 160/80 mm Hg
HR: 80 bpm
RR: 22 cpm
Temp: 39 °C
O2 Sat: 100% at RA

Skin and Nails: warmth, good turgor

(+) 3 x 1 cm, erythematous nodule, non-painful, well-defined border with intact
sensation at right lower infraorbital area
(+) 1 x 1 cm, erythematous nodule, non-painful, well-defined border with intact
sensation at left lower infraorbital area
(+) 2 x 3 cm, hyperpigmented brownish- black patch, hyposthetic, ill-defined border
at posterior axillary line
(+) 10 x 6 cm, hyperpigmented blackish patch, hyposthetic, ill-defined border with
central clearing lesion, above the right superior iliac spine
(+) 4 x 5 cm hyperpigmented blackish scaly patch with central hypopigmentation,
anesthetic, non-painful at the lateral distal third of the left lower extremity
No clubbing and cyanosis, with good capillary refill

HEENT:
Head: Hair is black, thick, and evenly distributed. Head is normocephalic and
atraumatic with absent scalp lesions. Face is symmetrical.
Eyes: symmetrical, well-distributed eyelashes and eyebrows, anicteric sclerae, pink
palpebral conjunctivae
Pupils isocoric, equally round and reactive to light and accommodation
Ears: no discharges, lesions, tenderness on ears and mastoids
Nose: (+) nasal congestion, nasal septum midline, no internal lesions, no sinus
tenderness, watery discharges, turbinates not hyperemic
Mouth & pharynx: no gum bleeding, no ulcerations on oral mucosa, tongue midline,
uvula midline, no tonsillar inflammation, good dentition
Neck: supple, trachea midline, no thyroid gland enlargement, absent neck vein
distention, no lymphadenopathy

Thorax & Lungs: Posterior chest is symmetrical, no retractions, equal chest expansion
No adventitious breath sounds heard

Cardiovascular: Adynamic precordium, distinct heart sounds, normal rate and regular
rhythm, no murmurs

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Abdomen: globular, normoactive bowel sounds, soft, no tenderness on all four quadrants

GUT: Negative kidney punch sign

Musculoskeletal: (-) atrophy, (-) limitation of range of motion

Nervous:
Mental status – patient is alert and cooperative, oriented to time, place, and person, aware
of objects in the environment, has good thought content, and coherent. Patient
demonstrates proper affect, no mannerisms, able to repeat sequences of words, and
has good memory.

Cranial Nerves
I – able to smell coffee in each nostril
II – can read nameplate at 2 feet distance
II, III – pupils equally round, reactive to light and accommodation
III, IV, VI – extraocular movements full and equal
V – temporal and masseter have good muscle tone
VII – face symmetrical; can raise both eyebrows; can frown; can show both upper
and lower teeth, and can puff out both cheeks
VIII – able to hear whispered voice
IX, X – good speaking voice; no hoarseness; can easily swallow; uvula midline; gag
reflex intact
XI – can shrug both shoulders against resistance; can turn head side to side
XII – no tongue deviation, can protrude tongue; can move tongue side to side; can
push tongue against inside of cheek

Motor: Patient is aware of body position, absent involuntary movements, has good
overall muscle bulk and tone. Muscle strength in all extremities of 5/5.

Sensory: unable to differentiate dull and sharp stimuli on patchy areas of the feet
Decrease sensation on patchy areas of the trunk, upper extremities and face

Motor Sensory Deep Tendon Reflexes

5/5 5/5 100% 100%

5/5 5/5 100% 100%

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SALIENT FEATURES

History
• 44 years old male
• came in due to nasal congestion associated with fever, chills, headache and
weakness
• diagnosed with Leprosy last 2005 and completed 1 year treatment of Multidrug
Therapy (Rifampicin, Clofazipime, Dapsone) with good compliance

Physical Examination
• high BP, febrile
• erythematous nodules, non-painful, well-defined border with no decreased
sensation to pain at the lower infraorbital areas
• multiple hyperpigmented brownish-black, hyposthetic to anesthetic, ill-defined
bordered patches at the posterior axillary line, above the superior iliac spine and at
the lateral distal third of the left lower extremity

ADMITTING IMPRESSION
Acute Sinusitis
T/C Lepromatous Reaction

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DIFFERENTIAL DIAGNOSIS

1. Psoriasis
Ruled in:
• erythematous nodule, sharply demarcated
• fever
• younger age of onset
Point against:
• symmetry of lesions
• extensor distribution (most common sites of involvement are scalp, elbows
and knees, hands, feet, trunk, and nails)
• Auspitz sign
• itchiness and silvery scales

2. Sarcoidosis
Ruled in:
• erythematous nodule
• fever, anorexia, headache, weakness
Point against:
• red, rounded patches, which become elevated and painful within days
• skin plaques are purple, indolent lesions
• blurring of vision
• Subcutaneous nodules appear most often on the arms and legs

3. Leukemia cutis
Ruled in:
• history of fever, chills, and lethargy
• single or multiple nodules
Point against:
• pancytopenia
• pallor
• hepatosplenomegaly

4. Acute Febrile Neutrophilic Disorder (Sweet’s Syndrome)

Ruled in:
• Non-pruritic erythematous nodules
• Fever, upper respiratory tract infections, headache
Point against:
• Skin lesions causes pain and burning sensation
• Extracutaneous manifestations (e.g pulmonary involvement which may
manifest as dyspnea or chronic cough)
• Proteinuria, hematuria

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 • Decreased creatinine clearance

COURSE IN THE WARDS

On admission, patient had complaints of difficulty of breathing, nasal stuffiness,

headache and fever. On physical examination, patient was febrile with temperature of
39.4°C. There was non hyperemic turbinates noted with watery secretions. His face had
erythematous nodule, non-painful, well-defined border with no decreased sensation to
pain at both lower infraorbital areas. Subsequent physical examination revealed an area of
hyposthesia on the hyperpigmented patches with ill-defined border at the posterior axillary
line, above the right superior iliac spine and the lateral surface of the distal third of the
left lower extremity. CBC revealed leukocytosis at 16.9 with neutrophilic predominance of
80.4% and lymphocytopenia at 6.3%, consistent with bacterial infection. Urinalysis revealed
turbid urine with high specific gravity at 1.030, +1 protein, and 3-5/hpf pus cells. Baseline
creatinine was within normal limits at 1.3 mg/dL. X-ray of the paranasal sinuses showed
normal lucency of the sinuses and midline nasal septum with no localizing signs. CT scan
of PNS showed densities seen within the inferior aspect of the maxillary sinuses, the
ethmoids and the left frontal sinus with obliteration of the osteomeatal complexes. Mucus
retention cyst was seen at the left maxillary sinus too. The impression was acute sinusitis
to consider lepromatous reaction. He was started on D5LR 1L at 30 gtts/min. He was
given Amoxicillin + Sulbactam (Ultramox) 1,500 amp IVTT q 8 ANST, Celecoxib
(Celebrex) 400mg cap, 1 cap OD, Midazolam 7.5mg PO at 8pm and Paracetamol 500mg
q 4, PRN for fever ≥ 37.8°C.
Patient still complains of nasal congestion, fever, inability to sleep, headache and
decreasing difficulty of breathing on the 1st hospital day. He was given Oxymetazoline
HCl (Drixine) nasal spray, 2 sprays per nostril BID for 3 days and Loratadine +
Pseudoephedrine (Clarinase) 1 tab BID.
On the 2nd hospital day, he was referred to an infectious specialist for co-
management and re-evaluation of persistent sinusitis and skin lesions. He was then
transferred to an isolation ward. Amoxicillin + Sulbactam (Ultramox) was discontinued
and started with Levofloxacin (Floxel) 500 mg 1 tab OD. Repeat CBC showed slight
increase in leukocytosis at 18.7 with neutrophilic predominance at 93%. ESR was
elevated at 128 mm/hr. ALT was 90 U/L. Typhidot and CRP were negative. Acute
sinusitis was improving. Hypersentivity reaction to Ultramox was considered regarding
his lesions.
From the 3rd hospital day onwards there was a note of progressing erythematous
nodules all over his body associated with fever. He was referred to a dermatologist on the
5th hospital day with an impression of Erythema Nodosum Leprosum. Multibacillary drug
regimen recommended by WHO was started (Dapsone 100 mg tab OD, Rifampicin 600
tab once a month, and Clofazamine 50 mg tab OD and 300 mg once a month). This will
be for two years. Prednisone 30 mg 1 tab after breakfast was also given. Slit smear to
AFB staining was done which revealed negative for two takings.
On the 7th hospital day, patient had markedly improved with no more complaints
of nasal stuffiness, fever, headache and difficulty of breathing. However, there was still
erythematous nodules noted all over his body. He was advised for discharge, with the

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following final diagnosis of Sinusitis, Bacteremia, Staph species, Erythema Nodosum
Leprosum. Patient’s relatives were advised on the duration of treatment before the patient
becomes non-infectious and on chemoprophylaxis.

DISCUSSION:

Cutaneous lesions of leprosy are varied so that their true nature is often missed.
The nodular lesions at the infraorbital areas which appeared did not bother our patient to
seek medical consultation. Admission was done because of nasal congestion, fever,
chills, headache and weakness. In the presence of nasal congestion, we often think of
more common diseases such as acute sinusitis and common colds. However, subsequent
physical examination revealed an area of hyposthesia on the hyperpigmented patches with ill-
defined border at the posterior axillary line, above the right superior iliac spine and the
lateral surface of the distal third of the left lower extremity . Only then was leprosy
suspected.

Leprosy is a chronic granulomatous infection and its sequelae, caused by

Mycobacterium leprae. It involves primarily the skin and nerves, but also other organs or
systems, including eyes, respiratory tract, lymph nodes, testicles, and joints. It requires
demonstration of acid-fast bacilli in tissue or a characteristic nerve abnormality.

There are around 500,000 new cases yearly, worldwide. Leprosy has declined in
most of the countries in the Western Pacific Region. China, Philippines and Viet Nam
continue to report 1 000 or more new cases annually. The national prevalence rate of
leprosy has consistently been less than one per 10,000 population since 1998. This is the
level at which leprosy is considered eliminated as a public health problem. The case
detection rate has continued to decrease from 1989 to 2004. Surveillance in 2004

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revealed that the prevalence of leprosy has gone down to 0.38 case per 10,000
population.

Despite the low prevalence rate of leprosy at the national level since 1998, 29
provinces were noted to have sub-national prevalence rates above one case per 10,000 in
the year 2000. However, five provinces did not meet the target and remained to have
more than one case of leprosy per 10,000 population in 2004. There are also eight cities
that have leprosy prevalence rate above one case per 10,000 population.

Leprosy is a very serious, multilating and stigmatizing disease in many parts of

the world and early diagnosis and therapy is the most important strategy for its control. It
is highly infective, but has low pathogenicity and low virulence with a long incubation
period.
Leprosy reactions are immunological phenomena that occur before, during or
after the completion of multi-drug therapy (MDT). They contribute immensely to the
burden of leprosy and need to be diagnosed and treated early to prevent nerve function
impairment and permanent disability.

Etiology

M. leprae, the cause of leprosy, is a non-cultivable, Gram-positive, obligate,

intracellular, acid-fast bacillus. In tissues or smears, M. leprae is quantified by the biopsy
index (BI), a logarithmic scale as to the number of bacilli per oil immersion field (OIF): a
BI of 6 is 1000 or more bacilli/OIF; a BI of 5 is 100 to 1000/OIF; a BI of 4 is 10 to
100/OIF; a BI of 3 is 1 to 10/OIF; a BI of 2 is 1 bacillus/1 to 10 OIFs; a BI of 1 is 1
bacillus/10 to 100 OIFs; and a BI of 0 is no bacilli in 100 OIFs. Because a BI of 6

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indicates 109 bacilli per gram of granuloma, tissue with a BI of 0, may have as many as
103 organisms per gram.

A patient is considered to be “paucibacillary” if no acid-fast bacilli are found in

tissue or smears, and to be “multibacillary” if one or more acid-fast bacilli are found.
Pathogenesis

Phenolic glycolipid-1 (PGL-1) is a glycolipid in the capsule of Mycobacterium

leprae. PGL-1 contains an antigenically distinct trisaccharide unit that is not found in any
other bacteria. PGL-1 makes up to 2% of the total bacteria mass, suggesting that the
function of the sugar chains may be related to functions unique to Mycobacterium leprae.
PGL-1 binds to laminin-2, which facilitates PGL-1 binding to the basal lamina of axons
on Schwann cells and the resulting invasion of the cells. This might explain the
neurotropism of these bacteria. Because this invasion can occur even when the bacteria
were dead, the invasion seems not to be driven by the bacteria, but by passive interaction
between glycolipids in the capsule of the cell wall and molecules in the basal lamina of
Schwann cells. If this binding could be blocked, a new therapeutic avenue might become
possible. However, laminin-2 is also present in the basement membrane of other tissues.
The basement membrane in muscle is composed of laminin, type IV collagen,
entactin/nidogen and heparan sulphate proteoglycan. One major component of the BM in
muscle is laminin-2, which is composed of a heavy chain laminin a2 and two light chains,
b1 and laminin g1. Other factors must also play a role in the fact that Mycobacterium
leprae has a predilection for neural tissue.

It has long been suspected that leprosy has a strong genetic component. A leprosy
susceptibility locus on chromosome 6 (region q25-q26) was discovered in 2004. This
DNA stretch included the Parkinson's disease gene PARK2 and the co-regulated gene
PACRG. The PARK2 gene is expressed by human Schwann cells and macrophages,
which are the primary host cells of Mycobacterium leprae.

Pathophysiology

Leprosy is not a highly infectious disease. The principal means of transmission is by

aerosol spread from infected nasal secretions to exposed nasal and oral mucosa. Leprosy
is not generally spread by means of direct contact through intact skin, although close
contacts are most vulnerable. The incubation period is 6 months to 40 years or longer.
The mean incubation period is 4 years for tuberculoid leprosy (TT) and is 10 years for
lepromatous leprosy (LL).

The areas most commonly affected are the superficial peripheral nerves, skin, mucous
membranes of the upper respiratory tract, anterior chamber of the eyes, and the testes.
These areas tend to be cool parts of the body. Tissue damage depends on the degree to
which cell-mediated immunity is expressed, the type and extent of bacillary spread and
multiplication, the appearance of tissue-damaging immunologic complications (ie, lepra
reactions), and the development of nerve damage and its sequelae.

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M leprae is an obligate intracellular, acid-fast, gram-positive bacillus with an affinity for
macrophages and Schwann cells. For Schwann cells in particular, the mycobacteria bind
to the G domain of the alpha-chain of laminin 2 (found only in peripheral nerves) in the
basal lamina. Their slow replication within the Schwann cells eventually stimulates a
cell-mediated immune response, which creates a chronic inflammatory reaction. As a
result, swelling occurs in the perineurium, leading to ischemia, fibrosis, and axonal death.

The genomic sequence of M leprae was only recently completed. One important
discovery is that although it depends on its host for metabolism, the microorganism
retains genes for the formation of a mycobacterial cell wall. Components of the cell wall
stimulate a host immunoglobulin M antibody and cell-mediated immune response, while
also moderating the bactericidal abilities of macrophages.

The strength of the host's immune system influences the clinical form of the disease.
Strong cell-mediated immunity (interferon-gamma, interleukin [IL]–2) and a weak
humoral response results in mild forms of disease, with a few well-defined nerves
involved and lower bacterial loads. A strong humoral response (IL-4, IL-10) but
relatively absent cell-mediated immunity results in LL, with widespread lesions,
extensive skin and nerve involvement, and high bacterial loads. Therefore, a spectrum of
disease exists such that cell-mediated immunity dominates in mild forms of leprosy and
decreases with increasing clinical severity. Meanwhile, humoral immunity is relatively
absent in mild disease and increases with the severity of disease.

Toll-like receptors (TLRs) may also play a role in the pathogenesis of leprosy. M leprae
activates TLR2 and TLR1, which are found on the surface of Schwann cells, especially
with TT. Although this cell-mediated immune defense is most active in mild forms of the
disease, it is also likely responsible for the activation of apoptosis genes and,
consequently, the hastened onset of nerve damage found in persons with mild disease.
Alpha-2 laminin receptors found in the basal lamina of Schwann cells are also a target of
entry for M leprae into these cells, while activation of the ErbB2 receptor tyrosine kinase
signaling pathway has been identified as a mediator of demyelination in leprosy.

The activation of macrophages and dendritic cells, both antigen-presenting cells, is

involved in the host immune response to M leprae. IL-1beta produced by antigen-
presenting cells infected by mycobacteria has been shown to impair the maturation and
function of dendritic cells. Because bacilli have been found in the endothelium of skin,
nervous tissue, and nasal mucosa, endothelial cells are also thought to contribute to the
pathogenesis of leprosy. Another pathway exploited by M leprae is the ubiquitin-
proteasome pathway, by causing immune cell apoptosis and tumor necrosis factor
(TNF)–alpha/IL-10 secretion.

A sudden increase in T-cell immunity is responsible for type I reversal reactions. Type II
reactions result from activation of TNF-alpha and the deposition of immune complexes in
tissues with neutrophilic infiltration and from complement activation in organs. One
study found that cyclooxygenase 2 was expressed in microvessels, nerve bundles, and
isolated nerve fibers in the dermis and subcutis during reversal reactions.

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Diagnosis

Clinical tests: Certain tests can be performed in the clinic to aid in the diagnosis of
leprosy.

o Tissue smear testing/slit-skin smears: An incision is made in the skin, and the
scalpel blade is used to obtain fluid from a lesion. The fluid is placed on a glass
slide and stained by using the Ziehl-Neelsen acid-fast method or the Fite method
to look for organisms. The bacterial index is then determined as the number of
organisms at 100X with oil immersion. Skin smears have high specificity but low
sensitivity because 70% of all patients with leprosy have negative smears.
However, this test is useful because it detects the most infectious patients.
o Histamine testing: This test is used to diagnose postganglionic nerve injury.
Histamine diphosphate is dropped on healthy skin and affected skin, and a
pinprick is made through each site. The site forms a wheal on healthy skin, but
not on skin where nerve damage is present.
o Methacholine sweat testing: An intradermal injection of methacholine
demonstrates the absence of sweating in leprous lesions. This test is useful in
dark-skinned patients in whom the flare with the histamine test cannot be seen.

Diagnostic criteria for leprosy: The diagnosis of leprosy is primarily a clinical one. In one
Ethiopian study, the following criteria had a sensitivity of 97% with a positive predictive
value of 98% in diagnosing leprosy. Diagnosis was based on 1 or more of 3 signs:

o Hypopigmented or reddish patches with definite loss of sensation

o Thickened peripheral nerves
o Acid-fast bacilli on skin smears or biopsy material

Classification: The Ridley-Jopling classification is used to differentiate types of leprosy

and helps in determining the prognosis. Purely neuritic leprosy (asymmetrical peripheral
neuropathies with no evident skin lesions), with or without tenosynovitis and symmetric
polyarthritis, is also possible. A general classification of disease is based on the number
of skin lesions present and the number of bacilli found on tissue smears. Paucibacillary
disease (indeterminate leprosy and TT) has fewer than 5 lesions and no bacilli on smear
testing. Five or more lesions with or without bacilli (borderline leprosies and LL) is
considered multibacillary disease.

o Indeterminate leprosy: This early form causes one to a few hypopigmented or,
sometimes, erythematous macules. Sensory loss is unusual. Approximately 75%
of affected persons have lesions that heal spontaneously. In some, the disease may
persist in this indeterminate form. In those with weak immunity, the disease
progresses to one of the other forms.

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o Tuberculoid leprosy: Skin lesions are few. One erythematous large plaque is
usually present, with well-defined borders that are elevated and that slope down
into an atrophic center. The lesions can become arciform or annular. They can be
found on the face, limbs, or elsewhere, but they spare intertriginous areas and the
scalp. Lesions can be dry and scaly, hypohidrotic, and hairless. Another
presentation involves a large, asymmetric hypopigmented macule. Both types of
lesions are anesthetic and involve alopecia.
 Spontaneous resolution can occur in a few years, leaving pigmentary
disturbances or scars. Progression can also occur, leading to borderline-
type leprosy. In rare instances in which a patient is untreated for many
years, the lepromatous type can develop.
 Neural involvement is common in persons with TT; it leads to tender,
thickened nerves with subsequent loss of function. The great auricular
nerve, common peroneal, ulnar, and radial cutaneous and posterior tibial
nerves are often prominent. Nerve damage can happen early, resulting in
wrist drop or foot drop.
o Borderline tuberculoid leprosy: Lesions in this form are similar to those in the
tuberculoid form, but they are smaller and more numerous. The nerves are less
enlarged and alopecia is less in borderline tuberculoid leprosy than in other forms.
Disease can remain in this stage, it can convert back to the tuberculoid form, or it
can progress to LL.
o Borderline borderline leprosy: Cutaneous lesions consist of numerous, red,
irregularly shaped plaques that are less well defined than those in the tuberculoid
type. Their distribution may mimic those of the lepromatous type, but they are
relatively asymmetric. Anesthesia is only moderate. Regional adenopathy may be
present. Disease may remain in this stage, it may improve, or it may worsen.
o Borderline lepromatous leprosy: Lesions are numerous and consist of macules,
papules, plaques, and nodules. Annular punched-out–appearing lesions that look
like inverted saucers are common. Anesthesia is often absent. As with the other
forms of borderline leprosy, the disease may remain in this stage, it may improve,
or it may regress.
o Lepromatous leprosy: Early cutaneous lesions consist mainly of pale macules.
Late infiltrations are present with numerous bacilli. Macular lesions are small,
diffuse, and symmetric. The skin may be smooth and shiny, but skin changes do
not occur in LL until late in the course. Therefore, early LL lesions have little or
no loss of sensation, nerves are not thickened, and sweating is normal. Nerve loss
is slow and progressive.
 Hypoesthesia occurs first over extensor surfaces of the distal extremities,
followed by weakness in the same areas.
 Alopecia affects the lateral aspects of the eyebrows (madarosis), spreading
to the eyelashes and then the trunk. Scalp hair remains intact.
 Lepromatous infiltrations can be diffuse, can occur as nodules (called
lepromas), or can be plaques. The diffuse type results in the thickened skin
appearance of a leonine facies. Neuritic lesions are symmetric and slow to
develop.

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  Eye involvement occurs, causing pain, photophobia, decreased visual
acuity, glaucoma, and blindness.
 Nasal infiltration can cause a saddle-nose deformity and impaired
olfaction. Hoarseness ("leprous huskiness") and stridor are a result of
laryngeal involvement.
 Oral lepromas, usually located on the hard and soft palate, uvula, tongue
("cobblestoning"), lips, and gums, can progress to necrosis and ulceration.
Tissue destruction may result.
 Infiltration of the helix or megalobule (elongation and wrinkling of the
earlobe) may occur.
 Lymphadenopathy and hepatomegaly can result from organ infiltration.
 Testicular atrophy results in sterility and gynecomastia.
 Aseptic necrosis and osteomyelitis can occur with repeated trauma after
joint invasion.
 Brawny edema of the lower extremities is a late finding.
 Histoid leprosy is a recognized clinical variant of LL. It can occur as a
result of M leprae resistance to monotherapy of MDT. One report of de
novo histoid leprosy suggests that it may also possibly evolve from
indeterminate leprosy. Paucibacillary and multibacillary forms also exist.
 Unlike the other types of leprosy, LL cannot convert back to the less
severe borderline or tuberculoid types of disease.

 Other: Lepra reactions are complications that occur in 50% of patients after the start
of therapy or occasionally before therapy

Management

The management of leprosy includes early pharmacotherapy and physical, social, and
psychological rehabilitation. The goals of pharmacotherapy are to stop the infection,
reduce morbidity, prevent complications, and eradicate the disease. Since 1981, MDT has
been advocated by the World Health Organization (WHO) and the United States. MDT
prevents dapsone resistance, quickly reduces contagiousness, and reduces relapses,
reactions, and disabilities.

The length of treatment ranges from 6 months to 2 years. Patients are considered
noninfectious within 1-2 weeks of treatment (usually after the first dose). These drugs are
conveniently packaged in monthly calendar blister packs. Monitor for drug resistance and
adverse reactions to medications.

• Paucibacillary disease can be treated with a combination of 2 drugs, whereas

multibacillary disease requires triple-drug therapy. Single skin lesions
(paucibacillary) can be treated with a single dose of 3 drugs. The length of
treatment depends on the type of disease and on the access to drugs.
• WHO and US treatment regimens for paucibacillary and multibacillary disease
are listed below. Therapy for single skin lesions is not universal, because 80% of

16
 single skin lesions heal spontaneously. Therefore, only the WHO has a
recommended treatment.
• Current WHO recommendations for treatment of leprosy are as follows:
o Paucibacillary disease - Dapsone at 100 mg/d plus rifampin at 600 mg
once a month for 6 months
o Multibacillary disease - Dapsone at 100 mg/d plus rifampin at 600 mg
once a month plus clofazimine at 300 mg once a month and 50 mg/d for 1
year
o Single skin lesion - A single dose of rifampin at 600 mg, ofloxacin at 400
mg, and minocycline at 100 mg
• Current US recommendations for the treatment of leprosy are as follows:
o Paucibacillary disease - Dapsone at 100 mg/d plus rifampin at 600 mg/d
for 1 year
o Multibacillary disease - Dapsone at 100 mg/d plus rifampin at 600 mg/d
plus clofazimine at 50 mg/d for 2 years
• In patients taking dapsone, the CBC count should be checked frequently early
during the therapy and then less frequently later during therapy.
• Skin lesions usually resolve within the first year of treatment, although some may
persist for up to 5 years in multibacillary disease.
• Potential deformities can be prevented by educating patients about how to
minimize existing nerve damage and by treating any sequelae of this damage.
Close follow-up is important to ensure patient compliance.

Complications

• Reactional states occur in approximately one third of patients and are acute
inflammations of the disease. They may be induced by MDT, physical or mental
stress, trauma, pregnancy, or surgical procedures. A leprous reaction should be
considered a medical emergency and mandates immediate care. These states can
result in permanent neurologic sequelae, resulting in disability and deformity.
Patients at the highest risk are those with multibacillary leprosy and/or preexisting
nerve impairment.
o Lepra type I (reversal) reactions usually affect patients with borderline
disease. Reversal reactions are a shift toward the tuberculoid pole after the
start of therapy, and they are type IV cell-mediated allergic
hypersensitivities, indicating an improvement in cell-mediated immunity.
Puberty, pregnancy, and childbirth can also precipitate type I reactions.
These reactions usually result in skin erythema, with edema and
tenderness of peripheral nerves. New skin lesions are common, and the
patient may have an acute febrile illness. The peak time for type I
reactions is during the first 2 months of therapy and for up to 12 months.
Corticosteroid treatment is aimed at controlling acute inflammation,
relieving pain, and reversing nerve and eye damage. With treatment,
approximately 60-70% of the patient's nerve function is recovered. If
neuritis is absent, NSAIDs may be helpful. MDT should be continued
during type I reactions.

17
 o Lepra type II reactions, or ENL, occur in approximately 10% of patients
with borderline lepromatous leprosy and in 20% of patients with LL.
These reactions are type III humoral (antibody-antigen) hypersensitivities,
with a systemic inflammatory response to immune complex deposition.
The most common presenting symptoms are crops of painful erythematous
nodules of the skin and subcutaneous tissue. Bullae, ulcers, and necrosis
also may occur. Nerve damage is slower than in reversal reactions. The
reaction usually manifests after a few years of therapy, and, although a
single acute episode is possible, relapses occur intermittently over several
years. Associated fever, malaise, arthralgias, neuralgia, iridocyclitis,
dactylitis, orchitis, and proteinuria may be present.
 The use of clofazimine in MDT substantially reduces the incidence
of ENL to 5%. Clofazimine has also been used to treat ENL.
 Thalidomide is effective except in the case of neuritis or iritis, in
which case corticosteroids should be used.
 Other treatment therapies reported to be effective include
colchicine, pentoxifylline, cyclosporine A, intravenous
immunoglobulin, and infliximab.
 Lowering the dose of dapsone may decrease the severity of bullae
and ulcers.
o Lucio phenomenon is a cutaneous necrotizing vasculitis that is
sometimes designated a type II reaction. It is common in Mexico and
Central America and is characterized by erythematous, geometric,
irregular-shaped macules that rapidly progress to ulceration and necrosis
on acral areas or extremities of patients with diffuse LL. Systemic
symptoms such as hepatosplenomegaly, fever, arthritis, and nephritis are
usually present. Thalidomide is ineffective in treating this type of reaction;
however, no consensus on treatment had been determined. Most patients
with Lucio phenomenon have not received MDT or were treated
irregularly; therefore, MDT is recommended. Azathioprine or
cyclophosphamide with corticosteroids with or without plasmapheresis
has also been used.
• The real challenge in managing leprosy is the treatment of reactional states.
o If the course of MDT is not complete, continue taking those medications
as directed.
o Systemic steroids are effective in reducing inflammation and edema in
reversal reactions; therefore, they are the most helpful medications in
preventing nerve damage.
o Prednisone at 40-80 mg/d should be given for 5-7 days then tapered
slowly over 3-6 months. This long course is necessary to decrease the
severity of disabilities and deformities. One study recommended a low-
dose (30 mg/d) regimen for 20 weeks for controlling type I reactions.
o Clofazimine can also be used as a steroid-sparing agent for reversal
reactions, alone or with corticosteroids.

18
 o Although the WHO does not support its use for ENL, thalidomide is
highly effective with ENL. It is ineffective for the treatment of reversal
reactions.
• Neuropathy induced by leprosy can result in trauma, pressure necrosis, or
secondary infection that goes unnoticed, leading to amputation of digits or limbs.
Wrist and foot drop are also common. Silent neuropathy can occur in the absence
of overt signs of nerve or skin inflammation. Even with corticosteroid treatment,
only approximately 60% of nerve function is recovered. Cyclosporine A may be
useful in controlling nerve impairment and pain.
• Injuries can result in ulcerations, cellulitis, scarring, and bony destruction. Foot
ulcers discovered early should be treated with rest because they heal if they are
not subject to weight bearing.
• Osteoporosis and fractures can result from bony changes due to leprosy.
Risedronate and other bisphosphates may help improve lumbar bone mineral
density.
• Contractures can develop and may result in fixation. Common sequelae include
clawing of hands and feet.
• Eye damage, especially in the anterior portion of the eye, can result in loss of the
corneal reflex, lagophthalmos, ectropion, entropion, and blindness. One study
found the risk of ocular complications in patients with multibacillary disease, after
completion of MDT, to be 5.6%, with eye-threatening complications to be 3.9%.
• Skin drying and fissures can be caused by autonomic disruption.

ERYTHEMA NODOSUM LEPROSUM

ENL or type 2 reaction is a serious, difficult to manage immunological complication of

borderline
lepromatous (BL) and lepromatous leprosy (LL). The majority of patients with ENL go
on to develop several episodes over many years, as multiple acute episodes or
chronic ENL.

The cutaneous manifestation of ENL is widespread crops of erythematous, inflamed

nodules and papules, which may be superficial or deep. Ulcerated, necrotic, pustular
and bullous forms have also been reported. Some nodules may persist as a chronic
painful panniculitis leading to fibrosis and scarring.
Neuritis, in the form of painful enlarged nerves and nerve function impairment, may
occur as part of ENL. The neuritis may be less dramatic than in T1R but it is
important to recognise nerve involvement early to prevent permanent loss of
function.

ENL may present as a systemic illness, with high fever, systemic upset and
prostration. Peripheral oedema and transient proteinuria can also occur. Iritis and
episcleritis can occur and may be sight threatening. Other features such as pain,
photophobia and lacrimation may be absent. Orchitis, lymphadenopathy,
organomegaly, joint involvement, dactylitis and bone tenderness, especially over the
tibia, are well recognised features of ENL.

Epidemiology and risk factors

19
There is wide geographic variation in the prevalence of ENL reactions. In Asia
reported figures vary between 19-26% of BL and LL cases in Nepal, India and
Thailand.
ENL reactions occur most commonly during the first year of MDT. One third of
patients with ENL have the diagnosis of leprosy made at the same time as their
reaction.

Lepromatous leprosy (LL) and a bacillary index (BI) greater than 4+ have been shown
to be risk factors for ENL. Pregnancy, lactation, puberty, intercurrent infection,
vaccination and psychological stress have been considered to precipitate ENL but
these associations have not been confirmed in prospective studies.

Pathology of erythema nodosum leprosum

The inflammatory infiltrate in ENL is situated in the dermis and the subcutis. The
constituent cells vary with the timing of the skin biopsy. In acute lesions where skin
biopsy is performed within 72 hours of occurrence, the predominant cell type is the
neutrophil. Eosinophils and mast cells may also be present. Skin biopsies performed
later show fewer neutrophils and increasing numbers of lymphocytes, plasma cells
and histiocytes, representing a chronic inflammatory infiltrate.

The other histological features reported in ENL are edema of the dermis and subcutis,
vasculitis and panniculitis. Changes due to leprosy will also be evident. The infiltrate
due to LL may contain histiocytes with fatty change and foamy cells arranged
diffusely. In biopsies from patients with BL leprosy the granuloma may contain
histiocytes and lymphocytes. In both cases large numbers of acid fast bacilli, usually
granular in appearance, will be found.

Immune complexes are important in the pathogenesis of ENL as demonstrated by the

presence of complexes of complement and M. leprae antigen in cutaneous lesions.
High levels of circulating TNF have been found in some individuals with ENL. There is
evidence of a cell mediated immune response in the pathogenesis of ENL. The major
T cell subtype in ENL is the CD4+ cell in contrast to lepromatous leprosy where CD8+
cells predominate. TNF and IL-6 have been shown to be present in skin lesions of ENL
while IL-4 is absent or low which supports a role for Th1 type T cells.

Treatment of erythema nodosum leprosum

The main aims in the management of ENL are the control of inflammation, pain relief
and prevention of further episodes. Mild cases of ENL can be treated with non
steroidal anti-inflammatory drugs (NSAIDs).

Corticosteroids
Prednisolone is commonly used for the management of moderate to severe ENL. The
WHO Global Strategy document does not give specific advice concerning the dosage
of prednisolone. We commonly start at a dose of prednisolone 40-60 mg daily but
some leprologists use higher initial doses. The dose of prednisolone should be slowly
reduced according to response. The majority of patients require multiple or
prolonged courses of prednisolone due to the natural history of the condition.
Tachyphylaxis to prednisolone may also develop.

Concerns about the use of corticosteroids in the management of reactions

20
The use of potent immunosuppressants is potentially problematic in areas endemic
for severe infections such as tuberculosis. Immunosuppression may also lead to fatal
strongyloidiasis.
Analysis of the adverse events attributable to prednisolone in the three TRIPOD trials
suggests that the drug is safe when used under field conditions in standardised
regimes. The trials used a total prednisolone dose of 1.96g and 2.52g. The steroid
treated group were significantly more likely to experience minor adverse events but
there was no difference in the likelihood of major adverse events between the
prednisolone and placebo groups. Three hundred of the 815 patients enrolled in the
three studies were followed for 24 months and none developed tuberculosis or
hypertension during that time.

The long term adverse effects of corticosteroid therapy in individuals with leprosy
reactions have not been studied. The amount of diabetes, cataract and hypertension
experienced by this group is not known.

It has been reported that patients receiving steroids for ENL develop more adverse
effects compared to those with T1Rs which may be due to the longer duration of
treatment in this group.

Thalidomide
Thalidomide is very effective in the treatment of moderate to severe ENL. It has a
rapid onset of action. Its beneficial effect is thought to be due to its action on TNF but
other mechanisms may also play a part. Prospective clinical trials have shown that
treatment with thalidomide has a quicker action of onset and reduces the number of
skin lesions, fever and systemic symptoms better than pentoxifylline, aspirin and
placebo. Treatment with thalidomide has also been shown to reduce the prednisolone
requirement of patients with chronic ENL.

We suggest using a starting dose of 400mg thalidomide at night in severe ENL and to
reduce the dose to 300mg as soon as possible. This dose can then be reduced by
100mg per month but a maintenance dose may be required in those with chronic
disease. Thalidomide should be used with extreme caution due to its teratogenic
potential. The System for Thalidomide Education and Prescribing Safety (STEPS)
programme adopted by the FDA in the USA has been shown to be very effective in
preventing pregnancies in women taking thalidomide. There has been a recent report
of three cases of thalidomide embryopathy in Brazil and importantly tablet sharing
was a major contributory factor.

Women of child bearing potential who require thalidomide should be provided with
information about its adverse effects and counselled on the importance of the need
to avoid pregnancy. A negative pregnancy test should be obtained before starting
thalidomide therapy and two methods of contraception should be prescribed. The
pregnancy test should be repeated every month. Only one month’s supply of
thalidomide should be prescribed.54 In many leprosy endemic countries such stringent
arrangements are not possible.

Somnolence and dizziness are the commonest adverse affects of thalidomide.

Cutaneous adverse effects occur in 3% of individuals and may be exanthems or rarely
erythema multiforme and toxic epidermal necrolysis. Thalidomide causes a peripheral
neuropathy but there are no data regarding thalidomide-induced neuropathy in
patients with ENL. Deterioration of nerve function in patients receiving thalidomide
should not be assumed to be due to their leprosy.

Clofazimine

21
Clofazimine is a mild anti-inflammatory agent. It can be used for the treatment of
mild to moderate ENL but has a slow onset of action. The clofazimine component of
MB MDT probably reduces the incidence of ENL but this has not been formally tested.
Clofazimine at a dose of up to 300mg daily can be given to help control ENL. It is
complicated by increased pigmentation and the possibility of clofazimine crystal
enteropathy. This higher dose should not be continued for more than 12 months.

Other drugs
A recent Brazilian double blind RCT has shown that pentoxifylline is inferior to
thalidomide in controlling cutaneous and systemic features of ENL. The pentoxifylline
was also less well tolerated. Colchicine and chloroquine have been evaluated in small
studies and their effect was marginal. There are case reports and case series on the
use azathioprine, methotrexate, oral zinc, and the chimeric anti-TNF monoclonal
antibody, infliximab, for the treatment of ENL.

Involvement of the Paranasal Sinuses by Lepromatous Leprosy

The role of nasal infection in the transmission of leprosy has been extensively studied.
The paranasal sinuses play an important role in transmission of leprosy due to their large
surface area of mucous membrane and the constant flow of secretions. Leprosy can affect
the paranasal sinuses because the mucosal lining is in continuity with the nasal cavity.
The paranasal sinuses can also be involved secondarily as a result of bacillaemia and they
act as a reservoir of infection. CT scan has become a major tool in investigating
pathology of the paranasal sinuses because it shows good soft tissue delineation and
visualization of bone. In one Indian study on CT images of untreated patients with
lepromatous leprosy, the pattern of mucosal pathology involving the paranasal sinuses
found out that the anterior group of ethmoidal air cells was more commonly involved
(65%) than the posterior group (35%). Bilateral involvement was commonest (65%). In
this same study, they also found out that the ethmoid sinuses were mostly involved
followed by maxillary sinuses. In a 2007 study by Kiris et al on lepromatous leprosy
patients who had been treated, concluded that persistent infection was still commonly
encountered. They noted that paranasal sinus CT examination is a useful method for the
evaluation of patient response to treatment and follow up; however, a CT scan alone
cannot determine whether the leprosy is active.

Updates on treatment of ENL

Effective Treatment of Erythema Nodosum Leprosum with Thalidomide Is Associated

with Immune Stimulation

“To elucidate the mechanism of action of thalidomide in this syndrome, we prospectively

investigated 20 patients with ENL who were treated with thalidomide for 21 days. All
patients responded to treatment, with the majority of them having complete resolution of
cutaneous lesions within 7 days. This response was associated with a marked but
transient increase in ex vivo mitogen-induced expression of interleukin (IL)–2 and
interferon-g by CD4+ and CD8+ T cells that was observed on treatment day 7, but these
returned to pretreatment levels by day 21.”

22
Treatment of recurrent erythema nodosum leprosum with infliximab.

“…TNF-α contributes to the pathogenesis of erythema nodosum leprosum in humans and

that TNF-α blockade may be considered as a therapeutic alternative in patients with
severe erythema nodosum leprosum that has not responded to standard therapies.
However, because TNF-α blockade carries an increased risk of M. tuberculosis and
fungal infections, one needs to use infliximab in this setting with great care.”

Double-blind trial of the efficacy of pentoxifylline vs thalidomide for the treatment of

type II reaction in leprosy.

“In the present randomized double-blind clinical study we compared the effectiveness of
orally administered pentoxifylline vs thalidomide in treating type II reaction in 44
patients. Daily doses of 300 mg thalidomide or 1.2 g pentoxifylline were administered for
30 days to multibacillary leprosy patients undergoing type II reaction. Randomly chosen
patients were included in the study before, during, and after specific multidrug therapy.
Clinical evaluations were performed on the 1st, 7th, 14th, 21st, and 30th days of
treatment and laboratory tests were carried out on the 1st and 30th days.”

“As expected, overall, thalidomide proved to be more effective in the treatment of type II
leprosy reaction. Nevertheless, continuous treatment with pentoxifylline was effective in
relieving the clinical signs of ENL, especially limb edema and systemic symptoms, in
62.5% of the patients.”

Management of erythema nodosum leprosum by mycophenolate mofetil

“Mycophenolate mofetil has been tried in 20 cases of chronic relapsing erythema

nodosum leprosum reaction where long use of systemic steroid produce complications or
are contraindicated. Excellent results have been observed in all the cases to arrest the
reaction followed for a period of six to eight months duration.”

“These patients were started with Mycophenolate Mofetil at dose of 1 gram per day and
in a few cases dosage increment to 2 grams per day were necessary for control and
subsequent maintenance. The liver function, kidney function and routine blood counts
were done during the course of therapy. These patients were monitored for a period of six
to eight months. In two patients treatment was discontinued within a month due to the
systemic side-effects of the drug like nausea and vomiting and other gastro intestinal
symptoms and drug did not produce desired results. Maintenance dosages of 500 mg per
day was effective to control the ENL in most cases.”

REFERENCES:

Banerjee K, Banerjee R. Management of erythema nodosum leprosum

by mycophenolate mofetil. Indian J Dermatol 2008;53:142-3

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Faber WR, Jensema AJ, Goldschmidt WF. Treatment of recurrent

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Fucci da Costa AP, Augusto da Costa Ner y J, Wan-del-Rey de Oliveira

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Haslett PAJ, Roche P, Butlin CR, et al. Effective treatment of erythema

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Kahawita IP, Walker SL, Lockwood DNJ. Leprosy type 1 reactions

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Kiris A et al. 2007. Paranasal sinus computed tomography findings in

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