A case of erythema nodosum leprosum reaction with diffuse alveolar haemorrhage, successfully treated by pulsed methylprednisolone

ary We present a case of erythema nodosum leprosum (ENL) reaction with dse alveolar haemorrhage (DAH) in a patient who completely recovered with pulsed methylprednisolone. Our case illustrates that ENL could be a predisposing factor for DAH and a high dose of corticosteroid plays an important role in successfully treating such a patient.

Abnormalities in intracellular processing and expression of interferon-gamma receptor in adherent cells from lepromatous leprosy patients

Peripheral blood mononuclear cells in lepromatous leprosy (LL) patients produce low levels of interferon-gamma (IFN-gamma) and interleukin-12 (IL-12), and these cells exhibit partial or complete deficiency in the IL-12 receptor. The behavior of the IFN-gamma receptor (IFN-gamma R) has not been described in cells from people with leprosy. We found higher levels of mRNA for IFN-gamma R1 and IFN-gamma R2 in adherent cells stimulated with IFN-gamma and Mycobacterium leprae membrane proteins from LL patients compared with healthy subjects. Flow cytometry showed no significant difference in IFN-gamma R1 expression between LL patients and healthy subjects. Immunoblotting detected only the mature glycosylated form of the 61-67 kDa IFN-gamma R2 protein in healthy subjects. In contrast, cells from LL patients showed three different expression patterns: (1) the immature deglycosylated form of the 34.8 kDa IFN-gamma R2 protein, (2) the mature glycosylated 61-67 kDa form, and (3) both forms. Our data indicate the existence of abnormalities in the intracellular processing and protein expression of the IFN-gamma R in response to specific stimuli such as IFN-gamma and M. leprae membrane proteins in adherent cells of LL patients.

Histopathological lesions of apparently normal skin in leprosy patients

This study was carried out on 50 patients with different clinical types of leprosy 38 males (76 % and 12 females (24%), ages ranged from 14 -70 years with a mean age +/- SD 49.22 +/- 12.97 years. Mean disease duration was 5.65 years +/- SD = 9.27 selected to study a group of leprosy patients and compare the clinical parameters with histopathological findings and bacteriologic status of the skin to evaluate the relevance of their patients. Patients were subjected to full medical history taking including disease duration, type and duration of previous or current therapies. Complete clinical examination, for the determination of the clinical type of leprosy. Skin slit smear (SSS) and skin biopsies were taken and examined after staining for histopathological assessment and Acid fast bacilli (AFB). SPSS package version (statistical Package for Social Sciences) was used for data analysis. The biopsy of normally looking skin showed classic histopathological features of leprosy in more than half of the cases (26 cases, 52%). The histopathological types of leprosy diagnosed in such cases were as follows: indeterminate leprosy (IL) in 4 cases (15.38%), Tuberculoid leprosy (TL) in 2 cases (7.69%), Borderline tuberculoid (BT) in 4 cases (15.38), Borderline Borderline (BB) i.e Query in 8 cases (30.76%), Borderline Lepromatous (BL) in 7 cases (26.92%) and Lepromatous leprosy (LL) in a patient (3.84%). Other 24 cases showed either no evidence of leprosy in (9 cases, 37.5%), or query findings (in the form of sweat gland changes either alone or in combination with thickened nerves and superficial and deep perivascular lymphohistiocytic infiltrate) in 15 cases (62.5%). Histopathology of skin lesion biopsies showed TL in 3 cases (6%), BT in 8 cases (16%), BB in 8 cases (16%), BL in 14 cases (28%), LL in 12 cases (24%) and leprosy in reaction in 5 cases (10%). In 16 cases (32%), histopathological type of leprosy detected by microscopical examination of biopsies from skin lesions differed from that diagnosed by clinical examination.

Severe form of type 2 reaction in patients of Hansen's disease after withdrawal of thalidomide: case reports

Thalidomide, a racemic glutamic acid analogue, was first developed in 1954 and subsequently marketed in Europe, Australia and Canada as a sedative and anti-emetic. It was approved by the Food and Drug Administration (FDA) in the USA in 1998 for the treatment of the cutaneous manifestations of moderate to severe erythema nodosum leprosum (ENL) and suppression of the cutaneous manifestations of ENL recurrences. It is a good choice for management in patients who are dependent on corticosteroids. Common side effects of thalidomide are teratogenicity, peripheral neuropathy, sedation and constipation. We report 4 cases of Hansen's disease with recurrent ENL who were adequately managed on thalidomide. On sudden withdrawal of thalidomide, they relapsed with severe type 2 reaction including necrotic ENL.

Annular vesiculobullous eruptions in type 2 reaction in borderline lepromatous leprosy: a case report

An untreated case of BL presented with clinical features of type 2 reaction (T2R) confirmed by histopathology. The case was a 18-year-old female with borderline lepromatous leprosy who developed annular vesiculobullous eruptions oversome of the pre-existing plaques on arms and upper back along with fever and severe neuritis after a short course of ofloxacin intake prescribed for urinary tract infection. In addition to the above lesions, some of the existing lesions showed acute exacerbation characterized by erythema, oedema, tenderness and vesiculobullous eruption. This can be considered as an example of leprous exacerbation as described in older literature. T2Rs are common in lepromatous leprosy and not so uncommonly are observed in borderline lepromatous leprosy. The vesiculobullous and crusted lesions developing over the existing borderline plaques, some of them presenting in an annular pattern in T2R in the form of leprous exacerbation, have been reported rarely in the literature.

A man with erythematous nodules: what is the diagnosis? Lepromatous leprosy

A 65-year-old man presented with an approximately 5-year history of cutaneous nodules of the arms and legs. In addition, physical examination revealed bilateral thickening of ulnar and tibial nerves, distal weakness with hallux extension and finger abduction, and distal hypoesthesia of the left hallux. Histopathological analysis of the skin biopsy specimen showed a dense inflammatory infiltrate in the hypodermis, characterized by vacuolated macrophages containing multiple organisms. The Fite stain was positive confirming the diagnosis of multibacillary leprosy.

A case of lepromatous leprosy with multiple relapses

We report a case of multiple relapses in a lepromatous leprosy patient after treatment with World Health Organisation (WHO) recommended multibacillary multidrug therapy (MBMDT). The patient responded well to reintroduction of MDT after each relapse.

Occurrence and management of leprosy reaction in China in 2005

BACKGROUND

Leprosy reactions are a major cause of disability before, during and after anti-bacterial treatment. Prompt diagnosis and correct management of reaction is a crucial matter for improving the quality of leprosy health services.

OBJECTIVES

To describe the pattern of leprosy reaction and its management in China during 2005.

METHODS

A retrospective survey using a questionnaire was carried out in all the provinces of China at the beginning of 2006. Patients included were those presenting with leprosy reaction between 1 January and 31 December 2005.

RESULTS

452 questionnaires from 25 provinces were analysed. There were 313 male and 139 female patients who had 159 Type I reactions, 273 Type II reactions and 20 Type I and II mixed reaction. 72.4% of reactions occurred in the first year of MDT and 27.6% of patients during the second year of MDT. The highest frequency of reaction was during the first 6 months of MDT; 57.3% of patients developed new nerve impairment during and after MDT.

CONCLUSIONS

New nerve function impairment and disability still occurs among patients during and after MDT. The early detection and management of leprosy reaction remains important.

[Lepra: an uncommon cause of infectious neuropathy]

INTRODUCTION

Lepra is an uncommon disease within our setting. However, it was considered the most frequent cause of polyneuropathy only 50 years ago.

CASE REPORT

We present the case of a 37 year-old woman who consulted due to paresthesias in both hands and feet, livedo reticularis and complaints of frequent hand lesions. Examination of the skin detected nodular lesions and the neurophysiological study confirmed distal symmetric sensitive polyneuropathy with axonal predominance. The skin biopsy also showed histocytic infiltrate and mycobacterium lepra type intracytoplasmatic bacilli. This led to the diagnosis of Multibacillary lepromatous leprosy. Multiple treatment was begun, according to the World Health Organization recommendations, with good evolution. In spite of the attempts to eradicate lepra, its incidence continues to be elevated, especially in endemic areas, among which the south of Spain is included. It is generally associated to overcrowding and low social-economic level.

CONCLUSIONS

This is the last endemic case in the Valencian Community. The possibility of lepra should be considered among the possible causes of sensitive polyneuropathy, above all in patients in endemic areas.

A case of advanced lepromatous leprosy with rhino-oro-laryngological involvement in the post-elimination era

A patient presenting with symptoms and signs of congestive heart failure was incidentally found to be in advanced stage of leprosy. He had multiple lepromatous nodules over the entire body. The oral mucosa was yellowish with a matte appearance and the palate had a site ready to perforate. Nasal cavity revealed a small septal perforation with overlying crusts suggesting advanced rhinitis. Diagnosis of lepromatous leprosy was confirmed on histology. This case report emphasizes the existence of pockets of highly bacilliferous cases that continue to be a source of infection within the community and highlights the need for enhanced health education.

Lepromatous leprosy masquerading as acute sarcoidosis: a case report and literature review

Leprosy is uncommon in North America. Because it has a prolonged incubation period and can masquerade with a variety of manifestations, many patients with leprosy experience a significant delay in diagnosis and treatment. Lepra reactions are of 2 types: reversal (type 1) and erythema nodosum leprosum (ENL) (type 2). Type 1 or reversal reactions represent an increase in cell-mediated immunity, whereas type 2 or ENL is caused by antigen-antibody complex formation and deposition after antigen release from dying lepra bacilli. This article describes the diagnostic challenges presented by a Minnesota patient eventually found to have lepromatous leprosy. That challenge was compounded by the fact that the clinical scenario closely mimicked connective tissue/immune complex disease and by the fact that the patient presented in a location where the incidence and prevalence of leprosy is extremely low.

Lepromatous leprosy

Lepromatous leprosy is a form of chronic granulomatous disease that is caused by infection with Mycobacterium leprae. Early involvement is marked by widespread, ill-defined, erythematous papules and plaques. With early intervention, leprosy is a curable disease; however, if not recognized and treated promptly, permanent sequelae and disability result. We present a patient with long-standing lepromatous leprosy who exhibits many of these sequelae.

Development and evaluation of real-time RT-PCR assay for quantitative estimation of viable Mycobacterium leprae in clinical samples

Detection of live organisms by molecular methods has special significance in leprosy where causative organism can not be cultivated in vitro. Such techniques would be especially important for monitoring the progress of the disease. While real-time RT- PCR technology will be appropriate for this purpose, there is very little experience of use of such tools in leprosy. This study describes the development of a quantitative RT-PCR targeting 16S rRNA based on primers used in a semi quantitative RT-PCR and its application on clinical samples including slit scraping and biopsies. RNA was extracted from biopsies from 3 lepromatous leprosy (LL) cases and standard curve was generated by plotting crossing over point against the dilutions of input RNA quantity (number of bacilli used for RNA extraction). Real-time RT-PCR was performed for quantitative detection of live M. leprae in 28 slit (13/28 smear positive) scrappings and 32 biopsies (22/32 smear positive). Number of viable bacteria as estimated by solid stained bacilli and real-time PCR correlated (no difference p>0.05). The test achieved a theoretical analytical sensitivity limit of up to single live bacillus even considering 11.3% efficiency of RNA preparation which was calculated by spiking of known number of leprosy bacilli in non leprosy skin biopsies (PCR negative). All smear positive cases were positive by this assay. This assay appears to be a promising tool for detection and quantification of viable bacilli in selected clinical situations and should be of use even in smear negative cases also.

[Rheumatic manifestations in leprosy]

The classical manifestations of leprosy are cutaneous and neurological involvement; however, rheumatic manifestations are relatively common during the course of the disease and can be the initial manifestation. Herein are reviewed the clinical features of leprosy, particularly those that may mimic rheumatic diseases.

Necrotic erythema nodosum leprosum with oral mucosal involvement

Leprosy is a chronic, infectious disease with varied clinical presentations. The type 2 lepra reaction / erythema nodosum leprosum (ENL) classically involves extremities and face. Besides to the classical lesions of type 2 lepra reaction sometimes rare findings of vesicular lesions with necroticans may be observed. We are reporting a case of lepromatous leprosy with bullous reaction and necroticans involving usual sites along with the unusual involvement of oral cavity, which on first look mimicked necrotizing vasculitis or other bullous disorders. This manifestation of type 2 lepra reaction in oral mucosa should be kept in mind by the physicians while dealing with a case of type 2 lepra reaction.

Localized and persistent erythema nodosum leprosum - a rare variant?

Erythema nodosum leprosum (ENL) or Type-2 Lepra reaction is a manifestation of type III hypersensitivity response and usually occurs in certain cases of lepromatous and borderline lepromatous leprosy. It is usually generalized and evanescent, and responds well to oral corticosteroid therapy. Here we report an unusual case of persistent and localized ENL in a 19-year-old girl, which could be diagnosed with the aid of skin biopsy and histopathological examination.

A fatal case of Lucio phenomenon from India

A 65-year-old man presented with cutaneous ulcerations involving the legs, hands, abdomen, buttocks, and pinna, along with fever, arthralgia, and anorexia for the prior 10 days. On cutaneous examination, dark, irregular-shaped bizarre erythematous purpuric spots and angulated ulcers were seen over bilateral, upper extremities and trunk including dorsum of hands, finger tips and the pinnae of both ears. Most striking were the presence of multiple deep ulcers covered with a blackish eschar and in some areas yellow slough eroding the subcutaneous tissue with ragged margins. These ulcers were distributed symmetrically over the thighs, lower legs and gluteal region. Slit-skin smear examination revealed a bacterial index (BI) of 6+ with globi from earlobes, ulcers 3+, eyebrows 3+ and normal skin 2+ and morphologically showed mainly solid (20-30%), fragmented (60-70%) and granular (5-10%) acid-fast bacilli. Biopsy from the ulcer margin revealed an ulcerated epidermis and dermis. The dermis had infiltrate of foamy macrophages, and evidence of ischemic necrotizing vasculitis, with fibrinoid necrosis and new vessel formation. There was presence of clumps of acid-fast bacilli (AFB) within macrophages, periadnexally, perivascularly, and also within endothelial cells. These clinical and histopathological features helped us to arrive at the diagnosis of Lucio phenomenon in an untreated case of Lucio leprosy which is rarely reported from areas other than Mexico.

Erythrocyte superoxide dismutase, catalase activities and hydrogen peroxide induced lipid peroxidation in leprosy

OBJECTIVES

To assess erythrocyte superoxide dismutase (SOD) and catalase (CAT) activities and hydrogen peroxide induced lipid peroxidation in leprosy.

DESIGN

One hundred leprosy patients and 50 normal healthy controls were studied for the parameters. The data was analysed by grouping the patients into Ridley-Jopling (RJ) types [Tuberculoid leprosy (TT, n = 22), Borderline tuberculoid leprosy (BT, n = 28), Borderline leprosy (BB, n = 13), Borderline lepromatous leprosy (BL, n = 16) and Lepromatous leprosy (LL, n = 21)] and into different levels of Bacteriological Index (BI) [bacteriologically negative (n = 32), BI = 0.1-1 (n = 22), BI = 1.1-2 (n = 16), BI = 2.1-3 (n = 14), BI = 3.1-4 (n = 10) and BI = 4.1-6 (n = 06)].

RESULTS

The induced peroxidation was significantly high and the enzyme activities were significantly low in leprosy (total patients) as compared to controls. A progressive increase in peroxidation was detected along the leprosy spectrum from TT to LL and the increase was significant in BB, BL and LL groups as compared to controls. Induced peroxidation in LL group as compared to TT, BT and BB and in the BL group as compared to TT and BT were significantly different. A concomitant progressive decline in enzyme activity was detected along the leprosy spectrum from TT to LL. The SOD activity in BB, BL and LL and the CAT activity in BL and LL were significantly low as compared to controls. SOD activity in BB, BL and LL groups as compared to TT and in the LL group as compared to BT were significantly different. A progressive trend of increasing peroxidation and decreasing SOD and CAT activity were also detected along the leprosy groups with advancing level of BI. Induced peroxidation and SOD activity were significantly different in bacteriologically positive groups as compared to controls and in the BI levels 1.1-2, 2.1-3, 3.1-4 and 4.1-6 as compared to bacteriologically negative group. The peroxidation was significantly different in BI levels 2.1-3, 3.1-4 and 4.1-6 as compared to BI level 0.1-1. The CAT activity was significantly different in BI levels 2.1-3, 3.1-4 and 4.1-6 as compared to controls.

CONCLUSION

The study findings suggest oxidative stressful state associated with reduced antioxidant defence potential in erythrocytes of leprosy patients. The study implicates association of erythrocyte oxidative stress with bacterial load and type of leprosy.

Effect of cryo preservation on Mycobacterium leprae growth in the footpads of non-immunosuppressed mice

OBJECTIVE

To investigate using the mouse footpad system, whether the use of cryopreservants help in retaining the viability of Mycobacterium leprae samples stored at three different temperatures of 4 degrees, -20 degrees and -70 degrees C for 30 days.

DESIGN

Biopsies from eight untreated lepromatous leprosy cases were homogenised and inoculated into footpads of normal Swiss White mice within 24 hours (control) and remaining homogenates in each case was divided and stored at 4 degrees C, -20 degrees C and -70 degrees C respectively for 1 month, using either 10% skimmed milk (SM) or Roswell Park Memorial Institute media + 10% glycerol (RPMI) (test). Homogenates adjusted to contain 1 x 10(4) M. leprae/footpad was inoculated into 10 mice per set. Harvestings were done at 6th, 7th, 8th and 12th months. Footpad counts showing > 1 x 10(5) M. leprae at 6th month or later were considered as positive yield.

RESULTS

Control All the cases showed > 100 fold growth and 100% take. Viability at 4 degrees C: Only one case (SM) showed a 100 fold increase and 23% take. Viability at -20 degrees C: Two cases showed fold growth that was 40-60 fold less with takes of 63% (SM) and 71% (RPMI) respectively. Viability at -70 degrees C: Positivity was 45% but the fold increase was less as compared to control and takes were between 80-20%, except one RPMI where take was 100%.

CONCLUSION

The viability assessed using the mouse footpad was best and consistent in the inoculas that were injected within 24 hours of harvest from the host tissue (control group). None of the storage temperatures used matched with the controls with respect to bacterial yield or % takes. Among the three storage temperatures, -70 degrees C appeared to be better with 45% of the samples showing growth. There was no significant difference noted between the two preservatives used.

Wade's histoid leprosy: three clinical presentations

Wade's histoid leprosy is a rare form of multibacillary leprosy with distinctive characteristics which were first described in patients treated with a short course of sulfones. Wade's histoid leprosy may occur as a relapse, in the setting of sulfone resistance, or may present de novo. We report the clinical, histologic, immunologic, and bacteriologic features of three adult male patients with this rare variant of lepromatous leprosy as the initial presentation of the disease, observed in the Dermatology Department of Hospital Córdoba, Córdoba, Argentina between 1999 and 2003. Two of the three patients were from an endemic leprosy area. All patients presented with a number of erythematous to brownish gray, firm but elastic nodules involving mainly the extremities, which responded to treatment for multibacillary leprosy without reactional episodes.