Erythema Nodosum Leprosum: Reactional Leprosy

A case report and literature review: Mycobacterium leprae infection diagnosed by metagenomic next-generation sequencing of cerebrospinal fluid

BACKGROUND

Leprosy is a chronic infectious disease caused by Mycobacterium leprae (M. leprae) that is responsible for deformities and irreversible peripheral nerve damage and has a broad spectrum of clinical and serological manifestations. Leprosy primarily affects the peripheral nerves and rarely presents with central nervous system involvement. Diagnosing leprosy can still be difficult in some cases, especially when the infection involves uncommon clinical manifestations and extracutaneous sites. Delayed diagnosis and treatment of leprosy may lead to irreversible damage and death.

CASE PRESENTATION

We report a case of a 30-year-old female presenting with "repeated high fever with symptoms of headache for 14 days". On the day of admission, physical signs of lost eyebrows and scattered red induration patches all over her body were observed. The patient's diagnosis was based on the clinical characteristics using a combination of metagenomic next-generation sequencing (mNGS) of cerebrospinal fluid (CSF) and slit-skin smear. After confirming Listeria meningitis and multibacillary leprosy with erythema nodosum leprosum (ENL), a type 2 reaction, she was treated with ampicillin sodium, dapsone, rifampicin, clofazimine, methylprednisolone, and thalidomide. At the 1-year follow-up, the frequency and severity of headaches have significantly decreased and a good clinical response with improved skin lesions was found.

CONCLUSION

This case highlights the importance of considering leprosy, which is a rare and underrecognized disease, in the differential diagnosis of skin rashes with rheumatic manifestations, even in areas where the disease is not endemic, and physicians should be alerted about the possibility of central nervous system infections. In addition, mNGS can be used as a complementary diagnostic tool to traditional diagnostic methods to enhance the diagnostic accuracy of leprosy.

Split Dose of Prednisolone in the Treatment for Erythema Nodosum Leprosum: A Case Series

Background Erythema nodosum leprosum (ENL) is an immune complex-mediated reaction that clinically presents as tender erythematous evanescent nodules, mostly associated with systemic symptoms. Oral prednisolone is the drug of choice, with doses ranging from 0.5 to 1 mg/kg. Some cases may develop new lesions and systemic symptoms despite 1 mg/kg prednisolone, and in ideal practice, physicians escalate the prednisolone dose for immediate arrest of inflammation to prevent complications. However, a high dose of prednisolone has more side effects in the long term and causes more immunosuppression. Methods In cases of ENL, those not responding to a conventional once-daily regimen were given a split dose of oral prednisolone instead of increasing the dose. They were followed up for response, and serum cortisol was measured to see for hypothalamic-pituitary-adrenal (HPA) axis suppression. Results Eight cases of ENL (three nodular, three necrotic, one pustular, and one nodulcerative) had a dramatic response to split-dose therapy without any relapse and HPA axis suppression. Conclusion A split-dosing regimen can be a good treatment option in ENL with better control, less steroid dependency, and a lower relapse rate.

Leprosy Classification, Clinical Features, Epidemiology, and Host Immunological Responses: Failure of Eradication in 2023

Leprosy is of big concern in the medical fraternity. Leprosy is also known as Hansen's disease. It is a curable communicable disease that remains prevalent in most countries all over the globe. It is a chronic granulomatous infection commonly caused by Mycobacterium leprae and Mycobacterium lepromatosis, which mainly show an effect on the skin and peripheral nerves. To control the disease and minimize the impact of the disease, much effort has been put into it for decades. Nearly 0.2 million fresh cases were documented in 2017 worldwide in spite of being declared "eradicated" by the WHO in the year 2000. However, impressive achievements have been made in several countries, including India; still, we are lagging behind the ultimate goal of the final disappearance of leprosy. Extensive migration is a crucial element that may transmit leprosy to unaffected areas. Additionally, there are several areas in the USA where person-to-person leprosy transmission has been reported without a prior history of exposure. Recently, WHO instigated a new Global Leprosy Strategy 2021-2030, termed "Towards Zero Leprosy." In this article, we review the clinical features, leprosy epidemiology, transmission, classification, host immunological response, and diagnostic challenges.

Host-Related Laboratory Parameters for Leprosy Reactions

Leprosy reactions are acute inflammatory episodes that complicate the course of a Mycobacterium leprae infection and are the major cause of leprosy-associated pathology. Two types of leprosy reactions with relatively distinct pathogenesis and clinical features can occur: type 1 reaction, also known as reversal reaction, and type 2 reaction, also known as erythema nodosum leprosum. These acute nerve-destructive immune exacerbations often cause irreversible disabilities and deformities, especially when diagnosis is delayed. However, there is no diagnostic test to detect or predict leprosy reactions before the onset of clinical symptoms. Identification of biomarkers for leprosy reactions, which impede the development of symptoms or correlate with early-onset, will allow precise diagnosis and timely interventions to greatly improve the patients' quality of life. Here, we review the progress of research aimed at identifying biomarkers for leprosy reactions, including its correlation with not only immunity but also genetics, transcripts, and metabolites, providing an understanding of the immune dysfunction and inflammation that underly the pathogenesis of leprosy reactions. Nevertheless, no biomarkers that can reliably predict the subsequent occurrence of leprosy reactions from non-reactional patients and distinguish type I reaction from type II have yet been found.

Clinical and Histopathologic Characteristics of the Main Causes of Vascular Occlusion - Part I: Thrombi

La patología vascular oclusiva es causante de diversas y variadas manifestaciones clínicas, algunas de las cuales son de catastróficas consecuencias para el paciente. Sin embargo, las causas de tal oclusión son muy variadas, extendiéndose desde trombos por acción descontrolada de los mecanismos de coagulación, hasta anomalías de los endotelios de los vasos u oclusión por materiales extrínsecos. En una serie de dos artículos hacemos una revisión de las principales causas de oclusión vascular, resumiendo sus manifestaciones clínicas principales y los hallazgos histopatológicos fundamentales. Esta primera parte corresponde a las oclusiones vasculares que cursan con trombos.

Erythema nodosum as Leprosy reaction

Purpose.To present a clinical case of leprosy exacerbation on the background of ongoing therapy. Materials and methods.A 52-year-old patient with a diagnosis of "lepromatous (cutaneous) leprosy, leprosy LL" (multi-bacterial leprosy, lepromatous form, active stage), has an exacerbation in the form of nodular erythema at 3.5 years after the start of treatment. Due to the exacerbation of the leprosy process, dexamethasone therapy was performed intravenously in a dose of 4 mg/ml 3.0 ml + 0.9% NaCl 200.0 ml daily No. 10. Results. An exacerbation was diagnosed leprosy nodular erythema. The prescription of adequate therapy led to a complete regression of clinical manifestations. Conclusion.The described case is presented in connection with the rarity of this dermatosis.

What is New in the Pathogenesis and Management of Erythema Nodosum Leprosum

Erythema nodosum leprosum (ENL) is a manifestation of type II lepra reaction, seen in lepromatous or borderline lepromatous leprosy. Although it is a common reaction encountered in clinical practice, there are an increasingly large number of newer updates in the pathophysiology and management of this condition. The treatment options have expanded far beyond just thalidomide and steroids and now extends to TNF-α inhibitors, thalidomide analogs, tenidap, cyclosporine A, plasma exchange, and even IVIG amongst others. These updates and the current knowledge of ENL are summarized in this review.

Differential Expression of IFN-γ, IL-10, TLR1, and TLR2 and Their Potential Effects on Downgrading Leprosy Reaction and Erythema Nodosum Leprosum

Leprosy reactions are acute immunological events that occur during the evolution of chronic infectious disease causing neural damage and disabilities. A study using blood samples of 17 leprosy reaction patients and 17 reaction-free was carried out by means of associations between antigens, receptors, and expression of cytokines, using path analysis providing new insights into the immunological mechanisms involved in triggering leprosy reactions. Toll-like receptors (TLR) such as TLR1 and TLR2, presented balanced expression in the reaction-free multibacillary (MB) group (TLR1: 1.01 ± 0.23, TLR2: 1.22 ± 0.18; p = 0.267). On the other hand, downgrading type 1 reaction (T1R) (TLR1: 1.24 ± 0.17, TLR2: 2.88 ± 0.37; p = 0.002) and erythema nodosum leprosum (ENL) (TLR1: 1.93 ± 0.17, TLR2: 2.81 ± 0.15; p = 0.004) revealed an unbalance in relation to the expression of these receptors. When the path analysis was approached, it was noted that interleukin 10 (IL-10) expression showed a dependence relation with phenolic glycolipid I (PGL-I) in downgrading T1R (direct effect = 0.503 > residual effect = 0.364), whereas in ENL, such relationship occurred with lipoarabinomannan (LAM) (direct effect = 0.778 > residual effect = 0.280). On the contrary, in the reaction-free leprosy group, interferon-gamma (IFN-γ) levels were dependent on the association between TLR2 and TLR1 (0.8735). The high TLR2 expression associated with IL-10 levels, in the leprosy reaction groups, may be hypothetically related to the formation of TLR2/2 homodimers and/or TLR2/6 heterodimers linked to evasion mechanisms in downgrading reactions and pathophysiology of ENL.

Cutaneous leprosy in Central Florida man with significant armadillo exposure

Leprosy is a chronic infectious, granulomatous disease caused by the intracellular bacillus Mycobacterium leprae that infects macrophages and Schwann cells. While relatively rare in the USA, there is about 200 new cases of leprosy every year with the majority occurring in the southern parts of the country. It is believed to be linked to the region of the nine-banned armadillo in patients with no significant travel history outside of the country. In this case report, we encountered a 58-year-old Central Florida man that had extensive exposure to armadillos and presented with the typical symptoms of large erythaematous patches, numbness and peripheral nerve hypertrophy. Once diagnosed properly, patients are then reported to the National Hansen's Centre who provides the multidrug therapy for 12-24 months. Due to its rarity and its ability to mimic other more common ailments, leprosy should be included in the differential diagnosis in patients that have significant exposure to armadillos, live in the southern part of the country or have recently travelled to countries that have a high prevalence of leprosy.

Epidemiological profile of leprosy reactions in a referral center in Campinas (SP), Brazil, 2010-2015

Leprosy patients can present reactions during the course of the disease. There are no official data on these reactions in Brazil. We aimed to describe the epidemiological characteristics of patients with such reactions, analyzing information from patient records at a referral center in Campinas (SP), from 2010 to 2015.

Leprosy reactions: The predictive value of Mycobacterium leprae-specific serology evaluated in a Brazilian cohort of leprosy patients (U-MDT/CT-BR)

Background

Leprosy reactions, reversal reactions/RR and erythema nodosum leprosum/ENL, can cause irreversible nerve damage, handicaps and deformities. The study of Mycobacterium leprae-specific serologic responses at diagnosis in the cohort of patients enrolled at the Clinical Trial for Uniform Multidrug Therapy Regimen for Leprosy Patients in Brazil/U-MDT/CT-BR is suitable to evaluate its prognostic value for the development of reactions.

Methodology

IgM and IgG antibody responses to PGL-I, LID-1, ND-O-LID were evaluated by ELISA in 452 reaction-free leprosy patients at diagnosis, enrolled and monitored for the development of leprosy reactions during a total person-time of 780,930 person-days, i.e. 2139.5 person-years, with a maximum of 6.66 years follow-up time.

Principal findings

Among these patients, 36% (160/452) developed reactions during follow-up: 26% (119/452) RR and 10% (41/452) had ENL. At baseline higher anti-PGL-I, anti-LID-1 and anti-ND-O-LID seropositivity rates were seen in patients who developed ENL and RR compared to reaction-free patients (p<0.0001). Seroreactivity in reactional and reaction-free patients was stratified by bacilloscopic index/BI categories. Among BI negative patients, higher anti-PGL-I levels were seen in RR compared to reaction-free patients (p = 0.014). In patients with 0<BI<3, (36 RR, 36 reaction-free), higher antibody levels to PGL-I (p = 0.014) and to LID-1 (p = 0.035) were seen in RR while difference in anti-ND-O-LID positivity was borderline (p = 0.052). Patients with BI≥3 that developed ENL had higher levels of anti-LID-1 antibodies (p = 0.028) compared to reaction-free patients. Anti-PGL-I serology had a limited predictive value for RR according to receiver operating curve/ROC analyses (area-under-the-curve/AUC = 0.7). Anti LID-1 serology at baseline showed the best performance to predict ENL (AUC 0.85).

Conclusions

Overall, detection of anti-PGL-I, anti-LID-1 and anti-ND-O-LID antibodies at diagnosis, showed low sensitivity and specificity for RR prediction, indicating low applicability of serological tests for RR prognosis. On the other hand, anti-LID-1 serology at diagnosis has shown prognostic value for ENL development in BI positive patients.

Trial Registration

ClinicalTrials.gov NCT00669643

Leprosy is a debilitating dermato-neurologic disease caused by Mycobacterium leprae. One of the main difficulties in the clinical management of leprosy patients is the development of leprosy reactions which are immune inflammatory episodes that can cause irreversible handicaps, incapacities and deformities. There are two major types of leprosy reactions: reversal reaction (RR) and erythema nodosum leprosum (ENL). Currently, there is no laboratory test able to predict the emergence of leprosy reactions among recently diagnosed patients. In order to investigate laboratory markers for the occurrence of leprosy reactions, we investigated the prognostic value of serologic responses to M. leprae antigens (PGL-I, LID-1, ND-O-LID) in 452 leprosy patients enrolled at the Clinical Trial for Uniform Multidrug Therapy Regimen for Leprosy Patients in Brazil/U-MDT/CT-BR. At diagnosis higher anti-PGL-I, anti-LID-1 and anti-ND-O-LID seropositivity rates were seen in patients who developed ENL and RR compared to reaction-free patients. The anti-PGL-I serology at diagnosis show low sensitivity to predict RR and anti-LID-1 serology at diagnosis has shown prognostic value for ENL development.

Quality of life in patients with erythema nodosum leprosum in Kuala Lumpur, Malaysia

BACKGROUND

There is a paucity of data on quality of life issues in patients with leprosy suffering from erythema nodosum leprosum (ENL). Thus, we aim to study the effect of ENL on quality of life.

MATERIALS AND METHODS

This cross-sectional study was conducted in Hansen's Clinic, Hospital Kuala Lumpur between January 2010 and December 2013 among patients with multibacillary leprosy using the Dermatology Life Quality Index (DLQI).

RESULTS

A total of 153 patients participated with 31.4% suffering from ENL. The mean age at presentation was 40.5 ± 16.49 years. The mean DLQI was 7.1 ± 3.72. Patients with ENL were younger (mean age 36.5 vs. 42.4, P = 0.026), had higher mean bacteriologic index (4.3 vs. 3.8, P = 0.004), had physical deformities (47.9% vs. 31.4%, P = 0.049), and had higher mean DLQI score (9.1 vs. 6.2, P < 0.001). All the DLQI domains were higher in patients suffering from ENL except the treatment domain. Symptoms and feeling was the domain with the largest effect followed by daily activities and leisure. Personal relationship had the lowest effect.

CONCLUSION

Quality of life impairment in patients with leprosy in Malaysia is moderate, with larger effect among patients with ENL. The impairment in ENL is comparable to itchy skin conditions such as urticarial and is worse than chronic skin disease such as psoriasis. Thus, it is essential that management of leprosy incorporate quality of life issues.

Serum Th1/Th2 and macrophage lineage cytokines in leprosy; correlation with circulating CD4(+) CD25(high) FoxP3(+) T-regs cells

Not only macrophages, T-helper (Th)1 and Th2, but also CD4(+) CD25(high) FoxP3(+) regulatory T cells (T-regs) are involved in immune response to Mycobacterium leprae. We aimed to evaluate serum interleukin (IL)-1β and IL-12p70 (macrophage cytokines), interferon-γ (IFN-γ) (Th1 cytokine), IL-4 (Th2 cytokine) and circulating CD4(+) CD25(high) FoxP3(+) T-regs, in untreated leprosy patients. Forty three patients and 40 controls were assessed for the mentioned cytokines using ELISA. Patients were assessed for circulating T-regs using flow cytometry. Patients were subgrouped into tuberculoid (TT), pure neural leprosy (PNL), borderline cases, lepromatous (LL), type 1 reactional leprosy (RL1) and erythema nodosum leprosum (ENL). Serum IL-12p70, IFN-γ and IL-4 were significantly higher in patients versus controls (P < 0.05). Serum IL-4 was highest in LL and lowest in RL1 (P = 0.003). Serum IL-1β levels was significantly higher in multibacillary versus paucibacillary patients (P = 0.006). Significantly higher T-regs levels was detected in TT, RL1 and PNL, while the lowest levels in ENL(P < 0.001), with significant differences versus controls (P < 0.05). FoxP3 expression% was significantly lower in PNL than other patients and controls (P < 0.05). T-regs/T-effs was lowest in ENL(P < 0.05). IFN-γ correlated positively with T-regs but negatively with IL-1β (P = 0.041&0.046 respectively), which correlated positively with T-effs%( P = 0.05). IL-4 correlated positively with T-regs FoxP3 expression% (P = 0.009). We concluded that: Circulating T-regs were increased in TT, RL1 and PNL patients, known of relatively high cell-mediated immunity. This finding was supported by low FoxP3 expression (in PNL) and correlation between T-regs count and IFN-γ level. Overproduction of IL-4 in LL may infer liability to develop ENL, with disease progression and immune hyperactivation, marked by deficient T-regs and increased T-regs FoxP3 expression%. IL-1β probably has a pro-inflammatory role in multibacillary patients as correlated with T-effs%.

Leprosy in Denmark 1980-2010: a review of 15 cases

Background

Leprosy, caused by Mycobacterium leprae, is a chronic and progressive granulomatous disease affecting mainly the skin and the peripheral nervous system. If left unrecognized, the infection can lead to permanent nerve damage and disability. The clinical presentation depends on the immune response of the patient and can result in a wide spectrum of symptoms. Leprosy is a rare encounter in Scandinavia but remains endemic in some parts of the world, with some areas reporting an increasing incidence. We performed a retrospective record review of leprosy cases in Denmark from 1980 to 2010 with the purpose of presenting the most common geographical, demographic and clinical findings and to discuss the diagnostic and therapeutic challenges of patients with leprosy.

Case presentation

In total 15 cases were reviewed. The majority (87 %) of leprosy patients in Denmark were born in South- and Southeast Asia, and were presumed to have contracted the infection in their countries of origin. Patients were predominately young males (mean age: 28.6 years). Anaesthetic skin lesion with or without nerve enlargement were the most common clinical presentations (73 %). Immunological leprosy reactions were seen in 40 % of the cases. Diagnoses were based on clinical findings and skin biopsies. Treatment length varied but all patients received multidrug regimens.

Conclusion

Leprosy should be kept in mind when encountering patients with suspicious skin lesions originating from leprosy endemic areas or with history of travel or work in the tropics. Due to the long incubation period with symptoms presenting long after immigration or return, clinicians often do not have the diagnosis in mind. The wide spectrum of symptoms and immunological reactions further complicates the diagnostic process. Treatment of leprosy and the complicated immunological reactions, which frequently accompanies the infection, should be performed in collaboration with a specialist.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1768-6) contains supplementary material, which is available to authorized users.

Leprosy Reaction in Thai Population: A 20-Year Retrospective Study

Background. Leprosy is a chronic infectious disease that presents with varying dermatological and neurological symptoms. The leprosy reactions occur over the chronic course of the disease and lead to extensive disability and morbidity. Objective. To analyze and identify the risk factors which contribute to leprosy reactions. Methods. In a retrospective study, we reviewed the medical records of leprosy patients registered at the leprosy clinic, Ramathibodi Hospital, Thailand, between March 1995 and April 2015. One hundred and eight patients were included; descriptive analysis was used for baseline characteristics and a binary logistic regression model was applied for identifying risk factors correlated with leprosy reactions. Results. Of the 108 cases analyzed, 51 were male and 57 were female. The mean age of presentation was 45 years. The borderline tuberculoid type was the most common clinical form. Leprosy reactions were documented in 61 cases (56.5%). The average time to reaction was 8.9 months. From multivariate analysis, risk factors for leprosy reactions were being female, positive bacillary index status, and MB treatment regimen. Conclusions. Leprosy reactions are common complications in leprosy patients. Being female, positive bacillary index status, and multibacillary treatment regimen are significantly associated with the reactions. Early detection in cases with risk factors followed by appropriate treatment could prevent the morbidity of leprosy patients.

Assessment of serum level of interleukin-1b and interleukin-12 in leprosy: impact of previous Bacillus Calmitte Guerin vaccination

Macrophages play an important role in attempt to eliminate mycobacteria, via production of cytokines, including interleukin-1, and interleukin-12. Bacillus Calmitte Guerin (BCG) vaccination, known to induce interleukin-1β in tuberculosis, was originally aimed at tuberculosis control, but it showed efficacy against leprosy. Our aim was to estimate serum levels of interleukin-1β and interleukin-12, in leprosy, and to assess the impact of previous BCG vaccination on their levels. Serum interleukin-1β and interleukin-12 p70 were estimated in 43 leprotic patients and 43 controls by enzyme-linked immunosorbent assay. Patients were grouped according to presence or absence of reactions, as well as bacillary load. Serum interleukin-1β was significantly higher in patients as compared to controls (p = 0.047), and was significantly different in patients' groups (p = 0.036); with significantly higher level in multibacillary patients, both non reactional and with erythema nodosum leprosum, compared with paucibacillary/non reactional patients (p = 0.012 and 0.049 respectively). A statistically significant higher interleukin-1β was found in BCG vaccinated paucibacillary patients as compared to unvaccinated patients (p = 0.031). Significantly elevated interleukin-12 was present in patients as compared to controls (p < 0.001), with no statistically significant difference comparing patients' groups. BCG vaccination showed stimulatory effect on monocytes only in the immunocompetent paucibacillary leprosy patients, as evidenced by higher Interleukin-1β in this group. Interleukin-1β was shown to have a pro-inflammatory role in multibacillary patients with or without erythema nodosum leprosum. Targeting interleukin-1β may be promising to control episodic refractory erythema nodosum leprosum. Interleukin-12 may be a general marker of active Mycobacterium leprae infection.

Lucio's phenomenon: report of five cases

The different clinical forms of leprosy are mainly related to the variety of immunological responses to the infection. Several forms of lepromatous leprosy are recognized, including macular, nodular, and diffuse. Lucio's phenomenon is a rare but distinctive skin eruption seen in patients with diffuse lepromatous leprosy. The diffuse lesions of Lucio's phenomenon have a predilection for the extremities, can include nodules, and heal with atrophic stellate scars; histologically, a necrotizing vasculitis accompanied by a nonspecific inflammatory reaction may be seen. Because of its rarity and similarity with some manifestations of the rheumatic disease and other causes of vasculitis, Lucio's phenomenon may not be easily recognized, especially in non-endemic countries, which leads to confusing diagnosis and loss of time for treatment. We report five patients with vasculitis caused by Lucio's phenomenon.

Diagnosis of erythema nodosum leprosum (type 2 reaction) by cytology

OBJECTIVE

It was the aim of this study to evaluate the possible role of cytology in erythema nodosum leprosum (ENL) and its use for early treatment of the disease.

STUDY DESIGN

We present a prospective study conducted with 15 clinically diagnosed ENL cases. Among them, 13 cases had previously been diagnosed with lepromatous leprosy (LL) and 2 patients were new LL cases with signs and symptoms of ENL lesions. Haematoxylin and eosin stain with modified Ziehl-Neelsen stain was performed on fine needle aspiration material. One case was sent for biopsy.

RESULTS

Complete cytological diagnosis of ENL was done in all 15 cases. Histopathological study revealed classical ENL lesions which also showed ENL features in cytodiagnosis.

CONCLUSION

In the past, the accurate mode of diagnosis of ENL lesions was histopathology. However, clinicians have to wait a long time for the report and generally they start treatment only on the basis of clinical signs and symptoms. Cytodiagnosis of ENL lesions is an early, effective method for accurate diagnosis and helps to initiate treatment for these painful lesions.

A systematic review on the epidemiological data of erythema nodosum leprosum, a type 2 leprosy reaction

BACKGROUND

Erythema Nodosum Leprosum (ENL) is a humoral immunological response in leprosy that leads to inflammatory skin nodules which may result in nerve and organ damage, and may occur years after antibiotic treatment. Multiple episodes are frequent and suppression requires high doses of immunosuppressive drugs. Global occurrence is unknown.

METHODOLOGY/PRINCIPAL FINDINGS

Systematic review of evidence on ENL incidence resulted in 65 papers, predominantly from India (24) and Brazil (9), and inclusive of four reviews. Average incidences are based on cumulative incidence and size of study populations (n>100). In field-based studies 653/54,737 (1.2%) of all leprosy cases, 194/4,279 (4.5%) of MB cases, and 86/560 (15.4%) of LL cases develop ENL. Some studies found a range of 1-8 per 100 person-years-at-risk (PYAR) amongst MB cases. Hospital samples indicate that 2,393/17,513 (13.7%) of MB cases develop ENL. Regional differences could not be confirmed. Multiple ENL episodes occurred in 39 to 77% of ENL patients, with an average of 2.6. Some studies find a peak in ENL incidence in the first year of treatment, others during the second and third year after starting MDT. The main risk factor for ENL is a high bacteriological index.

CONCLUSIONS/SIGNIFICANCE

Few studies reported on ENL as a primary outcome, and definitions of ENL differed between studies. Although, in this review averages are presented, accurate data on global and regional ENL incidence is lacking. Large prospective studies or accurate surveillance data would be required to clarify this. Health staff needs to be aware of late reactions, as new ENL may develop as late as five years after MDT completion, and recurrences up to 8 years afterwards.

The +3187A/G HLA-G polymorphic site is associated with polar forms and reactive reaction in leprosy

Considering that variability in immune response genes has been associated with susceptibility to leprosy and with disease severity, leprosy presents clinicopathological variants that are highly associated with the immune response, HLA-G has a well-recognized role in the modulation of the immune response, and polymorphisms at the 3′ untranslated region (UTR) of the HLA-G gene may influence HLA-G production, we studied the polymorphic sites at the 3′ UTR of the HLA-G gene in leprosy and their association with disease severity. We evaluated by sequencing analysis the allele, genotype, and haplotype frequencies of the 3′ UTR HLA-G polymorphic sites (14-bpINDEL/+3003C-T/+3010C-G/+3027A-C/+3035C-T/+3142C-G/+3187A-G/+3196C-G) in 146 individuals presenting reactive leprosy from a highly endemic area, and associated with bacillary load and the type of reactive leprosy. A total of 128 healthy subjects were also studied. Allele, genotype, and haplotype frequencies for the 3′ UTR HLA-G polymorphisms in leprosy patients did not differ from those observed in healthy donors. The +3187A allele was responsible for protection against the development of multibacillary leprosy in a dominant model (AA + AG)/GG, OR = 0.11, P = 0.018), and the +3187A allele and +3187A-A genotype were overrepresented in type II reactive leprosy reaction. The effect of genetic factors on leprosy susceptibility may be hidden by environmental components in highly endemic areas. The HLA-G + 3187A polymorphic site, which is related to unstable mRNA production, was associated with the development of polar forms of leprosy and reactive leprosy reaction.

Mycobacterium tuberculosis infection is associated with the development of erythema nodosum and nodular vasculitis

Background

Mycobacterium tuberculosis (MTB) infection has been suggested to contribute to the pathogenesis of erythema nodosum (EN) and nodular vasculitis (NV), the classic forms of panniculitis. However, there is little evidence to demonstrate the presence of MTB in the skin lesions. This study is aimed at evaluating the association between MTB infection and the development of EN and NV in a Chinese population.

Methods

A total of 107 patients (36 EN, 27 NV, and 44 others) with vasculitis and 40 control cases with other skin diseases were recruited and their skin lesion samples were subjected to real time polymerase chain reaction (PCR) analysis of the IS6110 and mpt64 gene fragments of MTB. Their blood mononuclear cells were tested for MTB antigen-specific IFN-γ responses by QuantiFERON®-TB Gold In-Tube (IT) assays.

Results

PCR analysis revealed that 7/23 (30.4%) and 7/18 (38.9%) of the EN and NV samples were positive for the IS6110 DNA, respectively, which were significantly higher than 3/34 (8.8%) of other vasculitis (OV) and 3/40 (7.5%) of the control samples (p<0.05). The nested Real-Time PCR assay indicated that 6/7 (86%) of the IS6110-positive EN samples, all of the IS6110-positive NV and control samples, but only 1/3 of the IS6110-positive OV samples, were positive for the mpt64 gene. Similarly, 19/32 (59.4%) of the EN patients, 20/26 (76.9%) of the NV patients, and 17/36 (47.2%) of the OV patients were positive for MTB antigen-specific IFN-γ responses, which were significantly higher than 6/40 (15%) of the controls (p<0.05).

Conclusion

Our data strongly suggest that MTB infection and active TB are associated with the development of NV and EN in Chinese.

Erythema nodosum leprosum and reversal reaction in 2 cases of imported leprosy

Leprosy reactions, which are abrupt changes in the clinical condition of patients with immunologically unstable forms of the disease, can mask the cardinal signs of leprosy, delaying both diagnosis and treatment. The main complications that arise from delayed diagnosis reflect the characteristic features of the disease, involving impaired nerve function and both local (ulcers, pyogenic infection, osteomyelitis) and systemic compromise. Through clinical examination, sensory testing, and, where necessary, histopathology and microbiology, are essential when leprosy is suspected. Rapid initiation of anti-inflammatory treatment reduces the risk of functional impairment, the main concern in leprosy. We describe type 1 and type 2 leprosy reactions in 2 patients who had not yet been diagnosed with the disease.

[Leprosy with an unusual course]

In developed countries, Hansen disease, or leprosy, is a rare and little-known disease. Over the last few years, its prevalence in New Caledonia has remained stable (0.35 per 10,000 inhabitants). We report the case of an 11-year-old child who presented lepromatous leprosy complicated by a type 2 reaction. Despite appropriate treatment, the course was unusual with fever lasting a few weeks associated with asthenia, weight loss, and biological perturbations such as inflammatory syndrome, anemia, and hyperferritinemia. After a brief review of Hansen disease and its complications, we discuss the different hypotheses that can explain the clinical and biological progression of our patient (hemolytic anemia secondary to dapsone, type 2 reaction, and aspects of hemophagocytic syndrome) and describe therapeutic management, which led to a good outcome.

Leprosy reactions: coinfections as a possible risk factor

OBJECTIVE

This study aimed to determine the frequency of coinfections in leprosy patients and whether there is a relationship between the presence of coinfections and the development of leprosy reactional episodes.

METHOD

A cross-sectional study based on an analysis of the medical records of the patients who were treated at the Leprosy Clinics of the Ribeirão Preto Medical School, University of São Paulo, was conducted from 2000 to 2010. Information was recorded regarding the age, sex, clinical status, WHO classification, treatment, presence of reactions and coinfections. Focal and systemic infections were diagnosed based on the history, physical examination, and laboratory tests. Multinomial logistic regression was used to evaluate the associations between the leprosy reactions and the patients' gender, age, WHO classification and coinfections.

RESULTS

Two hundred twenty-five patients were studied. Most of these patients were males (155/225 = 68.8%) of an average age of 49.31±15.92 years, and the most prevalent clinical manifestation was the multibacillary (MB) form (n = 146), followed by the paucibacillary (PB) form (n = 79). Erythema nodosum leprosum (ENL) was more prevalent (78/122 = 63.9%) than the reversal reaction (RR) (44/122 = 36.1%), especially in the MB patients (OR 5.07; CI 2.86-8.99; p<0.0001) who exhibited coinfections (OR 2.26; CI 1.56-3.27; p<0.0001). Eighty-eight (88/225 = 39.1%) patients exhibited coinfections. Oral coinfections were the most prevalent (40/88 = 45.5%), followed by urinary tract infections (17/88 = 19.3%), sinusopathy (6/88 = 6.8%), hepatitis C (6/88 = 6.8%), and hepatitis B (6/88 = 6.8%).

CONCLUSIONS

Coinfections may be involved in the development and maintenance of leprosy reactions.

Lepra: sepsis en un paciente con reacción tipo II. Reporte de un caso

La  lepra  es  una  patología  infecciosa  de  carácter  crónico, caracterizada por un amplio compromiso cutáneo, asociado a neuropatía, con bajas tasas de mortalidad, pero con un alto índice de discapacidad. Es causada por  la  infección por el bacilo, Mycobacterium leprae. A pesar que se conoce desde la antigüedad se considera un problema persistente de salud pública  en  áreas  subtropicales  donde  es  endémica.  Su mecanismo de  transmisión, es por medio de gotitas  respirato-rias. Su espectro clínico es muy variado, depende de  la  forma en que el sistema  inmunitario del huésped reacciona  frente al agente  infeccioso,  por  lo  que  se  reconocen  los  polos determinados como  tuberculoide y  lepromatoso, una  forma indeterminada y borderline. Por otro lado se considera que la reacciones lepróticas (tipo 1, tipo 2 y fenómeno de lucio) son complicaciones  de  la  hiperreactividad  inmunológica  que aparece  cuando  se afecta el equilibrio  inmunológico en el huésped.  En  1982  la  Organización  Mundial  de  la  Salud estableció  la  terapia multidrogas  como  herramienta  eficaz para  el  control  de  esta  entidad.  Actualmente  el  régimen farmacológico  se  establece  teniendo  en  cuenta  la clasificación  que  distingue  al  enfermo  en  paucibacilar  y multibacilar. Presentamos un paciente masculino de 64 años, con  antecedente  de  lepra  lepromatosa multibacilar  desde hace 3 años, con tratamiento irregular, suspendido 6 meses antes  de  clínica  de  ingreso  consistente  sepsis  de  origen urinario, con posterior septicemia asociada al catéter, a quien se le realiza tratamiento antibiótico de amplio espectro, con evolución satisfactoria del estado hemodinámico y manejo de la lepra ambulatorio.

Leprosy initially misdiagnosed as sarcoidosis, adult-onset still disease, or autoinflammatory disease

Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae. We describe the case of a 20-year-old man from India living in Italy since 2003, who presented with erythematous papules and nodules distributed on his arms, legs, and face in 2006. He also had episodes of high fever, polyarthritis, and episcleritis. Sarcoidosis was suspected on the basis of elevated angiotensin-converting enzyme and bronchoalveolar lavage fluid, and the patient was treated with corticosteroids for about a year. A flare of the disease occurred each time corticosteroid was tapered or suspended. An autoinflammatory disease was then suspected and treated with immunosuppressant. Only the third deep skin biopsy revealed the presence of M. leprae. The lack of clinical suspicion and the unfamiliarity with the histology of leprosy delayed diagnosis and treatment. Leprosy should be considered in the differential diagnoses of patients presenting with rheumatic and cutaneous manifestations especially when they come from countries where the disease is endemic.

[Nail involvement in leprosy]

Leprosy, a disease caused by Mycobacterium leprae, primarily affects the skin and nerves, but the nails are also involved in as many as 3 out of 4 patients .The factors that trigger nail changes in leprosy are numerous and include repeated trauma, neuropathy, vascular impairment, infections, lepra reactions, and the drugs used to manage the disease. The changes most often reported include subungual hematomas, onycholysis, onychauxis, onychogryphosis, pterygium unguis, and onychoheterotopia, most of which can be attributed to nerve damage and trauma. Furthermore, the acro-osteolysis that occurs in the advanced stages of the disease may present with brachyonychia, racquet nails, or even anonychia. Infections of the nail bed leading to paronychia and onychomycosis should also be taken into account in leprosy. Other typical changes include longitudinal striae, pitting, macrolunula, Terry nails, leukonychia, hapalonychia, and Beau lines. In this review, we describe the principal nail changes associated with leprosy. These changes, which are highly varied and diverse in origin, are in fact a reflection of the significant morbidity caused by M. leprae infection.

Could leprosy reaction episodes be exacerbated by oral infections?

INTRODUCTION: This study evaluated whether leprosy reactions could be associated with oral infection. METHODS: Leprosy patients (n = 38) with (Group I) and without (Group II) oral infections were selected. Reactions were identified from the clinical and histopathological features associated with serum C-reactive protein (CRP) and10kDa interferon-gamma-induced protein (IP-10) levels, determined before and after elimination of the foci of infection. RESULTS: Group I presented more reactions than group II did, and improvement of the reactions after dental treatment. Serum CRP and IP-10 did not differ before and after the dental treatment, but differed between the groups. CONCLUSIONS: Oral infection could be an exacerbating factor in leprosy reactions.

The difficulty in diagnosis and treatment of leprosy

Leprosy is still an important and debilitating disease with a broad clinical spectrum. However, this disease occurs most often endemically, and as an imported disease it can also still be recognized in the nonendemic industrialized world.

Canadian case report of erythema nodosum leprosum successfully treated with prednisone and thalidomide

BACKGROUND

Erythema nodosum leprosum (ENL) is a disease rarely encountered in Canada. It is characterized by multiple remissions and recurrences, often requires long-term treatment, and can result in debilitating sequelae.

OBJECTIVE

To promote rapid recognition and adequate therapy for ENL.

METHODS

Case report of a 39-year-old man diagnosed with an ENL. The clinical and histopathologic features, treatment provided, and response to treatment are detailed in this article.

RESULTS

ENL presented itself as painful cutaneous lesions on the face and limbs, bilateral paresthesia of the fourth and fifth fingers, and systemic symptoms. Prednisone 40 mg daily for a week and then 60 mg daily for another week reduced the lesions by 80% and the pain by 50%. Although prednisone 60 mg daily was continued for one more week and then stopped, thalidomide was started at a dose of 300 mg daily for 4 weeks and then reduced gradually, which led to complete resolution.

CONCLUSION

At the 7(1/2)-month follow-up, the patient remained completely asymptomatic.

The recurrence of leprosy reactional episodes could be associated with oral chronic infections and expression of serum IL-1, TNF-α, IL-6, IFN-γ and IL-10

The aim of this study was to determine whether the presence of leprosy reactional episodes could be associated with chronic oral infection. Thirty-eight leprosy patients were selected and divided into 2 groups: group I - 19 leprosy patients with oral infections, and group II - 19 leprosy patients without oral infections. Ten patients without leprosy, but presenting oral infections, were assigned to the control group. Leprosy patients were classified according to Ridley and Jopling classification and reactional episodes of the erythema nodosum type or reversal reaction were identified by clinical and histopathological features associated with serum IL-1, TNF-α, IL-6, IFN-γ and IL-10 levels. These analyses were performed immediately before and 7 days after the oral infection elimination. Patients from group I presenting oral infections reported clinical improvement of the symptoms of reactional episodes after dental treatment. Serum IL-1, TNF-α, IL-6, IFN-γ and IL-10 levels did not differ significantly before and after dental treatment as determined by the Wilcoxon test (p>0.05). Comparison of the 2 groups showed statistically significant differences in IL-1 and IL-6 at baseline and in IL-1, IL-6 and IL-10 on the occasion of both collections 7 days after therapy. Serum IL-6 and IL-10 levels in group I differed significantly at baseline compared to control (Mann-Whitney test; p<0.05). These results suggest that oral infection could be involved as a maintenance factor in the pathogenesis of leprosy reactional episodes.

Mycobacterium leprae actively modulates the cytokine response in naive human monocytes

Leprosy is a chronic but treatable infectious disease caused by the intracellular pathogen Mycobacterium leprae. Host immunity to M. leprae determines the diversity of clinical manifestations seen in patients, from tuberculoid leprosy with robust production of Th1-type cytokines to lepromatous disease, characterized by elevated levels of Th2-type cytokines and a suboptimal proinflammatory response. Previous reports have indicated that M. leprae is a poor activator of macrophages and dendritic cells in vitro. To understand whether M. leprae fails to elicit an optimal Th1 immune response or actively interferes with its induction, we have examined the early interactions between M. leprae and monocytes from healthy human donors. We found that, in naïve monocytes, M. leprae induced high levels of the negative regulatory molecules MCP-1 and interleukin-1 (IL-1) receptor antagonist (IL-1Ra), while suppressing IL-6 production through phosphoinositide-3 kinase (PI3K)-dependent mechanisms. In addition, low levels of proinflammatory cytokines were observed in association with reduced activation of nuclear factor-kappaB (NF-kappaB) and delayed activation of IL-1beta-converting enzyme, ICE (caspase-1), in monocytes stimulated with M. leprae compared with Mycobacterium bovis BCG stimulation. Interestingly, although in itself a weak stimulator of cytokines, M. leprae primed the cells for increased production of tumor necrosis factor alpha and IL-10 in response to a strongly inducing secondary stimulus. Taken together, our results suggest that M. leprae plays an active role to control the release of cytokines from monocytes by providing both positive and negative regulatory signals via multiple signaling pathways involving PI3K, NF-kappaB, and caspase-1.

Clinical and epidemiological study of leprosy cases in the University Hospital of Brasília: 20 years -- 1985 to 2005

Hansen's disease, also known as leprosy, is an infectious disease still prevalent in Brazil. It is a chronic illness with acute immunological phenomena known as leprosy reactions. In the Federal District of Brazil, the University Hospital of Brasília is the reference centre for leprosy care. The study aimed to characterize the clinical and epidemiological profile of Hansen's disease patients at the University Hospital of Brasília, by descriptive, retrospective analysis of 1,124 patients over the period from 1985 to 2005. The pattern of leprosy in this study demonstrated that type 2 leprosy reactions were common, especially in the lepromatous form and presented a direct correlation with the bacilloscopic index. The prevalence and frequency of severe complications, such as leprosy reactions, emphasize the importance of the ongoing study of leprosy and the need for continual improvement in the scope of knowledge concerning its treatment.

Leprosy and international adoption: a case report and review of diagnostic and treatment dilemmas

Hansen disease, commonly known as leprosy, is uncommon in the United States and poses difficult diagnostic and treatment challenges. A 10-year-old girl was adopted from Ethiopia with a history of "multibacillary leprosy" and "multidrug treatment" for 12 months. Three months after her arrival in the United States and 4 months after treatment was completed, she presented with new papules and plaques on her left nose and ear. Herein, we present her case and review current treatment options in leprosy in children and the management of immunologic reactions.