Beneficial Effect of Minocycline as Additional Treatment to Prednisone for Pustular Erythema Nodosum Leprosum

Introduction

Pustular erythema nodosum leprosum (ENL) is an atypical manifestation associated with chronic ENL. The use of corticosteroid alone might not be sufficient for this condition, and addition of another anti-inflammatory drug is often necessary. Minocycline is a tetracycline antibiotic with anti-neutrophilic properties, which may accelerate the treatment of pustular ENL. This case report aimed to elaborate on the beneficial effect of minocycline for pustular ENL.

Case

We report a case of pustular ENL in a 23-year-old male who had been released from treatment (RFT) of lepromatous leprosy (LL). The patient had been on prednisone for six months as treatment for ENL. The condition recurred when prednisone was tapered to 10 mg daily. Eventually, pustules developed on the erythematous nodules, and the lesions did not improve despite seven weeks of treatment with 40-60 mg prednisone. Later, 100 mg minocycline once daily was given in addition to 60 mg prednisone once daily and improvement was rapidly observed on the ninth day after minocycline administration. This condition was sustained for four weeks with prednisone tapering, and no side effects were reported during the treatment.

Discussion

Minocycline is an antibiotic with anti-inflammatory properties. Only a few studies have been conducted regarding the use of minocycline in chronic ENL, but there was no reported case of minocycline use for pustular ENL in RFT patient. The addition of minocycline to prednisone may accelerate the improvement of pustular ENL. We observed an improvement after the ninth day of minocycline administration compared to seven weeks of prednisone monotherapy. No new ENL lesions occurred during four weeks of minocycline administration therapy.

Conclusion

Pustular ENL is an atypical manifestation of chronic ENL, and the addition of minocycline to prednisone may accelerate its therapeutic effect on the patient.

Atypical presentations of erythema nodosum leprosum: Diagnostic and therapeutic aspects

Classic erythema nodosum leprosum (ENL) is characterized clinically by abrupt eruption of tender erythematous nodules, papules and plaques. Variable atypical patterns have been described, for example pustular, bullous, ulcerative, necrotic and Sweet's syndrome-like ENL. We aim to review previously reported cases of atypical ENL addressing the diagnostic and therapeutic aspects of these uncommon presentations. A search of medical literature for all cases of atypical ENL was conducted in the PubMed database till 2020. Data of patients with atypical ENL were collected and analyzed to describe the epidemiological, clinico-histological and therapeutic features. The major five clinically described presentations of atypical ENL include vesiculo-bullous lesions (46 % of patients), ulcero-necrotic lesions (41 %), erythema multiforme-like lesions (28 %), Sweet's syndrome-like lesions (11 %) and pustules (9 %). The skin lesions were accompanied by fever and constitutional symptoms in all patients. Oral steroids and thalidomide were the main lines of therapy in most of the reported patients. Dermatologists and pathologists should keep in mind the clinical variability of ENL to avoid misdiagnosis and delayed management. Early recognition can help control disease progression and save the patients from further complications.

Type 2 leprosy reaction with Sweet's syndrome-like presentation

Leprosy is a chronic disease characterized by manifestations in the peripheral nerves and skin. The course of the disease may be interrupted by acute phenomena called reactions. This article reports a peculiar case of type 2 leprosy reaction with Sweet's syndrome-like features as the first clinical manifestation of leprosy, resulting in a delay in the diagnosis due to unusual clinical presentation. The patient had clinical and histopathological features reminiscent of Sweet's syndrome associated with clusters of vacuolated histiocytes containing acid-fast bacilli isolated or forming globi. Herein, it is discussed how to recognize type 2 leprosy reaction with Sweet's syndrome features, the differential diagnosis with type 1 leprosy reaction and the treatment options. When this kind of reaction is the first clinical presentation of leprosy, the correct diagnosis might be not suspected clinically, and established only with histopathologic evaluation.

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.