Thalidomide in the treatment of erythema nodosum leprosum (ENL) in an outpatient setting: A five-year retrospective analysis from a leprosy referral centre in India

Case Report: Type 2 Leprosy Reaction Mimicking Sweet Syndrome: A Case Report and Literature Review

Type 2 leprosy reaction is a type of acute inflammation that predominantly affects borderline lepromatous leprosy and lepromatous leprosy patients and occurs before, during, or after therapy. The atypical variant, which resembles Sweet syndrome, could easily lead to misdiagnosis. Here, we report a case of a 52-year-old man who presented with type 2 leprosy reaction that mimicked Sweet syndrome. In addition, we review published cases and summarize their features to raise awareness of this atypical variant to enable improved diagnosis and management.

Leprosy: treatment, prevention, immune response and gene function

Since the leprosy cases have fallen dramatically, the incidence of leprosy has remained stable over the past years, indicating that multidrug therapy seems unable to eradicate leprosy. More seriously, the emergence of rifampicin-resistant strains also affects the effectiveness of treatment. Immunoprophylaxis was mainly carried out through vaccination with the BCG but also included vaccines such as LepVax and MiP. Meanwhile, it is well known that the infection and pathogenesis largely depend on the host's genetic background and immunity, with the onset of the disease being genetically regulated. The immune process heavily influences the clinical course of the disease. However, the impact of immune processes and genetic regulation of leprosy on pathogenesis and immunological levels is largely unknown. Therefore, we summarize the latest research progress in leprosy treatment, prevention, immunity and gene function. The comprehensive research in these areas will help elucidate the pathogenesis of leprosy and provide a basis for developing leprosy elimination strategies.

Leprosy reactions: Unraveling immunological mechanisms underlying tissue damage in leprosy patients

Leprosy is a chronic granulomatous infectious and disabling disease caused by two mycobacteria, Mycobacterium leprae and Mycobacterium lepromatosis. Acute inflammatory responses, known as leprosy reactions, are significant contributors to disabilities. Three types of leprosy reactions have been identified based on excessive cytokine release (e.g. type 1) or the accumulation of immune complexes in tissues inducing multiorgan damage (e.g. types 2 and 3). The type of leprosy reaction has implications on treatment and management strategies, yet are not well understood by health workers caring for leprosy patients. We attempt to describe the immunologic mechanisms behind the different leprosy reactions and the rationale for tailoring clinical treatment and management to the particular type of leprosy reaction based on the underlying immunologic situation.

Recurrent crops of tender subcutaneous nodules in a 44-year-old man

Erythema nodosum leprosum (ENL) is a type 2 leprosy reaction associated with multibacillary leprosy. We describe a case of ENL as the first manifestation of borderline lepromatous leprosy.

Cardiovascular events associated with thalidomide and prednisone in leprosy type 2 reaction

BACKGROUND

Thalidomide is the drug of choice for the treatment of type 2 leprosy reactions and is often associated with corticosteroids. The use of these drugs in multiple myeloma is associated with the risk of cardiovascular events, but there have been few studies assessing this risk in leprosy patients.

OBJECTIVE

To evaluate the occurrence of cardiovascular events in patients with multibacillary leprosy and their correlation with the use of thalidomide and prednisone.

METHODS

Analytical cross-sectional study of all patients diagnosed with multibacillary leprosy treated at the Dermatology Service between 2012 and 2022, using electronic medical records. Thromboembolic vascular events, both arterial and venous, including acute myocardial infarction, were considered. The main independent variable was the concomitant use of thalidomide and prednisone during follow-up.

RESULTS

A total of 89 patients were included, of which 19 used thalidomide and prednisone concomitantly. There were five cardiovascular events (26.3%), three of which of deep venous thrombosis. The combined use of medications was associated with the events (PR=6.46 [3.92 to 10.65]; p<0.01).

STUDY LIMITATIONS

Small number of events, single-center retrospective study.

CONCLUSION

The hypothesis of an association between cardiovascular events and the concomitant use of thalidomide and prednisone is supported, but more robust prospective studies are required for a better assessment.

Systemic manifestation of necrotic erythema nodosum leprosum: A case report of a fatal leprosy

Necrotic erythema nodosum leprosum (ENL) is an uncommon manifestation of type 2 lepra reaction, encountered in lepromatous and borderline lepromatous cases of leprosy. Necrotic ENL is associated with the involvement of multiple organs, therefore delayed diagnosis and treatment will lead to complications and poor prognosis. The aim of this case report was to report a challenging case of necrotic ENL misdiagnosed with multiple cellulitis since there were no signs of prior leprosy nor had any antimycobacterial treatment. A 45-year-old man was presented to the surgery department of Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia, with complaints of fever, joint pain, and painful tender skin lesions with ulceration over the trunk, extremities, and ears for one month. The patient was diagnosed clinically with multiple cellulitis and underwent a debridement procedure. Clinical improvement was absent, the patient was then consulted to the dermatology department. Physical examination showed normal vital signs, madarosis, inguinal lymphadenopathy, thickening of nerves, and sensation of numbness in both hands and feet. Laboratory examinations on admission showed leucocytosis, anemia, thrombocytopenia, hypoalbuminemia, hypocalcemia, and elevated creatinine and ureum level. A slit skin smears examination yielded positive acid-fast bacilli (AFB) with a bacteriological index (BI) value of 3+ and morphological index (MI) of 72%. The patient was diagnosed with lepromatous leprosy with necrotic ENL reaction. Intravenous methylprednisolone and cefoperazone-sulbactam were given. Multidrug therapy mulitbacillary (MDT-MB) without dapsone, and ofloxacin 400 mg was initiated. On day 17, the patient had septic shock. The patient became unconscious and experienced death. This case highlights that medical professionals should be aware of the various manifestations of necrotic ENL to correctly diagnose and provide treatment as soon as possible to prevent mortality, especially in leprosy-endemic country, Indonesia.

A real-world study of low-dose thalidomide in severe erythema nodosum leprosum highlighting its mechanistic rationale in a resource-constrained target population

BACKGROUND

Corticosteroids remain the main therapy in erythema nodosum leprosum (ENL), and long-term usage in chronic or recurrent ENL is a cause of significant morbidity and mortality. Thalidomide exerts dramatic effect in controlling ENL and helps reduce the dose of steroids, but the cost is a hindrance to its usage.

METHODS

Patients of ENL (steroid naïve and steroid-dependent) were recruited over a 1-year period. An escalating dose of low-dose thalidomide with a reducing dose of prednisolone was titrated depending on the control of disease activity. The primary aim was to reduce the dose of steroids to the lowest effective dose, and the secondary aim was to stop.

RESULTS

Sixteen patients of ENL were studied (mean duration of ENL 22.1 months, 15 severe ENL), and a majority (11/16, 68%) were on steroids with a mean duration of 11.27 months. All patients had steroid-related side effects (cushingoid habitus 81.8%, weight gain 54.5%, diabetes mellitus 9%, hyperlipidemia 18.18%, cataract 18.1%, osteoporosis 36.3%, striae 36.3%, acneiform eruptions 18.1%, and myopathy 9%). Steroids could be tapered in a majority of patients (n = 9) within 3 months (mean 2.44 months) with a low dose of thalidomide (25-150 mg/day, mean 78.3 mg) achieving a significant reduction in prednisolone dose (33.16 mg at baseline; 4.28 mg at 3 months, P < 0.05). Steroids could be stopped in 92% of patients by 3.03 months, and both drugs could be stopped in 80% of cases by 5.83 months.

CONCLUSION

The rapid and effective control of ENL with low-dose thalidomide in our series is comparable to the historical efficacy of high-dose thalidomide regimens, making it an affordable therapy in resource-constrained settings and an excellent steroid-sparing agent. The rapid onset of disease control is likely attributable to its action via neutrophils.

Effect of Synergism of Thalidomide and Liposomal Amphotericin-B on Leishmania tropica and Leishmania donovani Promastigote

This study aims to find safe and effective anti-leishmaniasis drugs; thus, the synergism between thalidomide and liposomal amphotericin-B was tested as antileishmanial on L. tropica and L. donovani promastigote in vitro. IC50, IC90 were determined at the Log phase of thalidomide and were (10), (25) µg/ml for L. tropica and (12.5), (30( µg/ml for L. donovani, Moreover IC50, IC90 were determined at Log phase of Liposomal amphotericin-B and were (5), (20) µg/ml for L. tropica and (5), (25) µg/ml for L. donovani. Additionally, synergistic effect IC50 of the two drugs were determined when Liposomal amphotericin-B fixed it, and thalidomide concentrations changed was (2.5+0.5) µg/ml on L. tropica and (2.5+1) µg/ml on L. donovan. When thalidomide was fixed, and Liposomal amphotericin-B was changed, it was (2.5+2) µg/ml for both L. tropica and L.donovani. The synergistic effect on the morphology of both promastigotes forms was observed. Keywords. Leishmaniasis, thalidomide, liposomal amphotericin-B, synergistic.

Overcoming Therapy Resistance in Colon Cancer by Drug Repurposing

Simple Summary

Despite improvements in standardized screening methods and the development of promising therapies for colorectal cancer (CRC), survival rates are still low. Drug repurposing offers an affordable solution to achieve new indications for previously approved drugs that could play a protagonist or adjuvant role in the treatment of CRC. In this review, we summarize the current data supporting drug repurposing as a feasible option for patients with CRC.

Abstract

Colorectal cancer (CRC) is the third most common cancer in the world. Despite improvement in standardized screening methods and the development of promising therapies, the 5-year survival rates are as low as 10% in the metastatic setting. The increasing life expectancy of the general population, higher rates of obesity, poor diet, and comorbidities contribute to the increasing trends in incidence. Drug repurposing offers an affordable solution to achieve new indications for previously approved drugs that could play a protagonist or adjuvant role in the treatment of CRC with the advantage of treating underlying comorbidities and decreasing chemotherapy toxicity. This review elaborates on the current data that supports drug repurposing as a feasible option for patients with CRC with a focus on the evidence and mechanism of action promising repurposed candidates that are widely used, including but not limited to anti-malarial, anti-helminthic, anti-inflammatory, anti-hypertensive, anti-hyperlipidemic, and anti-diabetic agents.

Enhancing autophagy in Alzheimer's disease through drug repositioning

Alzheimer's disease (AD) is one of the biggest human health threats due to increases in aging of the global population. Unfortunately, drugs for treating AD have been largely ineffective. Interestingly, downregulation of macroautophagy (autophagy) plays an essential role in AD pathogenesis. Therefore, targeting autophagy has drawn considerable attention as a therapeutic approach for the treatment of AD. However, developing new therapeutics is time-consuming and requires huge investments. One of the strategies currently under consideration for many diseases is "drug repositioning" or "drug repurposing". In this comprehensive review, we have provided an overview of the impact of autophagy on AD pathophysiology, reviewed the therapeutics that upregulate autophagy and are currently used in the treatment of other diseases, including cancers, and evaluated their repurposing as a possible treatment option for AD. In addition, we discussed the potential of applying nano-drug delivery to neurodegenerative diseases, such as AD, to overcome the challenge of crossing the blood brain barrier and specifically target molecules/pathways of interest with minimal side effects.

Etonogestrel-releasing contraceptive implant in a patient using thalidomide for the treatment of erythema nodosum leprosum: a case report

INTRODUCTION

Thalidomide is an immunomodulatory drug and first choice in the treatment of erythema nodosum leprosum. Given its teratogenic potential, it is essential that an effective contraceptive method is used, especially a long-acting reversible contraceptive (LARC) method. The subdermal etonogestrel (ENG)-releasing implant is an adequate method due to the high effectiveness and long-term use. However, interaction between thalidomide and ENG has not been well documented. Concern arises because thalidomide interacts with cytochrome P450 (CYP450) enzymes that metabolize sexual steroids. AIM: We aimed to study the effectiveness and safety of the ENG-implant in a thalidomide user.

METHODS

Case report of a sexually active 21-year-old patient with both Hansen's disease and leprosy reaction type 2 treated with thalidomide requiring effective contraception. Follow-up was up to 36 months after implant placement.

RESULTS

Contraception with ENG-implant was effective and safe, based on clinical parameters (reduction of menstrual flow and cervical mucus thickening) and laboratory parameters (gonadotropins and sexual steroids).

CONCLUSION

To the best of our knowledge, this is the first case reported which presents a patient in simultaneous use of thalidomide and ENG-implant. Although this case report preliminary supports effectiveness and safety of ENG-implant as a contraceptive option in women using thalidomide, rigorous drug-drug interaction research is needed to better characterize the interaction between thalidomide and the ENG-implant.

Case Report: Rapid Response to Low-Dose Thalidomide in a Case of Severe Steroid Recalcitrant Erythema Nodosum Leprosum

Erythema nodosum leprosum (ENL), or type 2 lepra reaction, presents with crops of evanescent, tender erythematous nodules accompanied by fever, arthralgia, malaise and organ-specific manifestations and is seen in borderline and lepromatous leprosy. The drugs approved for ENL include nonsteroidal anti-inflammatory drugs, systemic steroids, thalidomide and clofazimine. The management of ENL is challenging because long-term steroid use leads to steroid dependence. The present patient had severe steroid recalcitrant ENL with vesicular and pustular lesions mimicking Sweet's syndrome and was treated effectively with a low-dose thalidomide regimen (100 mg/d) as opposed to high dose (400 mg/d) recommended in literature. We discuss the patho-mechanics and clinical utility of a low-dose thalidomide regimen as an effective treatment option for ENL.

The role of thalidomide in dermatology

Thalidomide is a medication that has been in existence for over half a century, and has proven to be useful and effective in severe dermatological conditions. For dermatologists, the ability of thalidomide to reduce the levels of the cytokine tumour necrosis factor-α, along with its immunomodulatory and anti-angiogenic properties, is of great significance, with the added advantage of being an oral medication. Its use is of course strictly monitored, owing to its potential adverse effects (AEs), particularly teratogenicity, with precautions taken to ensure its safe and correct use by both prescriber and patient. In this review, we look at the background and mechanism of action of thalidomide, provide an overview of conditions it can be used for with case examples, explain the potential AEs and monitoring requirements, and discuss future developments.

Repurposing Cardiac Glycosides: Drugs for Heart Failure Surmounting Viruses

Drug repositioning is a successful approach in medicinal research. It significantly simplifies the long-term process of clinical drug evaluation, since the drug being tested has already been approved for another condition. One example of drug repositioning involves cardiac glycosides (CGs), which have, for a long time, been used in heart medicine. Moreover, it has been known for decades that CGs also have great potential in cancer treatment and, thus, many clinical trials now evaluate their anticancer potential. Interestingly, heart failure and cancer are not the only conditions for which CGs could be effectively used. In recent years, the antiviral potential of CGs has been extensively studied, and with the ongoing SARS-CoV-2 pandemic, this interest in CGs has increased even more. Therefore, here, we present CGs as potent and promising antiviral compounds, which can interfere with almost any steps of the viral life cycle, except for the viral attachment to a host cell. In this review article, we summarize the reported data on this hot topic and discuss the mechanisms of antiviral action of CGs, with reference to the particular viral life cycle phase they interfere with.

Thalidomide-Then and Now: Case Report of a Woman With Thalidomide Embryopathy and Review of Current Thalidomide Uses

Thalidomide was initially developed as a sedative; subsequently, its use was expanded to treat morning sickness in pregnant women. However, it was later discovered to be a teratogenic drug that was associated with embryopathy in women. A woman is described who was exposed to thalidomide in utero. She had several stigmata of thalidomide embryopathy. Although treatment of nausea and anxiety in pregnant women with thalidomide was discontinued in 1961, the drug has been found to be a useful agent for the management of several systemic conditions and dermatological disorders. Whether the treatment with thalidomide shall be incorporated in the therapeutic regime for patients with severe coronavirus disease 2019 (COVID-19) infection remains to be determined.

Comparative analysis of the use and control of thalidomide in Brazil and different countries: is it possible to say there is safety?

INTRODUCTION

One of the biggest drug disasters in history has not prevented thalidomide from being used to treat various clinical conditions. Currently, Brazil has a worrying scenario: high consumption of the drug and, cases of pregnant women using thalidomide, even after adopting restrictive legislation.

AREAS COVERED

This review of the literature and legislation sought to comparatively analyze the monitoring of thalidomide use in Brazil and other countries that use this drug. Finally, we discuss the differences between the countries.

EXPERT OPINION

This analysis allows us to think beyond the safe use of thalidomide, but the safety provided by any type of monitoring system. It seems that out-patients that use unsafe drugs are exposed to some degree of risk. To improve safety, more extensive improvements are needed than monitoring systems related to the use of thalidomide. Its safe use depends on a drastic reduction in the incidence of leprosy and Erythema Nodosum Leprosum in the world; investment in research and development of safe and effective therapeutic alternatives to thalidomide; improvement of health systems and their health surveillance systems, particularly in primary health care; awareness of health professionals and patients for greater responsibility in the use of medicines, especially thalidomide.

Recent Advances in the Development of Thalidomide-Related Compounds as Anticancer Drugs

INTRODUCTION

Thalidomide is an old well-known drug that was first used as morning sickness relief in pregnant women before being withdrawn from the market due to its severe side effects on normal fetal development, However, over the last few decades, the interest in this old drug has been renewed because of its efficacy in several important disorders for instance, multiple myeloma, breast cancer, and HIV-related diseases due to its antiangiogenic and immunomodulatory properties. Unfortunately, even in these cases, many aftereffects as deep vein thrombosis, peripheral neuropathy, constipation, somnolence, pyrexia, pain, and teratogenicity have been reported, showing the requirement of careful and monitored use. For this reason, research efforts are geared toward the synthesis and optimization of new thalidomide analogues lacking in toxic effects to erase these limits and improve the pharmacological profile.

AIMS

This review aims to examine the state-of-the-art concerning the current studies on thalidomide and its analogues towards cancer diseases (with few hints regarding the antimicrobial activity), focusing the attention on the possible mechanisms of action involved and the lack of toxicity.

CONCLUSION

In the light of the collected data, thalidomide analogues and their ongoing optimization could lead, in the future, to the realization of a promising therapeutic alternative for cancer-fighting.

The structure of isolated thalidomide as reference for its chirality-dependent biological activity: a laser-ablation rotational study

Thalidomide is a drug that presents two enantiomers with markedly different pharmacological and toxicological activities. It is sadly famous due to its teratogenic effects mostly caused by the preferential docking of the (S)-enantiomer to the target protein cereblon (CRBN). To compare the structure of the bound CRBN thalidomide enantiomers with that of the isolated molecule, the rotational spectrum of laser-ablated thalidomide has been studied by chirp-pulsed Fourier transform microwave spectroscopy in supersonic jets complemented by theoretical computations. A new setup of the laser ablation nozzle used is presented. Two stable equatorial and axial conformers of thalidomide have been predicted corresponding to the two possible bent conformations exhibited by the glutarimide moiety. Only the most stable equatorial conformer has been detected. The comparison of its structure with those of the (S)- and (R)-enantiomers bound to CBRN shows that the bound (S) species is only slightly distorted. On the contrary, the bound (R)-enantiomer exhibits a highly distorted structure which affects the degree of puckering of the glutarimide ring and especially to the orientation of the phtalimide and glutarimide subunits. This is consistent with a less stable (R)-enantiomer and the known preference of (S)-thalidomide to bind CRBN, which starts the process leading to teratogenic effects.