Development of leprosy in a patient with rheumatoid arthritis during treatment with etanercept: a case report

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder. There is a clear association between some disease-modifying drugs used to treat RA and infection. The introduction of the anti-tumor necrosis factor (TNF) therapies has improved the outcome of severe RA. The TNF-antagonism may increase susceptibility to granulomatous pathogens such as Mycobacterium tuberculosis, Listeria monocytogenes, and Histoplasma capsulatum.

METHODS

We report the case of a 37-year-old woman with RA receiving an anti-TNF agent, who developed a rash on her back and both legs, which was finally diagnosed as tuberculoid leprosy.

RESULTS

This is the first case of leprosy due to anti-TNF therapy reported in Europe.

CONCLUSIONS

Clinicians should be aware of this and other types of atypical and serious infections that patients may suffer from when treated with anti-TNF agents.

Post-traumatic inoculation tuberculoid leprosy after injury with a glass bangle

A lesion of tuberculoid leprosy in an Indian lady presenting at the site of injury from a broken glass bangle is reported. The diagnosis was by classical clinical features and histopathology. The importance of the skin in leprosy transmission is emphasised.

Borderline tuberculoid leprosy: an immune reconstitution phenomenon in a human immunodeficiency virus-infected person

Two months after starting highly active antiretroviral treatment (HAART), an individual with human immunodeficiency virus type 1 (HIV-1) infection and profound CD4+ T lymphocytopenia developed several erythematous plaques on his face, which were due to borderline tuberculoid leprosy with reversal reaction. The temporal association between the development of these lesions and changes in blood CD4+ lymphocyte count and plasma HIV-1 load observed during HAART strongly suggests that the presentation of leprosy resulted from immune reconstitution.

Histological changes in the nerve, skin and nasal mucosa of patients with primary neuritic leprosy

Primary neuritic leprosy (PNL) presents as a peripheral neuropathy with no visible skin patches and skin smears negative for acid fast bacilli. The pathogenesis of PNL is poorly understood. The aim of the study was to document the histological changes in the nerve, apparently normal skin and nasal mucosa in PNL and to study its significance to the pathogenesis of leprosy lesions. The study is based on a cohort of 208 PNL patients registered at the Schieffelin Leprosy Research and Training Centre, Karigiri. All patients had a nerve biopsy, 196 had a skin biopsy and 39 had a nasal mucosal biopsy. The findings reveal that PNL patients exhibit a spectrum of disease histologically in the nerve ranging from lepromatous to tuberculoid leprosy with a significant proportion (46%) manifesting a multibacillary leprosy histology. Findings in the apparently normal skin and nasal mucosa reveal that there are widespread changes due to leprosy in tissues such as the skin and nasal mucosa even when the disease appears clinically confined to a few nerves. PNL may be an early stage in the pathogenesis of the disease before the appearance of skin lesions. The number of nerves enlarged and lepromin status did not give any clue to the nature of underlying disease.

Cutaneous granulomas masquerading as tuberculoid leprosy in a patient with congenital combined immunodeficiency

Combined immunodeficiency disorders are characterized by abnormalities in cellular and humoral immunity. This classification includes common variable immunodeficiency (CVI), a primary immunodeficiency disorder characterized by hypogammaglobulinemia, recurrent bacterial infections, and significant T-cell abnormalities. Associated autoimmune diseases include rheumatoid arthritis, pernicious anemia, idiopathic thrombocytopenic purpura, and systemic lupus erythematous. Granulomatous lesions in lymphoid tissues, solid organs, and skin have been reported. We describe a patient with CVI who developed cutaneous granulomas with perineural invasion; to our knowledge, this is a previously undescribed feature.

[Leprous neuropathy--observation from the standpoint vasculitis]

Pathogenesis of leprous neuropathy was studied from the standpoint of vasculitis. In vasculitic syndrome, mononeuritis multiplex is the most specific peripheral nerve injury. It occurs most frequently in small vessel vasculitis. Among them, the incidence is highest in microscopic polyangitis (MPO), Churg-Strauss Syndrome (CSS), and Wegener's granulomatosis (WG). All of them are categorized as ANCA associated disease. Because the disease activity is parallel with ANCA titer and ANCA is related directory to the pathogenesis of necrotizing vasculitis as well as the occurrence of peripheral neuropathy. Other small vessel vasculitis, such as lupus or rheumatoid vasculitis which are believed to occur by immune complex mechanism, are accompanied seldom by peripheral neuropathy. In WG, there are granulomatous lesions in upper and lower respiratory tracts which are supposed to be induced by Th1 dominant CD4 T cell infiltration. In cases of leprosy, if peripheral neuropathy were related to small vessel vasculitis, there might be two different pathogenesis. One is granulomatous vasculitis like WG in tuberculoid type. The other is immune complex type necrotizing vasculitis like SLE in lepromatous type, especially ENL. The site of these events may be small vessel in epineurium. Further immunologic studies are needed to clarify detailed mechanisms of leprous neuropathy.

Effect of BCG on the risk of leprosy in an endemic area: a case control study

The effect of BCG on the risk of leprosy was measured using a case-control design in an area endemic for the disease. In this study, 397 newly diagnosed cases and 669 controls matched for age, sex and locality were selected from a defined population. Information on exposure to BCG, contact with another case of leprosy, and relevant socioeconomic variables were obtained from the subjects. Having infectious (multibacillary) and noninfectious (paucibacillary) contacts in the household increased the risk of disease 11.7 times (p less than 0.001) and 2.7 times (p less than 0.001), respectively. Overall, the protection offered by BCG was not significant (odds ratio = 0.8; p = 0.17). However, BCG appeared to increase the risk for indeterminate leprosy (adjusted odds ratio = 2.7; p = 0.09) while protecting against borderline disease (adjusted odds ratio = 0.39; p = 0.03). It is possible that BCG causes a shift in the overall cell-mediated immune response, thus increasing the risk for milder and transient forms of leprosy while protecting against more serious forms. These findings may have important implications for the design and interpretation of vaccine trials. Namely, trials should be designed to measure the protective efficacy of vaccines against the more serious forms of leprosy, which have the greatest public health significance.