Erythema nodosum leprosum reaction in a post kidney transplant patient

Leprosy Mailing List, January 19th, 2009

Ref.: Erythema nodosum leprosum reaction in a post kidney transplant patient
From: Ariyawansa D., Thalapathpitiya, Nugegoda , Sri Lanka


Dear Dr Noto,

I am treating a post kidney transplant (KT) patient with lepromatous leprosy (LL) with erythema nodosum leprosum (ENL) reaction. Herewith follows her clinical history.

A 29 year old female presented with tender erythematous nodules over arms & legs for 4 months; arthralgia and fever for 3 weeks.

She gave a past history of histologically confirmed LL leprosy with Bacillary Index (BI) of 4+ and Morphological Index (MI) of 10% in January 2005 treated according to WHO multi-drug therapy (Rifampicin, Clofazimine & Dapsone) for one year.

She has undergone renal transplantation in January 2008 and was subsequently given immunosuppressives (Cyclosporine, Prednisolone, Mycophenolate mofetil).

Slit skin smear done in September 2008 (with the current presenting symptoms) showed evidence of BI 4+ and MI 0% and histology confirmed evidence of lepromatous leprosy. We prescribed multi-drug therapy with the same regimen used in 2005 and Prednisolone 40 mg/day considering a diagnosis of LL leprosy with ENL reaction.

She developed severe symptomatic haemolysis dropping Haemoglobin from 11 to 7 g/dl. Therefore we discontinued Dapsone but continued the rest of medications. While tailing off Prednisolone gradually over 12-16 weeks she started developing ENL on 2 occasions at a dose of 25 -15 mg. Therefore during second occasion we increased the dose of clofazimine to a total dose of 150 mg on 16/01/2009.

My questions are:
1. Is there a prophylactic anti leprosy regimen to prevent leprosy recurrence for patients on immunosuppresives drugs who have had leprosy in the past?
2. What alterations of the regimen of treatment should we consider if this particular patient develops ENL again?
3. According to the literature search I did, I found only 10 case reports of post transplanted patients with leprosy. Do you have more information?

Kind regards,

Dr Dananja Ariyawansa
Sri Jayawardenepura General Hospital
Thalapathpitiya
Nugegoda
Sri Lanka