Erythema nodosum leprosum (ENL) reaction after completion of the 12-month multi-drug therapy (MDT) regimen

Leprosy Mailing List – January 27^th, 2010

Ref.: Erythema nodosum leprosum (ENL) reaction after completion of the 12-month multi-drug therapy (MDT) regimen.

From: B Naafs, Munnekeburen, The Netherlands

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Dear Pran,

I refer to your message dated LML Jan. 23^rd, 2010.

ENL reaction after completion of the 12-month MDT regimen is a well known phenomenon. It happened too when the treatment period was 24 months, but less. It was one of the arguments against the 12 month MDT treatment. But WHO never listens. I have in the past suggested that patients who develop ENL during treatment or are in risk of developing it after treatment, should continue clofazimine for another 1-2 years.

Ben

Possible neuropraxia due to improper/too long application of tourniquet

Leprosy Mailing List – January 27^th, 2010

Ref.: Possible neuropraxia due to improper/too long application of tourniquet.

From: Wim Brandsma, Pokhara, Nepal

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Dear Angelika,

Thank you very much for your message dated LML Jan. 23^rd, 2010. I feel sorry for the patients three out of four..

To me it seems that the surgeons need to review the 'technicalities' around the surgery not the procedures themselves though they take too much time. It looks that all three are suffering from neuropraxia due to improper/too long application of tourniquet. Nerves are likely to recover without prednisolone.

Regards,

Wim Brandsma

Alternative antibiotic regimens for leprosy

Leprosy Mailing List – January 27^th, 2010

Ref.: Alternative antibiotic regimens for leprosy

From: Leon Gilead, Jerusalem, Israel

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Dear Dr. van Brakel,

Thank you for your response (LML Jan. 21st , 2010).

The problems arise with patients refusing clofazimine (Lamprene) while being unable to take dapsone due to haemolysis or other side effects. There may also be a problem with double-drug therapy of Rifampicine and Dapsone in cases where the M. leprae are Dapsone resistant to begin with (about 70% of our patients in the last decade are Ethiopian immigrants, and as you are well aware, I'm sure, Dapsone resistance is quite common in Ethiopia), and hence we may actually get a Rifampicine monotherapy! This is especially problematic since we don't have the lab setting to check in vitro whether this resistance actually exists in our patients.

What is your approach, and of other readers? Has anyone a relevant input, regarding Prof. Ji Baohong's suggested alternative MDT regimen? It is composed of Rifampicine 600mg, Moxifloxacin 400mg and Clarithromycin 1gr or Minocycline 200gr all of which X1/month. It was suggested in a lecture given at the 17th ILC at Hydrabad 2008

– Ref: http://www.aifo.it/english/resources/online/books/leprosy/ila-india08/new-drugs-Ji_Bahong.pdf -.

Prof. Gelber reported, in the same meeting, about his experiments with Moxyfloxacin, and later published his observations (one of the publications abstract is in the following ref: -

(http://www.ncbi.nlm.nih.gov/pubmed/18573938?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=2) .-

Have you, or anyone else for that matter, tried this regimen or other regimens in clinical settings? If anyone has, were there any side effects or other problems observed?

Thanks again for your input.

Leon

Dr. Leon Gilead

Director of the Israeli Hansen's Disease Center

Department of Dermatology

Hadassah University Hospital

Jerusalem

Israel

Alternative regimens for multi-drug therapy (MDT) in leprosy

Leprosy Mailing List – January, 27^th, 2010

Ref.: Alternative regimens for multi-drug therapy (MDT) in leprosy

From: Diana Lockwood, London, UK

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Dear Salvatore,

In Reply to Dr Gilead's request (LML Jan. 19^th, 2010).

The whole topic of alternative regimens for MDT is given too little attention. I think that the level of adverse effects due to dapsone has been under-recognised and we are starting to see significant rates of adverse effects when we look for them. Patricia Deps (Lepr Rev. 2007 Sep;78(3):216-22.) has reported that 45% of Brazilian patients had adverse effects with leprosy MDT, 43.8% to Dapsone, 12.3% to Rifampicin and 9.2% to Clofazimine. In a study I am currently doing in India we are also seeing significant rates of anaemia in patients on Dapsone.

If a patients cannot tolerate Dapsone or Clofazimine then using single dose monthly Rifampicine, Ofloxacine and Minocicline (ROM) is an option. The study which gives one some confidence in using this is the study by Villarmosa et al (Am J Trop Med Hyg 2004 70(2): 197-200) who compared monthly ROM against MD-MDT in a group of BL and LL patients in the Philippines and they reported a satisfactory fall in the bacterial index (BI) of these patients. We have used this in a patients with LL who has liver failure. After a year on treatment his BI is falling and he has not yet had ENL.

I think that we should be doing larger studies to establish the role of monthly ROM in the anti-bacterial treatment of leprosy in patients with adverse effects or problems with compliance.

Diana

Diana Lockwood
Professor of Tropical Medicine
London School of Hygiene & Tropical Medicine
Keppel St
London WC1E 7HT
diana.lockwood(at)lshtm.ac.uk
Tel: 020 7927 2457
Fax: 020 7637 4314

Information about Monitoring and Evaluation Courses

Leprosy Mailing List – January, 25^th, 2010

Ref.: Information about Monitoring and Evaluation Courses

From: Osahon Jeremie I. Ogbeiwi, Wakefield, West Yorkshire, UK

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Dear Salvatore Noto,

This is in reference to Dr S K Abdul Hadi’s message (LML Jan 21^st , 2010) from the NLEP, Dhaka, Bangladesh. I am pleased to inform you that our private consultancy firm, based in Leeds, UK, organises Monitoring and Evaluation Courses overseas in the following grades:

1. Basic M & E Course - A regular quarterly course for programme staff, managers, coordinators or directors with little or no experience in M&E. Dates in Abuja, Nigeria: first weeks of March, June, September and December 2010.

2. Advanced M & E Course - A regular quarterly course for M&E staff and programme practitioners with basic M&E experience or at least a previous training in M&E. Dates in Abuja, Nigeria: second weeks of March, June, September and December 2010.

3. Customised or Organisation-specific M&E Course - this is a course designed to meet the M&E needs of client organisations. On invitation, we are available to convene such customised courses at locations and timeframes determined by the client organisation.

4. International Programme Management Course - a course that incorporates the essentials of monitoring and evaluation with programme planning and change managment. The first of this course will hold in UK from April 26 - 30, 2010.

Both Basic and Advanced courses involve a 5-day intensive, interactive, participatory and practical learning experience. Each however has a different focus that relates directly with the pre-course level of M&E capacity of participants, but with a similar momentum geared to building their understanding and skills in M&E processes. Since we started a year ago, we have successfully trained 96 participants from different backgrounds of experience and discipline.

Dr. S K Abdul Hadi will find more information about our firm, services and profile at our website: www.factfinderscsl.com . For specific details about the 2010 courses he may wish to send us an email at: director@factfinderscsl.com. It will be obvious from the profile that the background of the Convener and key facilitator of these courses, is in leprosy and tuberculosis, but the general application of M&E is inter-disciplinary.

The course outlines (Basic - Advanced) and application form for these courses are attached. I look forward to hearing from him.

Thank you.

Dr. Osahon Jeremie I. Ogbeiwi

Director/Executive Consultant

Factfinders Consultancy Services Limited | Incorporated in England and Wales

Company number: 06808469

Registered address: 12 Buttercup Lane, East Ardsley, Wakefield, West Yorkshire, WF3 2LU, UK.

Tel: +44 1924870166 | Mobile: +44 7999444545

Fax: +44 1924870166

Website: www.factfinderscsl.com

Factfinders CSL Network: http://groups.yahoo.com/group/factfinderscslnetwork

Statement of the ILEP President for the World Leprosy Day 2010

Leprosy Mailing List – January, 25^th, 2010

Ref.: Statement of the ILEP President for the World Leprosy Day 2010

From: Douglas Soutar, London, UK

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Dear Salvatore,

Please find an attachment and link to the Statement of the ILEP President, Mr Rene Stäheli, to mark the occasion of World Leprosy Day 2010. I hope you can post this on the Leprosy Mailing List to ensure its reaches a wide audience.

http://www.ilep.org.uk/fileadmin/uploads/Documents/News_documents/57thWLDMessageEng.pdf

Best regards,

Douglas Soutar

Douglas Soutar
General Secretary
International Federation of Anti-Leprosy Associations
Tel: 44 (0) 207 602 69 25 – Fax: 44 (0) 207 371 16 21 – Website: www.ilep.org.uk
E-mail: doug.soutar(at)ilep.org.uk

NB
The message is also attached in PDF format

Alternative antibiotic regimens in leprosy

Leprosy Mailing List – January, 25^th, 2010

Ref.: Alternative antibiotic regimens in leprosy

From: David M. Scollard, Baton Rouge, LA, USA

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Further to Dr. van Brakel’s comments (LML Jan. 21^st, 2010),

In the United States we have unique medical-legal complications that make it difficult to use Clofazimine routinely for many patients. As a result, many of our physicians use minocycline (100 mg/day) routinely for adults, instead of Clofazimine. This appears to work very well as an anti-microbial regimen. Minocycline also has known anti-inflammatory properties, but we do not have evidence to clearly indicate whether it is or is not effective in preventing or treating ENL.

David

David M. Scollard, M.D., Ph.D.

Chief, Clinical Branch

National Hansen’s Disease Programs

1770 Physician Park Dr.

Baton Rouge,LA 70816

Tel: 225-756-3713

FAX: 225-756-3819

e-mail: DScollard(at)hrsa.gov

Web: www.hrsa.gov/hansens

Leprosy Mailing List – January, 24^th, 2010

Ref.: Advertisement for the position of Director of the Armauer Hansen Research Institute (see attachment)

From: D. Frommel, Paris, France

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22/01/10

Dear Dr Noto,

I am enclosing the advertisement for the position of Director of the Armauer Hansen Research Institute, the sister institution of ALERT.

As a past director, 1988 -1993, I may only add that it was a highly interesting and gratifying job, provided one was not alien to patience. In addition, Ethiopia is one of the most beautiful country and Addis Ababa offers plenty of cultural advents, even a “Scuola elementare” and, an Italian Cultural Centre.

Thank you for forwarding this advertisement to the leprosy mailing list.

Yours sincerely,

Dominique Frommel

Nerve function loss after reconstructive surgery

Leprosy Mailing List – January, 23^rd, 2010

Ref.: Nerve function loss after reconstructive surgery

From: Piefer A., Kinshasa, Democratic Republic of Congo

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Dear Colleagues,

After years of political conflict reconstructive surgery has (re) started in the DR Congo (former Zaire) under basic conditions with a few cases. I would like to share a complication that I have just come across, hoping that readers of this mailing list can help us with their experience.

The situation has been as following:

8 cases were operated (2 cases for TMT, 1 cases of TPT, 4 cases for lumbrical replacement, of which one had an opponent’s replacement at the same time). Post operative 3 out of the 4 cases who received hand surgery present complication after surgery which was done in early December 2009 (we are still in the post operative therapy phase). Neither the case with ulnar / median correction nor the other cases presented similar complications. Surgery was performed by a surgeon under training with a very experienced supervisor (external consultant for leprosy reconstructive surgery). All patients have a detailed VMT/ST pre operative and as far as possible under the post operative situation a VMT / ST was done at the end of the 2^nd week of post operative therapy in order to assess the complications.

Here are the main findings:

Person operated	Surgery performed	Complication post operative	Observations	Treatment given to date
16 year old woman, completed PB MDT in May 2009, clinically with the only nerve function loss of the right ulnar nerve with remaining weak function of the 1st dorsal interossei and the ADD pollicis	Palmaris Longus extended with fascia lata to pulley insertion right hand	Loss of radial nerve and high median nerve function incl. loss of Palmaris Longus and pronator teres and brachioradialis. Partial ulnar nerve function remaining in the same way as pre-operative (1st dorsal interossei and the ADD pollicis)	Axillary block for the anaesthesia did not work, Ketamine was given. Duration of tonique about 1 ¾ hrs. Post op elevation during 3 weeks in POP, remaining thumb function gave the impression that all is ok. The extend of loss was discovered immediately after POP was removed after 3 weeks. No pain anywhere in the upper limb	Stimulation with ice and mobilisation as possible with continuing post op programme. Started 40 mg Prednisolone and Vit. B (Triblex forte) 2 days after POP was removed.
young man in his mid twenties, completed MB MDT in 2003, clinically with multiple nerve function impairments: bilateral mild lagophthalmos, loss of ulnar nerve function in the right hand, weakness in dorsi flexion of the right foot	EF4T with pulley insertion (ECRL transferred) right hand	Loss of radial nerve and high median nerve function incl. Loss of pronator teres and brachioradialis.	Axillary block for the anaesthesia did not work, Ketamine was given. Duration of tonique a little over 2 hrs. Post op elevation, immediate complains about sensation loss and swelling, immediate loss of thumb and finger movement. No pain anywhere in the upper limb.	POP was split after 2 days and conservative treatment for swelling as well as a short course (2 weeks) of Prednisolone (starting 40 mg). Prednisolone short course 40 mg (2 weeks, ongoing) and Vitamine B (Triblex forte) 2 days after POP was removed.
59 yr old man, completed MDT MB in 2008, left ulnar paralysis, mild lagophtalmos left eye.	Palmaris Longus extended with fascia lata to pulley insertion left hand	Loss of FPL, flexion of index, weakness in opponens and AB of the thumb as well as PL, loss of pronator teres and brachioradialis. Possible weakness in finger flexion– at this stage difficult to test	Axillary block for the anaesthesia did not work,local anaesthetics were given. Duration of tonique a little over 1 ½ hrs. Post op elevation, mild swelling first 2 days.	Normal post op programme is followed with active mobilisation of thumb and pronation/supination.

AB = Abduction or Abductor ... (muscle)

ADD = Adduction or Adductor ... (mucle)

ECRL = Extensor Carpi Radialis Longus

EF4T = Extension to Flexion 4 tails (surgical method for reconstruction of lost lumbrical function)

FPL = Flexor Pollicis Longus

MB MDT = multibacillary multidrug therapy

PB MDT = paucibacillary multidrug therapy

PL = Palmaris Longus

POP = plaster of Paris

post op = post operative

ST = sensory testing

TMT = Temporalis Muscle Transfer (technique to reconstruct lagophthalmos)

TPT = Tibialis Posterior Tendon Transfer

VMT = voluntary muscle test

We would be grateful for any comments and suggestions.

With best wishes and many thanks,

Angelika Piefer

The Leprosy Mission International in DR Congo

124 Avenue de la Mongala

Gombe, Kinshasa

Democratic Republic of Congo

E-mail: angelikap(at)tlmcongo.org or angelikapiefer(at)gmail.com

Erythema nodosum leprosum (ENL) reaction after completion of the 12-month regimen

Leprosy Mailing List – January 23^rd, 2010

Ref.: Erythema nodosum leprosum (ENL) reaction after completion of the 12-month regimen.

From: Pranab K. Das, Amsterdam, The Netherlands

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Dear Salvatore,

In reference to Dr Wim van Brakel's response to Dr. Gilead, I quote,

"We see many former patients nowadays who develop ENL reactions after their 12-month regimen has been completed, just due to the withdrawal of clofazimine",

how sure Dr van Brakel is about his statement? I shall be interested to hear more about it.

With regards,

Pranab K. Das

Information regarding Programme Evaluation course

Leprosy Mailing List – January 21^st, 2010

Ref.: Information regarding Programme Evaluation course.

From: Sk Abdul Hadi, Dhaka, Bangladesh

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Dear Salvatore Noto,

Happy New year & Greetings from National Leprosy Elimination Programme (NLEP), Bangladesh.

Please let us know the name of the appropriate Institute / Organization where we can undergo a training course on Programme Evaluation specially on leprosy, TB etc. If the Institute / Organization have designed course on programme evaluation please also let us know the starting date along with the duration of the course.

A lot of thanks in advance for taking trouble for NLEP, Bangladesh.

With best regards.

Sincerely yours,

Dr Sk Abdul Hadi

Deputy Programme Manager

NLEP, DGHS, Dhaka, Bangladesh

Alternative antibiotic regimens for leprosy

Leprosy Mailing List – January 21^st, 2010

Ref.: Alternative antibiotic regimens for leprosy

From: Wim H. van Brakel

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Dear Dr. Gilead,

Unless there is suspicion of antibiotic resistance to either dapsone or rifampicin, it is not necessary to replace the clofazimine component of MB MDT. People get better on double drug therapy just as well as they do on MDT, because most of the MDT effect is due to rifampicin. The only time you will miss the clofazimine component is when a patient is prone to develop ENL. We see many former patients nowadays who develop ENL reactions after their 12-month regimen has been completed, just due to the withdrawal of clofazimine.

With friendly greetings,

Wim van Brakel

Wim H. van Brakel, MD MSc PhD

Royal Tropical Institute
Leprosy Unit
and

Athena Institute

Faculty of Earth and Life Sciences

VU University

Correspondence address:

Wibautstraat 137k

1097DN Amsterdam
Netherlands
tel +3120 6939297

fax +3120 6680823
w.v.brakel(at)kit.nl

wim.van.brakel(at)falw.vu.nl