Assumption: “ENL is a process by which the human body wants to clean up all "foreign bodies" including leprosy bacilli fragments”

Leprosy Mailing List – March 25^th, 2011

Ref:  Assumption: “ENL is a process by which the human body wants to clean up all "foreign bodies" including leprosy bacilli fragments”

From: Indropo Agusni, Surabaya, Indonesia

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 Dear Dr Noto,

After more than 20 years dealing with leprosy patients, my observations come to an assumption that ENL is a process by which the human body wants to clean up all "foreign bodies" including leprosy bacilli fragments.  When the leprosy bacilli enter the body it is covered by PGL-1, a lipopolysacharide that hides proteins of the bacilli, which also suppresses the cellular response of the body by increasing the humoral dominancy.  During MDT, most of bacilli become fragmented and induce many new specific humoral antibodies. When the amount of these antibodies is large enough, together with the complement system, the body will "expel" the foreign material (fragments of bacilli) that we clinically observe as ENL.

I remember one of my leprosy patients who suffered from chronic ENL with steroid dependency.  Since we did not have thalidomide and wanted to stop the steroid dependency, we just let her on routine symptomatic treatment without steroids.  Then a severe ENL series occurred up to general ulcerations.  But after two months, the reactions declined and gradually she recovered to normal condition.  This patient showed how the body removes all the foreign materials by their own mechanism.

So the important thing is to understand that ENL actually is a process of our own body to clean out all the foreign materials, like bacilli fragments of M. leprae.  To stop the immunological reaction will lead to the delay of cleaning of bacilli fragments.  What actually is needed is to prevent severe inflammation process without delaying the cleaning progress of the bacilli fragments. It seems thalidomide has fulfilled this requirement but unfortunately it has teratogenic effects.  If we can find a substance that reduced the inflammation without delaying the cleaning process of M. lepraefragments then we could manage the ENL problem.

Best regards,

Dr Indropo Agusni MD - DVLeprosy Study Group, Institute of Tropical Disease, Airlangga University
Surabaya, Indonesia