Leprosy Mailing List – April 29th,
2012
Ref.: Difference between Jopling’s downgrading and
upgrading reactions.
From: J A. Barreto, S Paulo, Brazil
Dear Dr Noto,
Many thanks
for circulating our clinical case of about “Borderline leprosy in reaction in a
boy from Brazil” (LML March 24th, 2012). Herewith I would like to comment
on the difference between Jopling’s downgrading reaction and upgrading reaction.
Initially,
the most important feature is the presence of viable (“solid” or globi)
bacilli. In downgrading reaction, there are viable bacilli, despite the
presence of a granulomatous epithelioid reaction; which is seen on the
tuberculoid side of the leprosy spectrum. Actually a “granulomatous
epithelioid reaction” can be found on the following three distinct
conditions:
First
condition
True TT
leprosy (rare).
In this case, bacilloscopy in biopsy specimens ranges from 0 to 1+, and
bacilli are usually found, when present, inside dermal nerve branches.
Second
condition
BT leprosy (most common). In this case,
bacilloscopy in biopsy is positive, usually 2+ or 3+, inside dermal nerve
branches, macrophages (less common), sub-epidermal area and smooth muscle of
hair follicles.
Third
condition
Type 1
reaction. Borderline tuberculoid (BT) and
mid borderline (BB) leprosy can show epithelioid cells, which in turn means
that macrophage differentiation and antigen processing was done, due to IL2
plus IFN-gamma and TNF alfa functions. What does it mean the presence of
epithelioid cells together with viable (solid or globi) bacilli? This is
easy to understand: it means that the macrophage differentiation was not proper
and bacilli are still multiplying. This pattern is typical of the
non-treated borderline group, where cellular immunity is partial, and is the
reason why most BT patients downgrade to borderline lepromatous (BL),
progressively or during reactions. According to Ridley, indeed, most of
BL patients results from downgraded BT.
Coming back
to the clinical case we presented; the boy had globi under the epidermis, and
it means that this is a downgrading reaction. Upgrading reaction will
never show globi, that is to say aggregations
of viable (solid or well stained) bacilli. This boy also did not receive
antibiotics. Clinicians in the past had already noticed that downgraded
reaction occurred in untreated borderline patients [B Naafs personal
communication].
Unfortunately,
leprosy knowledge has been lost since the Ridley and Jopling (R&J)
Classification was forgotten, and a new classification (W.H.O.) based only on
the number of lesions is nowadays the rule.
Best regards,
Jaison A.
Barreto
Dermatologist
and Dermatopathologist
More details
can be found on the suggested bibliography.
(Ridley DS.
Skin biopsy on leprosy. 2ed. 1987 and Hastings RC. Leprosy 2ed. 1994)