Leprosy Mailing List – January 26, 2014
Ref.: (LML) Facial Erythematous Patches
From: Jaison Barreto, ILSL, Bauru, São Paulo , Brazil
Dear Pieter
This has reference to the LML dated 10-1-2014 from Dr PN Rao regarding persistent facial patches. Cases like this are not uncommon in Brazil. This is clearly a case of type 1 reaction in a borderline patient. I see many cases, almost every week, at the national reference I work, and the history is almost always the same: "a referred PB patient with untreatable reaction".
One of the most important problem of patients like this is the fact that they are usually treated as having PB leprosy. Most of them have, initially, less than five lesions, i.e., PB leprosy. Many times, the histopathology of these lesions shows a "tuberculoid" pattern (BT). Once Fite-Faraco staining is usually not done, even in most laboratory of histopathology (they use to do only Ziehl staining), in many instances, bacilloscopy of lesion (BBI), unfortunately, does not show the real bacilloscopy (2+ or more). Also, once the bacilloscopy of ear lobes, elbows and knees are negative on these cases, the consequence is a confirmation of the misdiagnosis.
When the reaction appears, for these patients (whose are being - or were - treated with PB MDT) only corticosteroid is given. Of course, the dilatation of vessels diminishes, the lesion becomes flattened, and reaction subsides, but the bacilli continue still alive, mainly inside the nerves and smooth muscle. Sometimes, even the bacilloscopy (slit skin smear) of a reactional (BT) lesion does not show bacilli, once it is not a good idea for M.leprae staying inside an epithelioid cell.
The consequence of this kind of approaching is a vicious circle: reaction, corticosteroids, "improvement" (diminishing of redness), immunnosuppression, M.leprae multiplication, new reaction, new administration of corticosteroids...
Once the time interval of duplication of M.leprae is 14 days, after 5 to 7 years (mean), a bacilloscopy of lesion (and sometimes ear lobes) finally shows bacilli due to a spreading of infection in an initially borderline patient.
And the time goes by...
Regards
Jaison
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
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