Leprosy Mailing List – July 1, 2015
Ref.: (LML) Bolus treatment and the prevention of nerve damage in Erythema Nodosum Leprosum ENL
From: Ben Naafs, Munnekesburen, the Netherlands
Dear editor,
Geeske Zijp, LML 30-06-2015, asked a very relevant question.
It may trigger a lot of advises. According to me there is not a generally accepted way to treat ENL.
I can only convey my opinion.
It was most likely a subpolar LL patient.
The start of treatment with MDT and prednisolone was obvious very beneficial. Whether the initial ENL went spontaneously or due to the treatment with MDT or due to the prednisolone is debatable.
The fact that the nerves became less enlarged can be due to the MDT but I think also due to the steroids.
Whether the steroids triggered the pathology which led to new ENL is a matter of discussion. The ENL can be “spontaneously”, but also the consequence of the malaria and the typhoid, or the discontinuation of the steroids.
The hepatitis may be due to ENL as well as the rheumatism. When with antimalarials and Cipro the malaria and the typhoid were eliminated as triggers, the ENL continued despite the anti ENL treatment with antimalarials and aspirin. Having hepatitis, rheumatism, fever, edema and ENL makes it a severe Type 2 leprosy reaction. The edema shows that after a week it is still active. The prednisolone given may have induced the improvement, but still though unlikely, it can be the natural cause.
My advice would be: taper the steroids within a month. Wait and see. Since the trigger is gone there may be no new severe attack of ENL. If it occurs again (I assume there is no thalidomide), I would give bolus treatment (at least with double the dose of steroids than you used before) and taper the steroids within a month. I would start Clofazimine in high dose and MTX. A possible repeated ENL I would treat with high dose steroids again, but again tapered down in a short time. This may prevent steroid addiction.
Now your specific question: Just I do not know. But I do not expect that this patient will develop dependency.
With regards,
Ben Naafs
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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