Leprosy Mailing List – October 20, 2016
Ref.: (LML) Workshop “Clinical Problems in Leprosy”, International Leprosy Congress, Beijing, September 2016
From: Ben Naafs, Munnekesburen, the Netherlands
Lectori salute,
Herewith, as promised, though a little bit late, my report about the clinical questions session during the World Leprosy congress in Beijing.
The meeting was a success according the participants. It was appreciated that the questions and the answers were discussed, everybody could have his and her say. It was assumed that the accumulated knowledge among the participants was more than that of selected “experts”. The meeting went very disciplined not in the least thanks to the chairing of prof Rao. We hope that the discussion will continue on LML.
The number of questions which were asked before the meeting showed to be too many, particular when during the meeting new questions were asked.
We will discuss the questions which were not discussed on LML.
My understanding of the answers are given here;
1 How to manage chronic recurrent ENL when there is no access to thalidomide?
It was emphasized that in 1929 it was published that nearly all ENL last less than a month, and that it was episodic.
Pulse treatment with high dose steroids, treat as long as the ENL is active. You may ad MTX (Methotrexate) to the steroids once a week for a few months.
In India there is a good experience with 100 mg dexamethasone in 500 ml dextrose three days a month with 50 mg azathioprine daily.
Clofazimine added to the treatment is still advocated.
Pentoxyphilline is not advised, it works against oedema and strongly TNF-@ but not against ENL. It is thus likely that Thalidomide works different than just anti TNF-@. The use of TNF@ blockers may help, but there action is still questionable in the light of previous remarks. .
It was mentioned that particular M. vaccae worked protecting against ENL, some of the other vaccines did as well. But this is mostly forgotten.
2 How long to continue steroid treatment for reversal reaction with nerve damage?
The 12 weeks advocated by the WHO may be useful for a minority of the patients. According to most 20 weeks treatment is better, but should not go lower than 10-15mg. Most think a maintenance dose of 15-20 mg for many months.
Starting dose in India 40mg, in Brazil 1mg/kg. According others 40 mg for BT and 30 mg for BL. Then go down 5 mg every 1-2 weeks. It is considered best to do a good follow-up and at least graded ST and VMT. The duration then is BT 3-4 months, BB 4-6 months and BL and LLs 5-9 months or (sometimes) longer.
3 Does histoid leprosy signifies drug resistance?
It can be related, but all patient may have it, it is a rare but normal form of leprosy. It can also point at HIV infection. But again: it may.
4 Treatment regimen in a patient of a leprosy reaction on anti TB treatment.
It was remarked that use of steroids happens regularly in TB, especially in the treatment of meningeal TB there is a lot of experience and this makes it clear that the combination is not by forehand contraindicated. When the TB is treated it can certainly be used to combat a reaction in leprosy. For anti-mycobacterial treatment for leprosy use during tb treatment, dapsone or if MB lamprene too. When daily Rifampicin in anti TB treatment stops, continue it once a month according WHO MDT. Also do not hesitate to take the opinion of pulmonologist whenever needed.
5 What are the indications for nerve decompression. When do we do nerve surgery.
When steroid decompression not works (steroids for more than 3 months), but you must be sure that there is compression. Pain could be an indication, but anti-neuropathic pain medication should be tried first. When there is a nerve-abscess. Surgery should be done by someone experienced. Some think you do not have to wait the full 3 months.
6 Can we issue certificates for of cure to MB and PB patients? If so when?
Some are of the opinion that this increased the stigma. Others indicate that most patients harbour persisters. So you can only say, as the patient is also immunological inactive, he is in remission. But you should act tailored to the situation. The patient first.
7 How soon after starting MDT is the risk of transmission zero?
After 4 months there is no take in mouse footpad. Single dose of rifampicin reduces the load of living bacteria 92%. Remenber that all contacts are already exposed and that a treated patients is a minimal risk.
8 Is MRI and ultrasound of peripheral nerves in leprosy useful?
They are certainly more than able to replace the in many hands unreliable nerve palpation. MRI is useful for diagnosis and probably for the follow-up. But is very expensive and need X-rays. Ultrasound is proving its usefulness but though it is relatively cheap it, needs experienced personal. Colour Doppler seems to be able to diagnose reactions. Some were of the opinion that electrophysiology can give more information, but it is expensive and mildly painful.
9 Does anyone knows of evidence from trials on appropriate steroid dose for young children?
There are hardly studies done. Some featured a child for more than 4-5 months on 1 mg/kg. Basically there was no reaction in the audience. But one should weigh site-effects against benefits. For Type 1 easier than type 2.
10 Since the dapsone syndrome can be killing particular in remotes societies in Nepal, Bangladesh and China, why not change dapsone in ofloxacin?
It indeed should be considered, also because of the haemolytic effect. However dapsone protects against type 1 reaction and Ofloxacin has a lot of site effects particular for children and elderly people. (Dapsone syndrome may be between 2-3 %, but could be underestimated).
11 There is a Koch postulate for infectious diseases why is this not fulfilled for leprosy.
M. leprae can not be cultured. But it not important any more as we have many animal models.
12 BBC news : Vaccine brings hope to India’s largest leprosy colony? How true?
It concerns the old well known Talwar’s vaccine which showed in the past not better than M. vaccae, M. icrc, M.w, or even M.bcg. In the past all these vaccines have been used for prevention trials and treatment trials. They all were able to give some protection against leprosy and were working against ENL. It is thought that it is a political claim, with commercial background.
13 Bacilli are changing, most other bacilli require new medication, but the treatment against leprosy MDT goes on since the 1980th. Are there new drugs in the pipeline?
Up till to date the present MDT seems quite effective and multi drug resistance is rare.
Ofloxacin, Clarithromycin, Minocycline are less active, Moxifloxacin may be better even than Rifa. But is not free available. A new drug Nitazoxanide, a broad-spectrum antiparasitic and broad-spectrum antiviral drug showed to be effective for intracellular infections. May be for leprosy too.
14 Do we need to revise the 3 cardinal signs for leprosy?
The 3 are: 1. Loss of sensation in a skin patch; 2. Enlarged peripheral nerves; 3. Positive skin smear.
Having only one may give suspicion , but it is not enough for a definite diagnosis. For each of the single criteria we have another diagnosis too. We have to realize that we need two out of three of them to have a definitive diagnosis of leprosy. If we have only one we can try to use other methods in support like electrophysiology, Ultra sound, biopsy, PCR, anti PGL1 and so on.
There was no time to answer more questions. We will try to bring them in discussion in coming LML’s. Look forward to further discussion.
Regards,
Ben Naafs
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
