Leprosy Mailing List – October 3, 2017
Ref.: (LML) More about the use of B663 and lessons we should never forget
From: Grace Warren, Sidney, Australia
As I said in my previous letter (LML, October 2, 2017) I frequently ordered B663 (Lamprene) as the initial drug (as monodrug ) while I checked for parasites, malaria and worms especially, and anemia, and other medical problems that may need to be treated adequately and often are not. In areas like SE Asia these med problems are so common the patients did not worry about reporting them. We need to check for them all - at initiation of therapy and whenever we are reviewing progress. It is often these intercurrent diseases that push the patient into reaction as his metabolic processes cannot cope with everything at once and so the Leprosy gets left of the urgent list as it does not kill.
One of the big factors is that as far as I know no person has ever been found to develop B663 resistance. Yes the labs have managed to produce B663 resistant organisms in research animals but never has it been found in patient. We cannot say the same for any other anti-leprosy drug (as far as I know). DDS resistance is so common that in some areas one must assume that new patients probably have DDS resistance. DDS also encourages anemia - and then there is G6PD problems which I found pretty common in the Chinese population (when looked for). But how often is it looked for nowadays?
B663 also has good anti-inflammatory action and is effective against some other bacterial infections that may be resistant to regular antibiotics. People talk of it causing irritation to some internal organs but if given with food (some say oil) or given soon after a meal - it seems to cause no real problems. I have often found it cures other infections that have been said to be resistant to antibiotics.
No I have not given it specially to cure the infection but some of the leprosy patients who had chronic infections did not respond to the usual antibiotics but after being put onto B663 the other infection also vanished.
I am not sure about provision of B663 – bought over the counter it is expensive – but does WHO merely provide free anti-leprosy drugs for a definite time period? I do not know what the arrangement now is - I merely did some of the original trials in the 1960s and would still use it if I had the opportunity. In fact I would go so far as to say that if I only had one anti-leprosy drug available I would make it B663.
In correspondence with Leprosy specialists in India I have been informed that there are many, perhaps in the hundreds of thousands of children with leprosy that has not been diagnosed. Leprosy is taught so little in medical colleges these days because of the advertisement that leprosy is no longer a public health problem in most countries of the world. I wonder how often immigrants are admitted to a new country after their medical examination, without any mention of leprosy or provision for its care or follow up. Even if they had leprosy, the Medical Officer in charge did not recognize the present signs of the disease.
Only a few years ago I was asked to consult an immigrant to a country where leprosy is not common and he acknowledged that he had had leprosy and had had some treatment, had abnormal sensory perception of the knees when he immigrated but was not listed as leprosy. After 5 years in the new country he developed nodules on which one of my student did slit skin smears and they were highly positive. And yes we found some large hard nerves, and sensory abnormalities in his legs. We put him on B663 and it settled easily and no further problem. I would certainly keep him on treatment till he is completely skin smear negative. There is no way one can check if there are any live bacilli in the nerves or other tissues. Yes the regular use of the MDT duration of dosage is reasonable but once a patient has shown reactions like this, one does wonder if he is ever really “Cured”.
One fascinating patient was diagnosed as neuritis on the long finger when she was 5 years old. The treatment was to paint with iodine every day, which was done for a short while but no record of how long or if it made any changes. No follow up. The patient acknowledges that when at school, the right hand behaved differently to the left. There was less hair growth and virtually no sweating and it was later realized she had abnormal sensation, strength and grip. Also absence of pain when trauma to the right hand (not to the left). But the hand seemed to function well. No one worried; said she was imagining things. When aged about 40 she met Stanley Brown who was intrigued and pointed out that some nerves on the back of the right had were large and hard and so was the ulna at the elbow, no evidence of skin lesions, or other typical signs. Ordinary skin biopsy negative but years later( about aged 60) shown to have a high Lymphocyte response showing she had caught leprosy somewhere and was now resistant. That of course was not known when Dr. Brown’s diagnosis was made so she did take a course of DSS (virtually the only drug used at that time) which seemed to produce no changes. At the time of the blood tests, it was discovered that as a small child she had had a nurse caring for her who about ten years later was diagnosed a markedly nodular lepromatous leprosy.
What a fascinating history. Inspires one to try and diagnose early and if in doubt treat with B663. Note that patient did not get any B663. She was obviously one of the 95% of those infected who self-cure.
In 1975 (or there about) I lectured in most of the Medical Colleges in Pakistan and in most of them I was told it was the first time they had had a lecture on leprosy in that College. In one City I gave a lecture on Leprosy to local medical society members and afterwards the head of the association thanked me and said “I wonder how many children I have missed”. What an acknowledgement for the head of their association in front of the members.
I guess it is unlikely to ever get the colleges to take teaching leprosy seriously nowadays. Even when I was at med school it was considered very special when we, in 1952, had one lecture on leprosy demonstrating a patient. We cannot go back and correct all that but somehow we can improve the possibilities of getting a higher proportion of patients diagnosed. “What you do not look for you never diagnose. What you do not know about you never recognize”.
Congratulation on the LML work for many years. Keep it up.
Former TLMI Consultant on Leprosy and Reconstructive Surgery for Asia
LML - S Deepak, B Naafs, S Noto and P Schreuder
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