Reversal reaction (RR or Type 1 reaction)

Leprosy Mailing List, September 22nd, 2008

Ref.: Reversal reaction (RR or Type 1 reaction)
From: Saunderson, P., Greenville, SC, USA


Dear Salvatore,

I would like to respond to Dr Ranawaka concerning her second case, the lepromatous patient with a recurrent reversal reaction (LML Aug. 25th, 2008).

I would like to present data from the AMFES study in Ethiopia, published in Leprosy Review in Sept 2000. In those papers, patients were classified as MB or PB, but I’ve looked again at the data to determine figures for LL patients.

Skin manifestations of RR:
It is true that the typical skin signs of a reversal reaction were mainly seen in borderline patients. Of the 594 patients in the study 98 (16%) showed skin signs of RR; of these 56% were BL cases, 35% were BT cases and only 7% were LL (2% were either TT cases or neural leprosy). But there were fewer LL patients, so skin signs appeared in 23% of all BL cases, 11% of BT cases and 7% of LL cases. (Note: for the purposes of this analysis the few BB cases were included with the BL cases).

Neuropathy as a sign of RR (while the underlying pathophysiology of neuropathy remains obscure, it is often linked to a reversal reaction and is treated in the same way, so many clinicians view neuropathy as another manifestation of RR).

Neuropathy is, if anything, slightly more common in LL cases. In the same cohort of 594 patients in Ethiopia, 258 (43%) developed neuropathy at the time of, or after diagnosis; it occurred in 47% of BL cases, 33% of BT cases and in 54% of LL cases. Similarly, in relation to the highest BI at diagnosis, neuropathy was least frequent in those with a BI of 0 (33%), but most frequent in those with a BI of 6 (59%). Thus new nerve function impairment, requiring treatment with steroids, is common in lepromatous leprosy.

Recurrence of the condition is common, occurring in 54% of the neuropathy cases mentioned above, but it is more common in LL cases. When standardized treatment with steroids was being developed in the 1980’s (at ALERT, under the leadership of Dr Marijke Becx), it was noted even then that multibacillary patients were more likely to get recurrent episodes; it has been standard practice at ALERT since the 1980’s to use the 12-week course of steroids for PB cases, but a 24-week course for MB cases with reversal reactions. The so-called Standard 12-week regimen comes from the WHO “Guide to Eliminate Leprosy as a Public Health Problem” (written in 1995 as an internal WHO document, but published in 2000), which aimed at producing safe and straightforward guidelines for field use.

The recently published WHO Operational Guidelines, linked to the Global Strategy for Further Reducing the Leprosy Burden and Sustaining Leprosy Control Activities (2006 – 2010), mentions treatment with a course of steroids, “…usually lasting 3 – 6 months” (page 27). The ILEP Learning Guide “How to Recognise and Manage Leprosy Reactions” suggests a 12 –week course for PB cases and a 24-week course for MB cases. Many individual leprologists prefer to tailor the steroid regimen to the response of the patient, but this can only be advocated in centers with broad experience in managing leprosy reactions and in managing patients on steroids. [ Note that both the Operational Guidelines and the ILEP Learning Guides are available as pdf files on the ILEP web-site: www.ilep.org.uk ]

Thank you for presenting this interesting case for discussion!

Dr Paul Saunderson, MD, MRCP
Medical Director: American Leprosy Missions
Head Office: 1 ALM Way, Greenville, SC 29601, USA
Home address: Østrem, 6013 Ålesund, Norway
Email: psaundersonatleprosy.org