Can the BI of a BL or LL patient clear in a few months?

Leprosy Mailing List – March 15^th, 2011

Ref.:   Can the BI of a BL or LL patient clear in a few months?

From: Dr. Grace Warren, Australia

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Dear Salvatore,

These are my comments about Dr Salafia’s request of information about the use of cyclosporine in erythema nodosum leprosum (ENL) reaction not responding to treatment.

One young teenager had chronic ENL we could not control till we discovered that a year before he has been diagnosed with typhoid fever and only given ten days antibiotics.  On checking his blood, levels for typhoid factor were very high.  We gave him a 6 weeks course of  the current anti-typhoid drug (I think it was Chloramphenicol). After that his blood picture cleared completely and he never had another ENL spot.

Also his skin smear bacteriological index (BI) cleared within a few months.  He had been  under treatment for BL/LL leprosy for several years and his BI would not fall as expected. We have found often that a chronic disease like TB or parasites (eg amoebae) interfere with the bodies ability to eliminate the leprosy bacilli.  The body goes for the “ BUGS”  or problems that are most life threatening.  In his case it was the Typhoid that could have killed him and once we cleared the Typhoid the body got rid of the leprosy!

Just realized that perhaps we ought to add that in patients with chronic ENL who are given steroids to control the ENL often do not show any fall in BI on steroids, even though they are on full MDT.  Then once the steroids stop the BI rapidly falls.  I have seen the same in those with chronic ENL in whom the worst of the reaction is controlled  by other means but without steroids.  The BI stays stable but there are no solid bacilli (negative morphological index [MI]).  The ENL continues to simmer on until the intercurrent disease is controlled and then bang the BI falls.

Please note that if the patient is on steroids  we really need to continue the MDT for an extended period.  We found back in the 1960/70s that if a patient was on double or triple (pre-MDT) anti-leprosy medication but on steroids the skin smear did not really fall till the steroids ceased.  I would recommend where WHO recommends only 12 months MDT, that MDT should be continued for at least as many extra months as the patient has received steroids.  I am seeing many patients who "relapse'  after being given steroids during the standard MDT course.

I thought these comments may help Dr Salafia and his patient.  We must not forget we need to treat the whole patient to enable him to adequately fight this infection, without causing more medical problems.

Grace Warren

Previously adviser in Leprosy and reconstructive surgery for The Leprosy Mission in Asia ( 1975-1995)