Management of "intractable" recurrent erythema nodosum leprosum (ENL) reaction

Leprosy Mailing List – February 26th, 2011

Ref:    Management of "intractable" recurrent erythema nodosum leprosum (ENL) reaction.

From: Barreto J., Bauru , Brazil

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Dear Dr Salvatore,

Thank you very much to Dr Antonio Salafia for his message dated Feb. 23^rd, 2011.  I have seen several cases treated with multibacillary multidrug therapy (MB-MDT) for 12 months that had "intractable" recurrent ENL, and several of them had parents/household contacts with active disease not diagnosed (mainly lepromatous leprosy with almost no symptoms).  After treatment of these patients, the ENL reactions subsided.  Whether this fact could be associated with re-infection or inadequate treatment (12 versus 24 months) must be discussed. 

Lepromatous leprosy is a disease with long incubation period, i.e., more than 10 years, and therefore the likely source of bacilli provoking the recurrent ENL may be within the family.  I suggest first to rule out active disease among household contacts, using bacilloscopy (slit-skin smear examination), even if they are asymptomatic.  Secondly, to rule out  resistance / inadequate treatment (bacilloscopy and/or biopsy).

Best regards,

Dr Jaison A. Barreto

Instituto Lauro de Souza Lima

Bauru, SP, Brazil