Unresponsive Type 2 (ENL) reaction

Leprosy Mailing List – March 2nd, 2011

Ref: Unresponsive Type 2 (ENL) reaction
From: Frankel R., Hawaii, USA
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Dear Salvatore,

I apologize for my tardy response as I have been away from home. I hope my comment has not been submitted by others and not yet seen by me.

With regard to the patient referenced by Dr. Antonio Salafia, LML 23-02-2011, I have seen many patients who reportedly do not respond to corticosteroids where the problem is not failure to respond but drug interaction resulting in a reduced amount of corticosteroid in the blood stream.

Most common in patients with leprosy is enzyme induction by rifampin (rifampicin), markedly reducing the amount of circulating corticosteroid. Is Dr. Salafia's patient receiving daily rifampin? If so, choices include changing the rifampin to monthly rather than daily, temporarily replacing rifampin with another antimicrobial agent, or increasing the amount of corticosteroid to levels far beyond what one would normally use. In my experience, this is almost always efficacious.

Kind regards,

Richard I. Frankel, M.D., M.P.H., F.A.C.P.

Emeritus Professor of Medicine

University of Hawai'i