Difference between Jopling’s downgrading and upgrading reactions.

Leprosy Mailing List – April 29^th, 2012

Ref.:   Difference between Jopling’s downgrading and upgrading reactions.

From: J A. Barreto, S Paulo, Brazil

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Dear Dr Noto,

Many thanks for circulating our clinical case of about “Borderline leprosy in reaction in a boy from Brazil” (LML March 24th, 2012).  Herewith I would like to comment on the difference between Jopling’s downgrading reaction and upgrading reaction.

Initially, the most important feature is the presence of viable (“solid” or globi) bacilli.  In downgrading reaction, there are viable bacilli, despite the presence of a granulomatous epithelioid reaction; which is seen on the tuberculoid side of the leprosy spectrum.  Actually a “granulomatous epithelioid reaction” can be found on the following three distinct conditions: 

First condition

True TT leprosy (rare).  In this case, bacilloscopy in biopsy specimens ranges from 0 to 1+, and bacilli are usually found, when present, inside dermal nerve branches.

Second condition

BT leprosy (most common).  In this case, bacilloscopy in biopsy is positive, usually 2+ or 3+, inside dermal nerve branches, macrophages (less common), sub-epidermal area and smooth muscle of hair follicles.

Third condition

Type 1 reaction.  Borderline tuberculoid (BT) and mid borderline (BB) leprosy can show epithelioid cells, which in turn means that macrophage differentiation and antigen processing was done, due to IL2 plus IFN-gamma and TNF alfa functions.  What does it mean the presence of epithelioid cells together with viable (solid or globi) bacilli?  This is easy to understand: it means that the macrophage differentiation was not proper and bacilli are still multiplying.  This pattern is typical of the non-treated borderline group, where cellular immunity is partial, and is the reason why most BT patients downgrade to borderline lepromatous (BL), progressively or during reactions.  According to Ridley, indeed, most of BL patients results from downgraded BT.

Coming back to the clinical case we presented; the boy had globi under the epidermis, and it means that this is a downgrading reaction.  Upgrading reaction will never show globi, that is to say aggregations of viable (solid or well stained) bacilli.  This boy also did not receive antibiotics.  Clinicians in the past had already noticed that downgraded reaction occurred in untreated borderline patients [B Naafs personal communication]. 

Unfortunately, leprosy knowledge has been lost since the Ridley and Jopling (R&J) Classification was forgotten, and a new classification (W.H.O.) based only on the number of lesions is nowadays the rule. 

Best regards,

Jaison A. Barreto

Dermatologist and Dermatopathologist

More details can be found on the suggested bibliography.

(Ridley DS. Skin biopsy on leprosy. 2ed. 1987 and Hastings RC. Leprosy 2ed. 1994)