ENL reaction in the first trimester pregnancy. What are the options? [see attachments]

 

Leprosy Mailing List – November 14^th, 2012

Ref.:    ENL reaction in the first trimester pregnancy. What are the options? [See attachments]
From:  S D Ghate, Mumbai, India

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Dear all,

I saw this lady on Thursday.

Case summary

She is 26 years old, was hospitalized with high grade fever & tender lesions on the body.  The history of fever and lesions is since 1 week only.  She gave history of 2 1/2 months of amenorrhoea.  The patient is in her second pregnancy, she has a daughter aged 2 ½ year.  No family history of Hansen's disease.

On examination
There were multiple erythematous, oedematous plaques all over the body, few of them annular; few plaques had eroded.  The lesions were tender.  No infiltration of face.

She had bilateral thickened ulnar nerves; these were mildly tender.  Other nerves were not thickened and non-tender.  There is no sensory or motor nerve function impairment NFI as of now.

Inx.
I have not done the slit-skin smear examination; will be doing it later.  I took skin biopsy.  Only complete blood count (CBC), Bilirubin, creatinine, urine routine tests were done.  She has anemia (Hb-9.3), mild leucocytosis (WBC 12000).  The USG has confirmed 10 weeks of fetus.

DD

My differential diagnoses were type 1 leprosy reaction (T1R), lupus erithematosus (LE), Sweets syndrome.
Histopathology Report
Biopsy shows nodular granulomatous inflammation centered around neurovascular bundles of superficial and deep dermis.  The granuloma consists of foamy macrophages and lymphocytes.  Occasional neutrophils dot the granulomas accompanied by scant nuclear dust and fibrin.  The dermoepidermal junction is spared by the granulomatous infiltrate.  Impression: In view of clinical features these findings are consistent with erythema nodosum leprosum (ENL or T2) reaction.

Treatment given_

She was given intravenous hydrocortisone 100 mg TID for 2 days.  The fever has subsided, but the skin lesions are same.

My problems

1) How to manage her leprosy?- to start MDT straightway or wait for the so called first trimester to complete?  Are these drugs safe in pregnancy after first trimester?

2) How to manage the reaction- as she has T2R, it has to be treated.  Other than prednisolone, there is no drug which is relatively safe.  The risk of cleft lip/palate is increased 6 times due to prednisolone.  NSAIDS are out, cannot give in the first trimester or third trimester due to various side effects.

3) Do you agree with diagnosis? Or think of alternatives?

 

I have found 2 interesting articles on chloroquine/HCQ to be safer option in pregnancy.  I am attaching those abstracts as Word doc.

Any other suggestions on managing this patient?  Please, give your opinions & suggestions.

 

Thanking you in advance.

 

Best regards,

 

Dr Sunil D Ghate
MD, DNB, DDV, MNAMS

Consultant dermatologist

Mumbai, India

 

 

 

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