Leprosy Mailing List – December 9th, 2012
Ref.: Erythema nodosum leprosum (ENL) reaction in Pregnancy
From: Dr. Grace Warren, Sydney, Australia
Dear Dr Noto,
Thank you for including on the leprosy mailing list the excellent letter from Dr Duncan on ENL reaction in Pregnancy [LML Nov. 17th, 2012]. I have similar experience.
Dr Duncan's early work taught that an important proportion of borderline lepromatous (BL) and lepromatous (LL) leprosy cases are diagnosed because they present with ENL soon after delivery. Her teaching on this was excellent pointing out that many women may have mild LL disease that she is trying to hide or else she has not realized she has active leprosy. However, during the first trimester the patient produces increasing quantities of steroids - to prevent abortion - and this rise in steroids limits the ability of the body to kill the acid fast bacilli (AFB). This may in turn encourage a spread of the disease until adequate anti-leprosy medication is commenced.
In Hong Kong, in the 1960s, we had an excellent laboratory technician who did slit-skin smears every month for the patients in reaction and on steroids. We were very interested to note that the Bacillary Index (BI) did not fall during any steroid treatment for ENL, even if it was continued for many months and the patient was on full anti-leprosy therapy as well. Hence we used methods other than steroids, where possible, to control the ENL so that we would continue to get BI falls. As we were involved in the early drug trials of Clofazimine (from 1966) we soon realized that here was a drug that worked with us - controlling reaction without producing undesirable toxic side effects and encouraging a fall in the BI.
I experienced that on many occasions the use of Clofazimine as she recommends is ideal. The development of the ENL soon after delivery is explained by the fall, after delivery, in steroids that are naturally high during pregnancy. So from many points of view one does not want to be giving Prednisolone to pregnant women as Dr Duncan states. Clofazimine has an excellent anti-reaction effect and our trials in Hong Kong showed that there are no real undesirable side effects. Although the mother may go a darkish brown, the baby does not seem to suffer any real undesirable after effect from the Clofazimine in pregnancy, even if it does have skin that is a little darker than expected. That will fade as the mothers Clofazimine dose decreases. It is interesting to note that the normal skin (not the infiltrated skin) in borderline patients does not discolor with Clofazimine. It is obviously taken up by the affected tissues not the normal skin.
Thank you Dr Duncan for sharing and reminding everyone of this fact as I know many of the more recently qualified clinicians use steroids very freely and would not be aware of some of the problems that can result from their use when there are other methods of controlling the problem. I am very cautious as I have seen too many patients who have suffered severely and some even died because they had been given steroids. May be not always in the best dosage, without adequate supportive therapies for other conditions that were contributing to their ill health, and with inadequate follow up long term. Modern Clinicians often tend to reject Clofazimine, but having watched its use since the beginning I would recommend that it be used more often. We have not yet seen a proven case of resistance to Clofazimine developing in a patient under correct treatment.
Thanks too for your including the" Strawberry ice cream statement". That is something that can certainly disturb the staff who have never seen it before!
Grace Warren,
Previously Superintendent Hong Kong Leprosarium (1960-1975)
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML Archives: http://www.aifo.it/english/resources/online/lml-archives/index.htm
Contact:
Dr Salvatore Noto
Padiglione Dermatologia Sociale
Ospedale San Martino
Largo Rosanna Benzi, n. 10
16132 Genoa, Italy
Tel: (+39) 010 555 27 83 - Fax: (+39) 010 555 66 41 - E-mail: salvatore.noto@hsanmartino.it
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