Leprosy Mailing List – January 13, 2015
Ref.: (LML) BT Hansen's Disease and nerve abscesses - surgical intervention or MDT alone?
From: Grace Warren, Sidney, Australia
Dear Pieter,
Thank you for the interesting letter from Dr Sunil Ghate of Mumbai.(LML January, 9, 2015), and for including the photographs. I am glad that he has got the biopsy stating it is Borderline/tuberculoid. This indicates that the patient already has M leprae sensitised T lymphocytes, and so we can assume that the abscesses are the result of the killing of the bacilli inside the nerves. He only lists a few nerves and fortunately the ulna at the elbow is not large enough to photograph.
Yes many people recommend that the abscess needs to be opened. Fair enough if it is very large and causing pain or there is already a definite neural deficit. However, there are not many surgeons who are expert at merely opening the nerve sheath to release the pressure without damaging more of the fibres. The aim is to relieve the pressure not remove the affected nerve! It is not an easy thing to do and unfortunately most of the people whom I have seen who have had the abscess opened ( relieved) have ended up with more neural deficit and often more nerve dysfunction due to the surgical trauma. If the infection is properly controlled he will hopefully not get to much more loss of function and the nerves may become firmer and more easily palpable over the years. He will probably have many more slightly firm and enlarged nerves in years ahead. I suspect that if it is really BT this may only occur on the one arm and the disease is localised to that area alone.
I have seen many patients with a similar problem during my work in Asia. While I consider that yes he needs a full MB course of MDT I would not hit him hard at once and that is why I am rushing to answer as soon as possible. I would not give the Rifampicin initially as this rapidly kills the bacilli and I have often found that within a month of the commencement of full MTD this type of patient goes into a full reaction. Many BL/BB patients they complain that the MDT has made them worse -- and some refuse to have more MDT!! So this type of patient I commence on Clofazamine alone initially for about 3 months. Then, if not obvious signs of a reaction, add the rest of the full MDT and give the full MDT for the recommended duration. Though I often do give for longer to ensure we have the disease properly controlled.
The dose of Clofazamine depends of size of patient and severity is relevant. Regular MDT recommends 300mgs once monthly and then 50 mgs daily but when using it for treatment of reaction or initiation of treatment aiming to minimise reaction I may give 200mgs daily or 300mgs daily in a large patient. Clofazamine is bactericidal but it is also anti-inflammatory and bacteriostatic. So if a largish dose is given for say 3 months it will kill bacteria and prevent those present from multiplying and so control the infection but it will also help minimise the swelling from the inflammation. It will also help eliminate any tendency to clinical reaction. I was involved in the original drug trials of Clofazamine in the 1960s and so am sure that even given alone it will control the disease with minimum problems and reaction. If I could only have one drug to treat leprosy I would use Clofazamine. So I would suggest to stop dapsone now and increase Clofazamine and give Lots of Vit B1 and Vit C (1000mgms daily) and Magnesium, preferable a good Multivitamin and mineral with at least 10mgms Vit B1 daily. I cannot think of anything else I ought to add at present. I know this is rather a radical approach but it sure has saved many from severe reaction and similar problems, and saved much nerve function.
I probably would not do anything about the enlargement of the nerves that is present except to keep record of them. They will probably persist for a long time maybe life- but with full MDT there should be no evidence of progression of the disease.
All the best.
Grace Warren
Previously Consultant in Leprosy and Reconstructive surgery for the Leprosy Mission in Asia (1975-1994)
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
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