FW: (LML) MB-patient from Guinea

 

Leprosy Mailing List – October 5 ,  2019

Ref.:    (LML) MB-patient from Guinea 

From:  Francisco Almeida, Recifi, Brazil

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Dear Dr. Pieter,

I appreciate the case report posted by the Dr. Strahm, and would like to share my experience with similar case reports.

This patient did not receive sufficient doses of MDT-MB treatment. In his history, was reported that he received MDT-MB during the period from 2017 to 2018, therefore, with treatment discontinued after 12 doses of treatment. Anergic and bacilliferous cases do not cure with 12 doses of MDT-MB. Often not with 24 doses.

I have several cases similar to yours that required specific multidrug therapy for much longer than WHO recommendations. In some situations, these patients only started to improve after changing the treatment regimen using secondary drugs. Even with negative drug resistance research for commonly tested gene loci (folp1, rpoB and Gyr-A) conducted after 24 doses of MDT-MB treatment.

The images show several areas still with tubercles and infiltrations, clearly demonstrating active disease. The intensity of leprosy reactions may become more severe after a course of treatment due to the partial recovery of immunocellular immunity promoted by the specific treatment, especially when the patient is not yet fully healed.

Apparently, this patient should be classified as subpolar lepromatous (BL) and in this case, both type 1 leprosy reactions (reversal reactions) and type 2 leprosy reactions (erythema nodosum leprosum) may occur simultaneously. The images show subcutaneous nodules in the legs and extensive ulcerated areas in the skin, which may also represent a severe type 1 reverse reaction.

I agree with the position of colleagues regarding the identification of triggers for the occurrence of leprosy reactions, as well as the use of anti-helmintics and the investigation of comorbidities, but in this case, is necessary, in addition to the management of the leprosy reaction, to restart the disease specific treatment. Either with the use of MDT-MB or with the use of secondary drugs (preferably, in principle additional MDT-MB).

The ulcerated lesions should be conducted with conventional antibiotic therapy and local care, as is already being done.

Although the initial bacilloscopic index (BI) declines after 12 doses of MDT-MB, in this patient profile, very often these indices may slowly rise again. On the other hand, not! Because there are also patients who have leprosy's relapses only in its neural form.

Finally, I remind the Doctor, that reverse reactions can drastically affect the peripheral nervous system, and if the patient experiences worsening of his neural function associated with the reaction episode, he will need the use of systemic corticotherapy for neural damage be minimized. I do not know if the doctor has thalidomide in your country. If so, the drug should also be associated with the treatment regimen for this leprosy reaction. If not, alternatively pentoxifylline, 1200mg / day, or clofazimine may be used as previously mentioned.

Best Regards,

Francisco Almeida.

 

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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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