FW: (LML) ENL and pregnancy

 

Leprosy Mailing List – December 12,  2019 

Ref.:    (LML) ENL and pregnancy

From:  Arry Pongtiku, West Papua, Indonesia

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Dear Pieter,

 

Good morning.

 

Thank you to share a case of dr Ramesh Sharma (LML December 6, 2019) and comment from dr Wim (Dec 8, 2019). I would resend my comments.

I remember when I talked to dr Emmy Syamsoe, an Indonesian leprosy expert and senior dermatologists. I said to her "many doctors still underestimate leprosy cases", she replied:" they must find difficulties if they handle recurrent/chronic reaction (ENL). Leprosy cases can not be underestimated."

 

First of all, I would also say using Thalidomide is not the choice for pregnancy.  I would like to share some of my experiences.

 

I firstly learned a case of ENL in the late pregnancy in 2007, the patient with madarosis and saddle nose (late diagnosis) got severe ENL two weeks with ulceration/wound before delivery. She was very sick. She admitted to hospital for delivery baby, however, unfortunately, her baby died. I came to hospital because I hear she was not treated well and people/nurses scare of leprosy or avoided. When I visited, the wounds were opened as an attachment. She said dr Arry "I do not want to die I have two children, even I did not believe I said you will be all right. We gave her antibiotic and I teach her husband how to do wound care.

 

We gave her a milk (Pedi sure), the milk with high protein for children/elderly and suggest more acceptable. MDT continued. One dermatologist said to give prednisone/steroid, I replied: "are you sure to give steroid in open wound?". Finally did not give steroids, just Pediasure milk and MDT and antibiotic, wound care run by her husband. ----successful.  6 months after cure, her husband, wants to marry another woman and living with a woman for 2 years, eventually not allowed to marry because he is a soldier/army.  Psychological pressure and pregnancy are stress factors/triggered that should be considered.

 

I also experienced a new couple, just married and his wife got ENL reaction two years, good status/good economy, the patient felt to suicide and hopeless and her sister wanted to have her husband. She was disappointed. She was crippled and very thin, anaemia. I visited her several time at home, dental problems, anaemia have been fixed it ,  they also moved another house, I also advised to postpone pregnancy. The patient improved and getting better even in a wheelchair, she comes to the office for fingerprint. We treated them with prednisolone protocol/tapering off and high dose lamprene protocol for ENL.  However, unexpectedly she was pregnant, she got severe ENL reaction during pregnancy, we have treated them again. She successfully delivered a baby with Sectio Cesaria, her baby girl name "Miracle", 6 months later I hear the patient died.  The baby grows well.

So phycological stress and pregnancy for leprosy patients should be considered it is a double stress.

 

I also found two reversal reaction cases of new leprosy detected during late pregnancy. We gave her MDT and prednisolone. They were more settled after delivery.

 

Pregnancy is a trigger factor of Reaction. MDT treatment make leprosy bacteria detached/ granular follow to a systemic blood circulation might be recognized as foreign bodies, may be a trigger factor of reaction.

 

Conclusions:

 

-We must consider any triggering factor of leprosy reaction.

-ENL protocol: prednisolone tapering off and high dose lamprene. Suggest prednisolone schedule make it shorter than RR protocol.

- Protocol for special cases must be established, for such ENL during pregnancy, leprosy and AIDS patients not infrequently we find in the field must have Standard Protocol

 

Thanks, dr Rames Sharma we pray for wisdom and for your case.

 

Salam,

Arry Pongtiku,MD, MHM, PhD

former Indonesia Leprosy National Adviser /NLR

 

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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.co

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