Leprosy Mailing List – March 26, 2023
Ref.: (LML) Are we against reducing the risk of painful ENL neuritis?
From: Joel Almeida, Mumbai, India
Dear Pieter & colleagues,
The pain of ENL is often severe. Sometimes severe enough to drive patients to the verge of suicide. Data can be analysed carefully for clues on how to reduce the risk of ENL.
One report compared 58 LL patients given one-year MDT to 139 LL patients given two-year MDT.(1) Patients with signs of "reaction" were examined weekly or fortnightly. Neuritis was defined as pain associated with swelling and tenderness of a nerve.
The Incidence Rate Ratio of ENL neuritis can be compared between the one-year and two-year MDT groups, specifically for the months 13 to 24 after the start of MDT. Months 13 to 24 is the period during which one group received MDT and the other did not.
A 600% increase in the risk of ENL with neuritis can be seen during this period in the one-year MDT group. Withdrawing MDT after 12 months appears to have been followed by a vast increase in the risk of ENL neuritis during months 13 to 24.
The Figure. Withdrawing MDT after 12 months appears to have allowed a vast increase in the risk of ENL neuritis during months 13 to 24
Corroborating evidence comes from other reports. Anti-microbial treatment had a marked effect on ENL signs and symptoms even when a range of anti-inflammatory or immunomodulatory drugs did not work.(2-4)
Continuing anti-microbial protection of LL patients beyond 12 months of MDT, and including anti-microbials in the treatment of ENL, seem necessary. Many colleagues in endemic areas do this already. They are serving their patients and populations well.
Are we really against reducing the risk of painful ENL neuritis?
Joel Almeida
References
1. Balagon MVF, Gelber RH, Abalos RM, Cellona RV. Reactions following completion of 1 and 2 year multidrug therapy (MDT) Am J Trop Med Hyg 2010 Sep;83(3):637-44. doi: 10.4269/ajtmh.2010.09-0586
2. Lastoria JC, deAlmeida TSC, Putlinatti MSdMA, Padovani CR. Effectiveness of the retreatment of patients with multibacillary leprosy and episodes of erythema nodosum leprosum and/or persistent neuritis: a single-center experience An Bras Dermatol. 2018 Mar-Apr; 93(2): 181–184. doi: 10.1590/abd1806-4841.20185387
3. Narang T, Bishnoi A, Dogra S et al. Alternate Anti-Leprosy Regimen for Multidrug Therapy Refractory Leprosy: A Retrospective Study from a Tertiary Care Center in North India . Am J Trop Med Hyg. 2019 Jan; 100(1): 24–30. doi: 10.4269/ajtmh.18-0256
4. Narang T, Sawatkar GU, Kumaran MS, Dogra S. Minocycline for Recurrent and/or Chronic Erythema Nodosum Leprosum JAMA Dermatol 2015 Sep;151(9):1026-8. doi: 10.1001/jamadermatol.2015.0384.
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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