Leprosy Mailing List – October 21, 2013
Ref.: (LML) MB patients without clear treatment status and chronic ENL
From: Jaison Barreto, Bauru, São Paulo, Brazil
Dear Pieter,
About this cases of "eternal ENL", the view of Dr. Walker and Dr. van Brakel are well stated.
I have seen several cases of recurrent ENL in the field and inside our Institute. There are 3 conditions that must be observed by the physician:
1. In some instances, as posted by Steve, the affected patient still presents active lesions, usually lepromas, and when we take a smear FROM THE LEPROMAS (not only from index points), there are still viable (not fragmented) bacilli. In this cases, however, not always we see growth of M. leprae in mouse foot pads. I think the cause of this paradox is because the tissue of old leproma still has a huge amount of clofazimine, which is bacteriostatic.
2. Some patients have infections or parasitosis, or sometimes not controlled diabetes. All we know that not specific inflammations or stress can stimulate immune system, and be the trigger of a immunological hypersensitivity.
3. I have seen that as many as 50% of patients who suffer from recurrent ENL still have contact with MB not diagnosed, when I call the household contacts and evaluate them. As many as 80% were not, indeed, evaluated, i.e., had previous dermatological and neurological examination. Most do not live at the same house, and often do not present clearly visible patches. Many (mainly grandfather/grandmother) have previous misdiagnosis of sinusitis, rheumatism, circulatory diseases, connective tissue disease, and other conditions.
So, once LL leprosy is very difficult to diagnose, and grandfather/grandmother/brothers are not commonly called to be evaluated when they do not live with the patient, I always call all the family when I find "uncontrollable reactions". I have seen that several "uncontrolled" Type 1 or Type 2 reactions become controllable after the beginning of treatment of ALL affected persons of the family. Leprosy MUST BE SEEN AS A DISEASE INSIDE THE FAMILY.
Finally, and interestingly, we all know that when an individual is exposed to antigens which he was previously sensibilized, the natural response is hypersensitivity: PPD reaction is high in active tuberculosis, Montenegro reaction is high in cutaneous leishmaniasis, rheumatic fever can occur just after the single contact between mucosa and Streptococcus, etc. Why this situation could not possible for leprosy? If we agree that antibody production to PGL-1 can occur just because there was a single contact between M. leprae and nasal mucosa, though this does not mean disease, why a hypersensitivity reaction cannot?
Best regards,
Jaison
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
