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Ramírez-Perea N, Moran-Castaño C, Perez-Molina JA. Should prophylaxis against Pneumocystis jirovecii pneumonia be considered in selected patients with leprosy reactions? Pneumonia (Nathan) 2024; 16:6. [PMID: 38576014 PMCID: PMC10996082 DOI: 10.1186/s41479-024-00127-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 02/19/2024] [Indexed: 04/06/2024] Open
Abstract
Leprosy reactions often require prolonged high-dose steroids or immunosuppressive drugs, putting patients at risk of Pneumocystis jirovecii pneumonia (PJP). However, no PJP cases are reported, possibly due to dapsone treatment for leprosy. In patients with leprosy reactions not receiving dapsone because of toxicity or resistance and requiring long-term immunosuppression, PJP prophylaxis should be considered.
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Affiliation(s)
- Nuria Ramírez-Perea
- Internal Medicine Department, Elda University Hospital, Alicante, 03600, Spain.
| | | | - Jose A Perez-Molina
- National Referral Unit for Tropical Diseases, Infectious Diseases Department, Ramon y Cajal University Hospital, IRYCIS, Madrid, 28034, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, 28029, Spain
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2
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Sharath S, Sinha S, Sardana K, Ahuja A. Sequential occurrence of upgrading and downgrading type 1 leprosy reactions: A case report. Trop Doct 2024; 54:185-188. [PMID: 38356319 DOI: 10.1177/00494755241229754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Affiliation(s)
- Savitha Sharath
- Senior Resident, Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Surabhi Sinha
- Assistant Professor, Department of Dermatology, Venereology and Leprosy, Lady Hardinge Medical College, New Delhi, India
| | - Kabir Sardana
- Director Professor and Head of the Department, Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Arvind Ahuja
- Director Professor and Head of the Department, Department of Pathology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
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3
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Driedger M, Teo I, Roth V. Leprosy with type 1 reaction in a patient from Ontario, Canada without recent travel misdiagnosed as vasculitic neuropathy: a case report. BMC Infect Dis 2023; 23:815. [PMID: 37990293 PMCID: PMC10662535 DOI: 10.1186/s12879-023-08811-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/10/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Leprosy is rare within non-endemic countries such as Canada, where cases are almost exclusively imported from endemic regions, often presenting after an incubation period of as many as 20 years. Due to its rarity and prolonged incubation period, diagnosis is often delayed, which may result in neurologic impairment prior to the initiation of treatment. In this report we describe a case that is novel in its incubation period, which is the longest reported to-date and may have contributed to diagnostic delay. The case also uniquely demonstrates the challenges of distinguishing leprosy reactions from new rheumatologic manifestations in a patient with established autoimmune disease. CASE PRESENTATION We describe an 84-year-old male patient with rheumatoid arthritis on methotrexate and hydroxychloroquine, with no travel history outside Canada for 56 years, who presented in 2019 with new-onset paresthesias and rash. His paresthesias persisted despite a short course of prednisone, and his rash recurred after initial improvement. He underwent skin biopsy in May 2021, which eventually led to the diagnosis of leprosy. He was diagnosed with type 1 reaction and was started on rifampin, dapsone, clofazimine and prednisone, with which his rash resolved but his neurologic impairment remained. CONCLUSION This case report serves to highlight the potential for leprosy to present after markedly prolonged incubation periods. This is especially relevant in non-endemic countries that is home to an aging demographic of individuals who migrated decades ago from endemic countries. The importance of this concept is emphasized by the persistent neurologic impairment suffered by our case due to untreated type 1 reaction. We also demonstrate the necessity of skin biopsy in distinguishing this diagnosis from other autoimmune mimics in a patient with known autoimmune disease.
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Affiliation(s)
| | - Iris Teo
- University of Ottawa, Ottawa, ON, Canada
- Division of Anatomical Pathology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Virginia Roth
- University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
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4
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Cruz VA, de Albuquerque CP, Guimarães MFBDR, Dionello CDF, Ribeiro SLE, de Souza VA, Gomes CM, da Mota LMH. New insights at the interface between leprosy and immune-mediated rheumatic diseases. Front Med (Lausanne) 2023; 10:1239775. [PMID: 37822467 PMCID: PMC10564075 DOI: 10.3389/fmed.2023.1239775] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/23/2023] [Indexed: 10/13/2023] Open
Abstract
Leprosy is an infectious and contagious disease of slow evolution, triggered by Mycobacterium leprae. Arthritis is its third most common manifestation, after cutaneous and peripheral nerve involvement. Since musculoskeletal symptoms may be the initial presentation of the disease, it is important for health professionals to recognize its rheumatic manifestations for early diagnosis and appropriate treatment, especially in endemic areas. In addition, cases of leprosy have increased globally, notably in patients undergoing treatment with TNF-α blockers and due to the increase in migration and travel of people from developing countries to developed countries. This review proposes to discuss the main scenarios of mimicry of different rheumatic diseases by leprosy, as well as the role of immunosuppressive drugs used in rheumatology practice in the treatment of reactional states and in the risk of developing the infection.
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Yerke Hansen P, Myers E, Rajalingam K, Labanowski M. A Rare Case of Hansen's Disease Complicated by G6PD Deficiency. Cureus 2023; 15:e42816. [PMID: 37664264 PMCID: PMC10471196 DOI: 10.7759/cureus.42816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
We present the case of a 37-year-old Haitian male who presented with a seven-month history of skin lesions on his face and extremities, weight loss, intermittent chills, difficulty in breathing, and bilateral paresthesias in his feet. The lesions were most prominent on the pinnae of the ears. Biopsy of the lesions revealed large, rounded granulomatous infiltrates and histiocytes. Acid fast (Ziehl-Neelsen technique) and Kinyoun stains were positive for numerous acid-fast mycobacteria within the histiocytes. A polymerase chain reaction (PCR) was positive for Mycobacterium leprae, which confirmed a diagnosis of lepromatous leprosy. Further analysis revealed positive purified protein derivatives (PPD) and QuantiFERON-TB™ test (QIAGEN, Hilden, Germany) with negative chest x-ray and sputum cultures. Labs also revealed vitamin D and G6PD (glucose-6-phosphate-dehydrogenasedeficiency. The patient was started on a combined therapy regimen of rifampin, moxifloxacin, and minocycline. In addition, he was started on vitamin D supplementation. After undergoing treatment for one year, there was notable regression of the patient's cutaneous lesions. Treatment is planned to continue for a total of 24 months. This case exemplifies the successful treatment of Hansen's disease in a patient with a G6PD deficiency. The patient's G6PD deficiency required avoidance of dapsone, which is typically used in the treatment of Hansen's disease. Furthermore, the patient's positive PPD and QuantiFERON-TB tests led to a delay in the treatment in order to rule out active tuberculosis. Left untreated, Hansen's disease has a high morbidity risk. Treatment regimens require careful consideration of coexisting comorbidities.
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Affiliation(s)
- Payton Yerke Hansen
- Surgery, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Elisha Myers
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Karan Rajalingam
- Surgery, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Mary Labanowski
- Internal Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
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Petiot A, Drak Alsibai K, Dossou C, Couppie P, Blaizot R. Leprosy in French Guiana, 2015 to 2021: Dynamics of a Persistent Public Health Problem. Acta Derm Venereol 2023; 103:adv6246. [PMID: 37144514 PMCID: PMC10171089 DOI: 10.2340/actadv.v103.6246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/28/2023] [Indexed: 05/06/2023] Open
Abstract
A resurgence of leprosy as a public health problem in French Guiana was reported over the period 2007 to 2014, particularly among Brazilians gold miners. Prolonged multidrug therapy and reversal reactions represent a therapeutic challenge. The objective of this study was to assess the evolution of leprosy in this European overseas territory. All patients with leprosy confirmed in histopathology between 1 January 2015 and 31 December 2021 were included. A total of 86 patients were included, including 64 new cases and 22 previously diagnosed cases. Sixty patients (70%) were male, 6 cases were paediatric. Brazilian gold miners represented 44.1% of reported occupations (15/34). Maroons represented the second community (13 patients, 15%). Multibacillary and paucibacillary forms were found in 53 (71%) and 22 (29%) patients, respectively. The annual prevalence never exceeded the threshold of 1/10,000. The mean incidence and prevalence were significantly lower than during the period 2007 to 2014 (p < 0.0001). Reversal reactions were found in 29 patients and almost always required a long course of steroids. Infliximab allowed a reduction in the length of treatment with steroids in 2/2 cases. In conclusion, the prevalence of leprosy has decreased significantly in French Guiana, but remains driven by the population of illegal gold miners. Anti-tumour necrosis factor (anti-TNF) drugs represent a promising option in the management of reversal reactions.
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Affiliation(s)
- Aurore Petiot
- Dermatology Department, Cayenne Hospital Centre, Cayenne, French Guiana
| | - Kinan Drak Alsibai
- Histopathology and Cytology Department, Cayenne Hospital Centre, Cayenne, French Guiana
| | - Carmelita Dossou
- Dermatology Department, Cayenne Hospital Centre, Cayenne, French Guiana
| | - Pierre Couppie
- Dermatology Department, Cayenne Hospital Centre, Cayenne, French Guiana
| | - Romain Blaizot
- Dermatology Department, Cayenne Hospital Centre, Cayenne, French Guiana.
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7
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Randhawa A, Kapila R, Schwartz RA. Leprosy: what is new. Int J Dermatol 2021; 61:733-738. [PMID: 34826151 DOI: 10.1111/ijd.15998] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 12/25/2022]
Abstract
Leprosy, also known as Hansen's disease, is an age-old chronic granulomatous infection characterized by prominent cutaneous and neurologic findings. Long known to be caused by Mycobacterium leprae, a new etiologic species was identified and linked in 2008, Mycobacterium lepromatosis. The BCG vaccine with highly variable efficacy may soon be replaced by the first leprosy-specific subunit vaccine LepVax, which has recently moved forward in human trials. Recent evidence supporting theories of zoonotic transmission from armadillos and the less-discussed Eurasian red squirrels has emerged. Knowledge on genetic polymorphisms that may increase leprosy susceptibility, such as the newly uncovered mitochondrial ribosomal protein S5 (MRPS5) polymorphism in the Chinese population, has provided a fresh perspective and direction. Further, we will delineate the latest information on leprosy, including the possible effects of leprosy coinfection with COVID-19, HIV, and HTLV-1, and the shift to newer leprosy therapies and treatment regimens.
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Affiliation(s)
- Avneet Randhawa
- Rutgers University New Jersey Medical School, New Jersey Medical School, Newark, NJ, USA
| | - Rajendra Kapila
- Rutgers University New Jersey Medical School, New Jersey Medical School, Newark, NJ, USA
| | - Robert A Schwartz
- Rutgers University New Jersey Medical School, New Jersey Medical School, Newark, NJ, USA
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Mehta H, Narang T, Dogra S, Kumar B. Methotrexate in erythema nodosum leprosum: Pitfalls to avoid. Trop Doct 2021; 52:226-227. [PMID: 34787533 DOI: 10.1177/00494755211056170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We read with interest the short report by Rani et al. entitled "An uncommon variant of erythema nodosum leprosum responding well to methotrexate: Report of two cases." The article describes two cases of erythema nodosum leprosum (ENL) with 'atypical features' and good response to low dose methotrexate. The authors address a few concerns regarding methotrexate in ENL, emphasizing the rational usage of this agent.
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Affiliation(s)
- Hitaishi Mehta
- Department of Dermatology, Venereology and Leprology; 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Tarun Narang
- Department of Dermatology, Venereology and Leprology; 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology; 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhushan Kumar
- Department of Dermatology, Shalby Hospital, SAS Nagar, Punjab, India
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Hanumanthu V, Thakur V, Narang T, Dogra S. Comparison of the efficacy and safety of minocycline and clofazimine in chronic and recurrent erythema nodosum leprosum-A randomized clinical trial. Dermatol Ther 2021; 34:e15125. [PMID: 34490707 DOI: 10.1111/dth.15125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/15/2021] [Accepted: 09/04/2021] [Indexed: 11/28/2022]
Abstract
Management of chronic/recurrent erythema nodosum leprosum (ENL) is challenging. The majority of these patients become steroid-dependent and suffer from the adverse effects of long-term corticosteroid use. Minocycline has shown promising results in a small series of chronic/recurrent ENL patients. The aim of this study was to compare the efficacy and safety of minocycline and clofazimine in patients with chronic/recurrent ENL. In this prospective randomized clinical trial, 60 participants with chronic/recurrent ENL were randomized (1:1) to receive either minocycline 100 mg once daily or clofazimine 100 mg thrice daily for 12 weeks along with prednisolone according to WHO protocol and followed up for 6 months. The outcome measures were mean time for initial control of ENL, proportion of patients having a recurrence of ENL, mean time for recurrence after initial control, additional prednisolone requirement, and frequency of adverse events. Initial control of ENL was achieved earlier in the minocycline group as compared to the clofazimine group (2.97 ± 1.9 weeks vs. 4 ± 1.96 weeks, respectively; p-0.048). The number of participants having ENL flares/recurrences during the study period was comparable in both groups (71.4% in clofazimine vs. 55.2% in minocycline group; p-0.2). The participants in the minocycline group remained in remission for a longer duration after initial control of ENL as compared to the clofazimine group (p-0.001). Mean additional prednisolone dose required for control of ENL flares/recurrences was also comparable in both groups (p-0.09). The minocycline group had fewer side effects than the clofazimine group (p-0.047). Minocycline led to a rapid and sustained improvement of ENL episodes with fewer adverse events showing a superior efficacy to clofazimine.
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Affiliation(s)
- Vinod Hanumanthu
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Thakur
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Tarun Narang
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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10
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Valentin J, Drak Alsibai K, Bertin C, Couppie P, Blaizot R. Infliximab in leprosy type 1 reaction: a case report. Int J Dermatol 2021; 60:1285-1287. [PMID: 33959960 DOI: 10.1111/ijd.15645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/30/2021] [Accepted: 04/13/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Julie Valentin
- Department of Dermatology, Andrée Rosemon Hospital, Cayenne, French Guiana
| | - Kinan Drak Alsibai
- Department of Pathology, Center of Biological Resources (CRB Amazonie), Andrée Rosemon Hospital, Cayenne, French Guiana
| | - Chloe Bertin
- Department of Dermatology, Andrée Rosemon Hospital, Cayenne, French Guiana
| | - Pierre Couppie
- Department of Dermatology, Andrée Rosemon Hospital, Cayenne, French Guiana.,Tropical Biome and Immunophysiopathology (TBIP), Université de Lille, CNRS, Inserm, Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, Centre Hospitalier de Cayenne, Université de Guyane, Cayenne, French Guiana
| | - Romain Blaizot
- Department of Dermatology, Andrée Rosemon Hospital, Cayenne, French Guiana.,Tropical Biome and Immunophysiopathology (TBIP), Université de Lille, CNRS, Inserm, Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, Centre Hospitalier de Cayenne, Université de Guyane, Cayenne, French Guiana
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11
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Khadilkar SV, Patil SB, Shetty VP. Neuropathies of leprosy. J Neurol Sci 2020; 420:117288. [PMID: 33360424 DOI: 10.1016/j.jns.2020.117288] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 09/02/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
Neuropathies form an integral part of the symptomatology of leprosy. Neuropathies of leprosy take various forms and shapes. At one end is the cutaneous nerve involvement adjacent to the anaesthetic skin patch and the other is of symmetrical pansensory neuropathy and the devastating sensory ataxia of leprous ganglionits. Lepra reactions add to the spectrum. Hosts immunological status largely decides the clinical manifestations seen in nerves and skin. A wide array of diagnostic techniques like ultrasonography, magnetic resonance neurography, serological markers, molecular tests, skin biopsy and in selected cases, the nerve biopsy with special stains and electron microscopy are obtainable to help the clinical diagnosis. The unsuspecting clinician, lack of community awareness and limited availability of diagnostic tests are important adverse factors in the total outcome. Multi drug therapy is efficacious and corticosteroids reduce the impact of nerve damage in leprosy. The efficacy, dose and duration of corticosteroid therapy are presently inexact and other immune suppressants like azathioprine are being evaluated. Chronic disabilities and residual deficits require attention of multiple specialties. In the coming time, focus on prevention could lead to favourable results. This review will discuss the classification systems, common and uncommon clinical features, diagnostic armamentarium and therapeutic and preventive aspects of neuropathies of leprosy.
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12
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Saxena S, Khurana A, B S, Sardana K, Agarwal A, Muddebihal A, Raina A, Paliwal P. Severe type 2 leprosy reaction with COVID-19 with a favourable outcome despite continued use of corticosteroids and methotrexate and a hypothesis on the possible immunological consequences. Int J Infect Dis 2020; 103:549-551. [PMID: 33326870 PMCID: PMC7831392 DOI: 10.1016/j.ijid.2020.12.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 01/04/2023] Open
Abstract
Type 2 leprosy reaction (T2LR), or Erythema Nodosum Leprosum (ENL), often poses a therapeutic challenge to clinicians and commonly requires long courses of steroids for control. While immunosuppressants are known to achieve control and lower steroid dependence in T2LR, the prospect of managing a severe T2LR in conjunction with COVID-19, with the concern of worsening COVID-19 with long-term immunosuppression has not previously been encountered. We report a case of severe T2LR treated with oral steroids and methotrexate, with COVID-19 infection acquired during hospital stay, and a favourable outcome achieved despite the continued use of immunosuppressants. We discuss the possible reasons for this both in terms of the drug pharmacodynamics and the immunological profile of T2LR.
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Affiliation(s)
- Snigdha Saxena
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Ananta Khurana
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India.
| | - Savitha B
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Kabir Sardana
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Aastha Agarwal
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Aishwarya Muddebihal
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Alok Raina
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Purnima Paliwal
- Department of Pathology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
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Abdelmaksoud A, Gupta SK. Management of leprosy patients in the era of COVID-19. Dermatol Ther 2020; 33:e13631. [PMID: 32441403 PMCID: PMC7267076 DOI: 10.1111/dth.13631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 01/14/2023]
Affiliation(s)
- Ayman Abdelmaksoud
- Mansoura Dermatology, Venerology and Leprology Hospital, Mansoura, Egypt
| | - Sunil Kumar Gupta
- Department of Dermatology, Venereology and Leprosy, AIIMS, Gorakhpur, India
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