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Erythema Nodosum Leprosum-Like Lesions Are a Histopathologic Pattern in Whipple's Disease and a Sign of the Immune Reconstitution Inflammatory Syndrome: A Case Series and Review of the Literature. Am J Dermatopathol 2017; 39:259-266. [PMID: 28098596 DOI: 10.1097/dad.0000000000000641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Inflammatory and subcutaneous nodules can arise in treated and untreated cases of Whipple disease (WD). The inflammatory immune reconstitution syndrome describes paradoxical clinical inflammatory worsening of a preexisting condition because of a return of immune function. Clinicopathologic examination of 4 patients with WD who presented with erythema nodosum leprosum (ENL)-like lesions and the findings of a systematic review of this phenomenon revealed that ENL-like lesions occurred in predominantly middle-aged male patients who suffered from WD, mostly on the legs. Patients showed a nonvasculitic, mostly septal panniculits with neutrophils, macrophages, and lymphocytes. Numerous bacteria-laden periodic acid-Schiff + macrophages and free bacilli were detected in the dermis, as well as subcutaneous septae and adipose lobules. These lesions occurred in both untreated and treated patients as part of inflammatory immune reconstitution syndrome. In conclusion, ENL-like lesions represent a characteristic histopathologic pattern associated with WD, which can occur in different contexts whenever there is a change in the immunological status of the patient. This change can be triggered by antimicrobial treatment, immunomodulatory and immunosuppressant therapy, or occur spontaneously, rarely.
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Pires CAA, Jucá Neto FOM, de Albuquerque NC, Macedo GMM, Batista KDNM, Xavier MB. Leprosy Reactions in Patients Coinfected with HIV: Clinical Aspects and Outcomes in Two Comparative Cohorts in the Amazon Region, Brazil. PLoS Negl Trop Dis 2015; 9:e0003818. [PMID: 26029928 PMCID: PMC4451982 DOI: 10.1371/journal.pntd.0003818] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 05/06/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Leprosy, caused by Mycobacterium leprae, can lead to scarring and deformities. Human immunodeficiency virus (HIV), a lymphotropic virus with high rates of replication, leads to cell death in various stages of infection. These diseases have major social and quality of life costs, and although the relevance of their comorbidity is recognized, several aspects are still not fully understood. METHODOLOGY/PRINCIPAL FINDINGS Two cohorts of patients with leprosy in an endemic region of the Amazon were observed. We compared 40 patients with leprosy and HIV (Group 1) and 107 leprosy patients with no comorbidity (Group 2) for a minimum of 2 years. Group 1 predominantly experienced the paucibacillary classification, accounting for 70% of cases, whereas Group 2 primarily experienced the multibacillary classification (80.4% of cases). There was no significant difference in the prevalence of leprosy reactions among the two groups (37.5% for Group 1 vs. 56.1% for Group 2), and the most frequent reaction was Type 1. The appearance of Group 1 patients' reversal reaction skin lesions was consistent with each clinical form: typically erythematous and infiltrated, with similar progression as those patients without HIV, which responded to prednisone. Patients in both groups primarily experienced a single episode (73.3% in Group 1 and 75% in Group 2), and Group 1 had shorter reaction periods (≤3 months; 93.3%), moderate severity (80%), with 93.3% of the patients in the state of acquired immune deficiency syndrome, and 46.7% presenting the reaction at the time of the immune reconstitution inflammatory syndrome. CONCLUSIONS/SIGNIFICANCE This study used a large sample and makes a significant contribution to the clinical outcomes of patients in the reactive state with comorbid HIV and leprosy. The data indicate that these diseases, although concurrent, have independent courses.
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Affiliation(s)
- Carla Andréa Avelar Pires
- Department of Dermatology, Division of Tropical Skin Diseases, Section of Leprosy, Universidade Federal do Pará, Belém, Pará, Brazil
- Department of Dermatology, Division of Tropical Skin Diseases, Section of Leprosy, Universidade do Estado do Pará, Belém, Pará, Brazil
| | | | - Nahima Castelo de Albuquerque
- Department of Infectious Diseases, Division of Tropical Diseases, Section of Leprosy, Universidade Federal do Pará, Belém, Pará, Brazil
| | - Geraldo Mariano Moraes Macedo
- Department of Infectious Diseases, Division of Tropical Diseases, Section of Epidemiological Vigilance, Universidade Federal do Pará, Belém, Pará, Brazil
| | - Keila de Nazaré Madureira Batista
- Department of Infectious Diseases, Division of Tropical Diseases, Section of Leprosy, Universidade Federal do Pará, Belém, Pará, Brazil
| | - Marília Brasil Xavier
- Department of Dermatology, Division of Tropical Skin Diseases, Section of Leprosy, Universidade Federal do Pará, Belém, Pará, Brazil
- Department of Dermatology, Division of Tropical Skin Diseases, Section of Leprosy, Universidade do Estado do Pará, Belém, Pará, Brazil
- Department of Infectious Diseases, Division of Tropical Diseases, Section of Leprosy, Universidade Federal do Pará, Belém, Pará, Brazil
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Arakkal GK, Damarla SV, Chanda GM. Immune reconstitution inflammatory syndrome unmasking erythema nodosum leprosum: a rare case report. Indian J Dermatol 2015; 60:106. [PMID: 25657440 PMCID: PMC4318046 DOI: 10.4103/0019-5154.147883] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) occurs as an acute symptomatic expression of a latent infection during the recovery of immune system in response to antiretroviral therapy in HIV patients. IRIS triggers both opportunistic and non-opportunistic infections. We report a case of IRIS in a patient with HIV, presenting as erythema nodosum leprosum (ENL), which led to unmasking of lepromatous leprosy following anti-retroviral therapy (ART).
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Affiliation(s)
- Geeta Kiran Arakkal
- Department of Dermatology, Venereology and Leprosy, Gandhi Medical College, Secunderabad, Andhra Pradesh, India
| | - Sudha Vani Damarla
- Department of Dermatology, Venereology and Leprosy, Gandhi Medical College, Secunderabad, Andhra Pradesh, India
| | - Geetha Madhuri Chanda
- Department of Dermatology, Venereology and Leprosy, Gandhi Medical College, Secunderabad, Andhra Pradesh, India
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Lsr2 of Mycobacterium leprae and its synthetic peptides elicit restitution of T cell responses in erythema nodosum leprosum and reversal reactions in patients with lepromatous leprosy. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2013; 20:673-82. [PMID: 23446220 DOI: 10.1128/cvi.00762-12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The Lsr2 protein of Mycobacterium leprae and its synthetic peptides have been shown to elicit lymphoproliferation and gamma interferon (IFN-γ) release by peripheral blood mononuclear cells (PBMCs) of patients with lepromatous leprosy (M. Chaduvula, A. Murtaza, N. Misra, N. P. Narayan, V. Ramesh, H. K. Prasad, R. Rani, R. K. Chinnadurai, I. Nath, Infect. Immun. 80:742-752, 2012). PBMCs from 16 patients with lepromatous leprosy who were undergoing erythema nodosum leprosum (ENL) (type 2) and 5 patients with reversal reactions (RR) (type 1) were stimulated with M. leprae, recombinant Lsr2, and six end-to-end synthetic peptides (A through F) spanning the Lsr2 sequence. During the reaction all patients with ENL showed lymphoproliferation (stimulation index, >2) in response to peptides A and F, with other peptides eliciting responses in 75 to 88% of the subjects. In PBMC cultures, both lymphoproliferation and IFN-γ release for peptide E were significantly higher than for peptides B and C and recombinant Lsr2 (P < 0.05, Wilcoxon signed-rank test). Five patients with RR also showed enhanced lymphoproliferative responses and IFN-γ release in response to Lsr2, M. leprae, and peptide E. Six months postreaction, 14 patients with ENL continued to exhibit responses to Lsr2 and its peptides, with the highest responses being elicited by peptide E. However, 5 subjects showed no lymphoproliferation and had reduced IFN-γ release in response to Lsr2 peptides (P < 0.001, Kruskal-Wallis test) but responded to recombinant Lsr2. Six patients with ENL had HLA-A*68.01, which the STFPEITHI program showed to have high peptide-binding scores of 20 to 21 for peptides E, B, and C. Eleven patients had HLA-DRB1*1501 and HLA-DRB1*1502, which had high binding scores for peptides C and E. Thus, Lsr2 and its peptides are recognized in leprosy reactions during and well after the subsidence of clinical signs.
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