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Dos Santos LS, Souza LB, Goulart IMB, Drummond MR, Velho PENF. Bartonella henselae DNA detection in patients with type 1 leprosy reactions for more than six months. Braz J Infect Dis 2024; 28:103743. [PMID: 38697215 PMCID: PMC11126756 DOI: 10.1016/j.bjid.2024.103743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/28/2024] [Accepted: 04/14/2024] [Indexed: 05/04/2024] Open
Abstract
Leprosy reactions are among the main causes of physical disability resulting from an infectious disease and can culminate in irreversible physical disabilities, therefore they should be considered a clinical emergency, as well as the elucidation of its cause. Co-infections are considered one of the main triggering causes of leprosy reactions, aggravating and maintaining these reactions for longer in these patients. After reporting a high rate of Bartonella henselae infection in patients with chronic type 2 leprosy reaction, 19/47 (40.4 %) compared to the control group, 9/50 (18.0 %), p = 0.0149, we conducted this study to observe the rate of infection by Bartonella sp. in a group of patients with chronic type 1 leprosy reactions. Blood samples from 14 patients with chronic type 1 leprosy reactions were analyzed by molecular and microbiological tests and compared. The results showed that, like patients with chronic type 2 leprosy reactions, this group of patients has a high proportion of B. henselae infection 6/14 (42.9 %), p = 0.88. We conclude that these bacteria can trigger chronic leprosy reactions and should be investigated in all chronic leprosy reactions patients. Summary Line: Our results showed that, like patients with chronic type 2 leprosy reactions, this group of patients has the same proportion of B. henselae DNA detection 6/14 (42.9 %), p = 0.88.
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Affiliation(s)
- Luciene Silva Dos Santos
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Laboratório de Pesquisa Aplicada em Dermatologia e Infecção por Bartonella, Campinas, SP, Brazil.
| | - Lais Bomediano Souza
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Departamento de Medicina, Campinas, São Paulo, SP, Brasil
| | | | - Marina Rovani Drummond
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Laboratório de Pesquisa Aplicada em Dermatologia e Infecção por Bartonella, Campinas, SP, Brazil
| | - Paulo Eduardo Neves Ferreira Velho
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Laboratório de Pesquisa Aplicada em Dermatologia e Infecção por Bartonella, Campinas, SP, Brazil; Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Medicina, Divisão de Dermatologia, Campinas, SP, Brazil
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2
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Yang J, Kong J, Li B, Ji Z, Liu A, Chen J, Liu M, Fan Y, Peng L, Song J, Wu X, Gao L, Ma W, Dong Y, Luo S, Bao F. Seventy years of evidence on the efficacy and safety of drugs for treating leprosy: a network meta-analysis. J Infect 2023; 86:338-351. [PMID: 36796681 DOI: 10.1016/j.jinf.2023.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/09/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE The World Health Organization (WHO) recommends multidrug therapy (MDT) with rifampicin, dapsone, and clofazimine for treating leprosy, which is based on very low-quality evidence. Here, we performed a network meta-analysis (NMA) to produce quantitative evidence to strengthen current WHO recommendations. METHOD All studies were obtained from Embase and PubMed from the date of establishment to October 9, 2021. Data were synthesized with frequentist random-effects network meta-analyses. Outcomes were assessed using odds ratios (ORs), 95% confidence intervals (95% CIs), and P score. RESULTS Sixty controlled clinical trials and 9256 patients were included. MDT was effective (range of OR: 1.06-1255584.25) for treating leprosy and multibacillary leprosy. Six treatments (Range of OR: 1.199-4.50) were more effective than MDT. Clofazimine (P score=0.9141) and dapsone+rifampicin (P score=0.8785) were effective for treating type 2 leprosy reaction. There were no significant differences in the safety of any of the tested drug regimens. CONCLUSIONS The WHO MDT is effective for treating leprosy and multibacillary leprosy, but it may not be effective enough. Pefloxacin and ofloxacin may be good adjunct drugs for increasing MDT efficacy. Clofazimine and dapsone+rifampicin can be used in the treatment of a type 2 leprosy reaction. Single-drug regimens are not efficient enough to treat leprosy, multibacillary leprosy, or a type 2 leprosy reaction. AVAILABILITY OF DATA AND MATERIALS All data generated or analyzed during this study are included in this published article [and its supplementary information files].
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Affiliation(s)
- Jiaru Yang
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China; Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC 3800, Australia
| | - Jing Kong
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Bingxue Li
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Zhenhua Ji
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China; The Institute of Oncology, Yunnan Cancer Hospital, Kunming Medical University, Kunming 650100, Yunnan, China
| | - Aihua Liu
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China; Yunnan Province Key Laboratory of Children's Major Diseases Research, The Affiliated Children Hospital, Kunming Medical University, Kunming 650030, Yunnan, China.
| | - Jingjing Chen
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Meixiao Liu
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Yuxin Fan
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Li Peng
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Jieqin Song
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Xinya Wu
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Li Gao
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Weijiang Ma
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Yan Dong
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Suyi Luo
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China
| | - Fukai Bao
- Evidence-Based Medicine Team, The Institute for Tropical Medicine, Kunming Medical University, Kunming 650500, Yunnan, China; Yunnan Province Key Laboratory of Children's Major Diseases Research, The Affiliated Children Hospital, Kunming Medical University, Kunming 650030, Yunnan, China.
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3
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Mulugeta SS, Maseresha BM, Wassihun SG, Moyehodie YA. Risk Factors for Disability Upgrading Among Leprosy Patients During Treatment: Multilevel Modeling Analysis. SAGE Open Nurs 2022; 8:23779608221129936. [PMID: 36238938 PMCID: PMC9551338 DOI: 10.1177/23779608221129936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background Leprosy not only brings about bodily incapacity but also creates a nasty image of affected individuals, triggering discrimination and social stigma. The purpose of this study was to evaluate the status of leprosy disability in patients registered at the All African TB and Leprosy Rehabilitation and Training Center. Methods The study consists of 205 leprosy patients who were undergoing treatment at the All African TB and Leprosy Rehabilitation and Training Center from January 2015 to December 2019. Regional states of the patients were used as a clustering effect in the multilevel logistic regression model. Results In total, 205 (66.3%) completed records revealed patients with leprosy were disabled. Among these, 64.88% of them were males. In multilevel binary logistic regression analysis, the individual-level variables, such as median age (AOR = 1.1; 95% CI: 1.043, 1.13) of patients, patients with duration of symptom [7-12 months (AOR = 2.26; 95% CI: 1.50, 3.39), 13-24 months (AOR = 2.13; 95% CI: 1.44, 3.15), and more than 24 months (AOR = 2.67; 95% CI: 1.8, 4.02)], the absence of sensory loss (AOR = 0.84; 95% CI: 0.72, 0.96), and patients with asymmetry lesion distribution (AOR = 0.74; 95% CI: 0.65, 0.85), were the most significant determinant factors of disability. The default leprosy patient (AOR = 15.53; 95% CI: 1.82, 134.96) and new leprosy patient (AOR = 0.51; 95% CI: 0.33, 1.68) were the significant determinant factors of disability due to leprosy patients. Conclusion An individual-level factor on the risk of disability was higher as age increased and for patients with a longer duration of symptoms. The risk of disability was lower for patients who do not lose their sensation and for patients whose lesion distribution is asymmetrical. The community-level factor, patient categories, was also a significant factor in disability due to leprosy. Furthermore, programs should emphasize raising community awareness, focusing on key messages and early case detection campaigns, such as active surveys, as well as the availability of leprosy care in a public health facility.
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Affiliation(s)
- Solomon Sisay Mulugeta
- Department of Statistics, College of Natural and Computational
Sciences, Debre Tabor
University, Debre Tabor, Amhara,
Ethiopia,Solomon Sisay Mulugeta, Department of
Statistics, College of Natural and Computational Sciences, Debre Tabor
university, P.O. BOX. 272, Debre Tabor, Amhara, Ethiopia. E.mail:
| | - Bezanesh Melese Maseresha
- Department of Statistics, College of Natural and Computational
Sciences, Debre Tabor
University, Debre Tabor, Amhara,
Ethiopia
| | - Selamawit Getachew Wassihun
- Department of Statistics, College of Natural and Computational
Sciences, Mekdela Amba University, Debre Tabor, Amhara, Ethiopia
| | - Yikeber Abebaw Moyehodie
- Department of Statistics, College of Natural and Computational
Sciences, Debre Tabor
University, Debre Tabor, Amhara,
Ethiopia
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4
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Abstract
Neuropathy and related disabilities are the major medical consequences of leprosy, which remains a global medical concern. Despite major advances in understanding the mechanisms of M. leprae entry into peripheral nerves, most aspects of the pathogenesis of leprosy neuropathy remain poorly understood. Sensory loss is characteristic of leprosy, but neuropathic pain is sometimes observed. Effective anti-microbial therapy is available, but neuropathy remains a problem especially if diagnosis and treatment are delayed. Currently there is intense interest in post-exposure prophylaxis with single-dose rifampin in endemic areas, as well as with enhanced prophylactic regimens in some situations. Some degree of nerve involvement is seen in all cases and neuritis may occur in the absence of leprosy reactions, but acute neuritis commonly accompanies both Type 1 and Type 2 leprosy reactions and may be difficult to manage. A variety of established as well as new methods for the early diagnosis and assessment of leprosy neuropathy are reviewed. Corticosteroids offer the primary treatment for neuritis and for subclinical neuropathy in leprosy, but success is limited if nerve function impairment is present at the time of diagnosis. A candidate vaccine has shown apparent benefit in preventing nerve injury in the armadillo model. The development of new therapeutics for leprosy neuropathy is greatly needed.
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Affiliation(s)
- Gigi J Ebenezer
- Neurology/Cutaneous Nerve Laboratory, Johns Hopkins University, The John G Rangos Bldg, room: 440, 855 North Wolfe Street, Baltimore, MD, 21205, USA.
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Barcelos RMFM, Sousa GSD, Almeida MVD, Palacio FGL, Gaíva MAM, Ferreira SMB. Leprosy patients quality of life: a scoping review. Rev Esc Enferm USP 2021; 55:e20200357. [PMID: 34495209 DOI: 10.1590/1980-220x-reeusp-2020-0357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 05/18/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To explore the scientific evidence regarding the leprosy patients quality of life. METHOD Scoping review according to the Joanna Briggs Institute methodology, with articles indexed in PubMed, Cochrane, LILACS, Embase, CINAHL, Scopus, Web of Science, PsyINFO, INFOLEP, and Google Scholar databases, published in full in Portuguese, English, or Spanish. RESULTS Seventy-four studies were identified, with 71 of quantitative approach and 3 with a mixed method. There was a predominance of studies published in Brazil (58.1%), with an adult population, (97.3%) and recruited in reference centers for the treatment of leprosy (52.7%). There was greater use of the WHOQOL-bref (50%) and SF-36 (18.9%) instruments to assess quality of life. The study showed that the greatest impairment in quality of life was related to the delay in the diagnosis of the disease, to leprosy reactions, physical disabilities, neuropathic pain, and stigma. CONCLUSION Most studies were developed in endemic countries, with adults, and based on observational studies, and the worst scores obtained were associated with physical domain impairment.
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de Barros B, Lambert SM, Negera E, de Arquer GR, Sales AM, Darlong J, Dias VLA, Rozario BJ, Pai VV, Alinda MD, Listiawan MY, Hagge DA, Shah M, Lockwood DNJ, Walker SL. An assessment of the reported impact of the COVID-19 pandemic on leprosy services using an online survey of practitioners in leprosy referral centres. Trans R Soc Trop Med Hyg 2021; 115:1456-1461. [PMID: 34077950 PMCID: PMC8195135 DOI: 10.1093/trstmh/trab084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/15/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic has led to governments implementing a variety of public health measures to control transmission and has affected health services. Leprosy is a communicable neglected tropical disease caused by Mycobacterium leprae and is an important health problem in low- and middle-income countries. The natural history of leprosy means that affected individuals need long-term follow-up. The measures recommended to reduce transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can create barriers to health services. We evaluated the impact of the COVID-19 epidemic response on leprosy services and disease management. Methods We conducted a cross-sectional online survey with healthcare professionals in leprosy referral centres. Results Eighty percent of leprosy diagnostic services were reduced. All respondents reported that multidrug therapy (MDT) was available but two reported a reduced stock. Clinicians used alternative strategies such as telephone consultations to maintain contact with patients. However, patients were not able to travel to the referral centres. Discussion This study highlights the effects of the initial phase of the SARS-CoV-2 pandemic on leprosy services in a range of leprosy-endemic countries. Many services remained open, providing leprosy diagnosis, MDT and leprosy reaction medications. Centres developed innovative measures to counter the negative impacts of the COVID-19 pandemic.
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Affiliation(s)
- Barbara de Barros
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Saba M Lambert
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK.,Department of Dermatology, ALERT Center, Addis Ababa, Ethiopia
| | - Edessa Negera
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Anna M Sales
- Leprosy Laboratory, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, Brazil
| | | | - Vivianne L A Dias
- Leprosy Laboratory, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, Brazil
| | | | | | - Medhi Denisa Alinda
- Department of Dermatology and Venereology, Faculty of Medicine Universitas Airlangga, Dr Soetomo Teaching Hospital, Surabaya, Indonesia
| | - M Yulianto Listiawan
- Department of Dermatology and Venereology, Faculty of Medicine Universitas Airlangga, Dr Soetomo Teaching Hospital, Surabaya, Indonesia
| | - Deanna A Hagge
- Department of Dermatology and Mycobacterial Research Laboratories, Leprosy Mission Nepal, Anandaban Hospital, Kathmandu, Nepal
| | - Mahesh Shah
- Department of Dermatology and Mycobacterial Research Laboratories, Leprosy Mission Nepal, Anandaban Hospital, Kathmandu, Nepal
| | - Diana N J Lockwood
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephen L Walker
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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7
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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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8
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Nanjan Chandran SL, Tiwari A, Lustosa AA, Demir B, Bowers B, Albuquerque RGR, Prado RBR, Lambert S, Watanabe H, Haagsma J, Richardus JH. Revised estimates of leprosy disability weights for assessing the global burden of disease: A systematic review and individual patient data meta-analysis. PLoS Negl Trop Dis 2021; 15:e0009209. [PMID: 33651814 PMCID: PMC7954345 DOI: 10.1371/journal.pntd.0009209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/12/2021] [Accepted: 02/05/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Leprosy is a chronic bacterial infection caused by Mycobacterium leprae, which may lead to physical disability, stigma, and discrimination. The chronicity of the disease and disabilities are the prime contributors to the disease burden of leprosy. The current figures of the disease burden in the 2017 global burden of disease study, however, are considered to be under-estimated. In this study, we aimed to systematically review the literature and perform individual patient data meta-analysis to estimate new disability weights for leprosy, using Health-Related Quality of Life (HRQOL) data. METHODOLOGY/PRINCIPAL FINDINGS The search strategy included all major databases with no restriction on language, setting, study design, or year of publication. Studies on human populations that have been affected by leprosy and recorded the HRQOL with the Short form tool, were included. A consortium was formed with authors who could share the anonymous individual-level data of their study. Mean disability weight estimates, sorted by the grade of leprosy disability as defined by WHO, were estimated for individual participant data and pooled using multivariate random-effects meta-analysis. Eight out of 14 studies from the review were included in the meta-analysis due to the availability of individual-level data (667 individuals). The overall estimated disability weight for grade 2 disability was 0.26 (95%CI: 0.18-0.34). For grade 1 disability the estimated weight was 0.19 (95%CI: 0.13-0.26) and for grade 0 disability it was 0.13 (95%CI: 0.06-0.19). The revised disability weight for grade 2 leprosy disability is four times higher than the published GBD 2017 weights for leprosy and the grade 1 disability weight is nearly twenty times higher. CONCLUSIONS/SIGNIFICANCE The global burden of leprosy is grossly underestimated. Revision of the current disability weights and inclusion of disability caused in individuals with grade 0 leprosy disability will contribute towards a more precise estimation of the global burden of leprosy.
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Affiliation(s)
- Shri Lak Nanjan Chandran
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anuj Tiwari
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Betul Demir
- Department of Dermatology, Firat University Hospital, Elazig, Turkey
| | - Bob Bowers
- The Leprosy Mission International- Bangladesh, Dhaka, Bangladesh
| | | | | | - Saba Lambert
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Juanita Haagsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan Hendrik Richardus
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- * E-mail:
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9
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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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10
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Perez-Molina JA, Arce-Garcia O, Chamorro-Tojeiro S, Norman F, Monge-Maillo B, Comeche B, Lopez-Velez R. Use of methotrexate for leprosy reactions. Experience of a referral center and systematic review of the literature. Travel Med Infect Dis 2020; 37:101670. [PMID: 32302727 DOI: 10.1016/j.tmaid.2020.101670] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 04/06/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Patients with leprosy can present with systemic inflammatory complications called leprosy reactions (LR), which can be severe and cause a loss of nerve function. The treatment of choice is prolonged corticosteroid therapy, frequently associated with severe side effects. We have used methotrexate as a corticosteroid-sparing regimen with good results. METHODS To evaluate the role of methotrexate in managing LR, we performed a systematic review of the literature including our cases. We evaluated studies, prospective and retrospective, in both adults and children, which included any dose/regimen of methotrexate for the treatment of LR type 1 or 2. RESULTS The systematic search revealed 261 records that yield 21 patients including our 3 cases (19 adults/two children), who were treated with methotrexate for LR type 1 and 2. There were 14 males. Median age was 35 years (P25-P75 28 to 52). Patients showed lepromatous (7), borderline lepromatous (9) or borderline tuberculoid (3) leprosy, among the 19 cases in which the type of leprosy was specified. As for the type of LR, 15 patients showed erythema nodosum leprosum (ENL), five showed LR type 1 and one showed polyarthritis and previous ENL. Methotrexate at weekly doses ranging from 7.5 mg to 20 mg (median 15 mg per week), typically administered with low-dose corticosteroids, was effective and safe as a corticosteroid-sparing agent. CONCLUSIONS Methotrexate could be a suitable ancillary treatment or alternative to corticosteroids, especially in populations who are more prone to its adverse events. However, this evidence is based only on case reports and short clinical series.
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Affiliation(s)
- Jose A Perez-Molina
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.
| | - Octavio Arce-Garcia
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Sandra Chamorro-Tojeiro
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Francesca Norman
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Begoña Monge-Maillo
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Belén Comeche
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Rogelio Lopez-Velez
- National Referral Centre for Tropical Diseases, Infectious Diseases Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
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11
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Maymone MBC, Venkatesh S, Laughter M, Abdat R, Hugh J, Dacso MM, Rao PN, Stryjewska BM, Dunnick CA, Dellavalle RP. Leprosy: Treatment and management of complications. J Am Acad Dermatol 2020; 83:17-30. [PMID: 32244016 DOI: 10.1016/j.jaad.2019.10.138] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 01/25/2023]
Abstract
In the second article in this continuing medical education series, we review the treatment of leprosy, its immunologic reactions, and important concepts, including disease relapse and drug resistance. A fundamental understanding of the treatment options and management of neuropathic sequelae are essential to reduce disease burden and improve patients' quality of life.
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Affiliation(s)
- Mayra B C Maymone
- Department of Dermatology, University of Colorado School of Medicine, Denver, Colorado
| | - Samantha Venkatesh
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Melissa Laughter
- Department of Dermatology, University of Colorado School of Medicine, Denver, Colorado
| | - Rana Abdat
- Department of Dermatology, Tufts Medical Center, Boston, Massachusetts
| | - Jeremy Hugh
- Department of Dermatology, University of Colorado School of Medicine, Denver, Colorado
| | - Mara M Dacso
- National Hansen's (Leprosy) Disease Program, Baton Rouge, Louisiana; University of Texas Southwestern Medical Center, Dallas, Texas
| | - P Narasimha Rao
- Special Interest Group on Leprosy, Indian Association of Dermatologists, Venereologists and Leprologists, Delhi, India
| | | | - Cory A Dunnick
- Department of Dermatology, University of Colorado School of Medicine, Denver, Colorado
| | - Robert P Dellavalle
- Department of Dermatology, University of Colorado School of Medicine, Denver, Colorado.
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12
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Glucocorticoids in Leprosy Reversal reaction. SERBIAN JOURNAL OF DERMATOLOGY AND VENEREOLOGY 2020. [DOI: 10.2478/sjdv-2019-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Leprosy is a disease that is caused by Mycobacterium leprae which results in lots of disabilities in the patients. Leprosy is treated by multi-drug therapy regimen; however, this therapy might cause leprosy reactions in the patients. There are several types of lepromatous reaction: type 1 reaction, type 2 reaction and neuritis. Type 1 reaction mainly occurs in BB, BL and BT forms of leprosy and is characterized by exacerbation of preexisting lesions. The therapy of this reaction according to the WHO guideline is corticosteroid therapy. This article will explain several key points related to the corticosteroid therapy in leprosy reversal reactions, including the side effects and alternative therapies available.
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13
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Guimenes Albuquerque R, Grüdtner Buratto G, Hirotsu C, Maeda SM, Floriano MC, Levy Andersen M, Tufik S, Tomimori J. Comparison of quality of life evaluated by SF-36 and DLQI in multibacillary and paucibacillary leprosy patients from Sao Paulo, Brazil. Int J Dermatol 2019; 58:1415-1422. [PMID: 31148144 DOI: 10.1111/ijd.14489] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 04/07/2019] [Accepted: 04/25/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Dermatological diseases have a negative impact on quality of life (QoL), affecting mental and physical health. Leprosy patients usually present with a worse QoL compared with those affected by other conditions. Reactions, neural damage, and pain are some of the consequences that contribute to the lower QoL. However, due to the wide spectrum of the disease, symptoms vary according to leprosy's subtype. This study aimed to compare the QoL between paucibacillary and multibacillary leprosy patients. Individuals were also compared considering the presence of reactions and a correlation between questionnaires was performed. METHODS A total of 104 patients with leprosy aged 18 years old and over were selected. QoL was assessed by the Brazilian-Portuguese validated versions of the Medical Outcomes Study 36-item short-form health survey (SF-36) and the Dermatology Life Quality Life Index (DLQI). RESULTS Multibacillary patients showed a more impaired physical function, worse bodily pain, lower score of SF-36, and higher interference of skin on the performance of daily activities when compared to the paucibacillary group. Individuals without reactions presented lower bodily pain and less effect of the skin on clothing choices compared to those with reactions. The SF-36 domains exhibited weak correlations with most DLQI questions, and the linear regression model showed that 32% of changes in QoL were related to the skin aspect. CONCLUSIONS Multibacillary leprosy patients have a worse QoL when compared to paucibacillary patients. Reactions played a small role in the QoL of our cohort of patients.
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Affiliation(s)
| | | | - Camila Hirotsu
- Department of Psychobiology, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - Solange M Maeda
- Department of Dermatology, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - Marcos C Floriano
- Department of Dermatology, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - Monica Levy Andersen
- Department of Psychobiology, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - Sergio Tufik
- Department of Psychobiology, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - Jane Tomimori
- Department of Dermatology, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
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14
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Saleem MD, Oussedik E, Picardo M, Schoch JJ. Acquired disorders with hypopigmentation: A clinical approach to diagnosis and treatment. J Am Acad Dermatol 2018; 80:1233-1250.e10. [PMID: 30236514 DOI: 10.1016/j.jaad.2018.07.070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/09/2018] [Accepted: 07/13/2018] [Indexed: 02/07/2023]
Abstract
Acquired hypopigmented skin changes are commonly encountered by dermatologists. Although hypopigmentation is often asymptomatic and benign, occasional serious and disabling conditions present with cutaneous hypopigmentation. A thorough history and physical examination, centered on disease distribution and morphologic findings, can aid in delineating the causes of acquired hypopigmented disorders. The second article in this 2-part continuing medical education series focuses on conditions with a hypopigmented phenotype. Early diagnosis and appropriate management of these disorders can improve a patient's quality of life, halt disease progression, and prevent irreversible disability.
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Affiliation(s)
- Mohammed D Saleem
- Department of Internal Medicine, University of Florida College of Medicine and University of Florida Health, Gainesville, Florida.
| | | | - Mauro Picardo
- Department of Dermatology and Pediatric Dermatology, Cutaneous Physiopathology and Integrated Center of Metabolomics Research, San Gallicano Dermatologic Institute, IRCCS, Rome, Italy
| | - Jennifer J Schoch
- Department of Dermatology, University of Florida, Gainesville, Florida; Department of Pediatrics, University of Florida, Gainesville, Florida
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15
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Khadilkar SV, Yadav RS, Patel BA. Leprosy. Neuromuscul Disord 2018. [DOI: 10.1007/978-981-10-5361-0_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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16
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Wagenaar I, Post E, Brandsma W, Bowers B, Alam K, Shetty V, Pai V, Husain S, Sigit Prakoeswa CR, Astari L, Hagge D, Shah M, Neupane K, Tamang KB, Nicholls P, Richardus JH. Effectiveness of 32 versus 20 weeks of prednisolone in leprosy patients with recent nerve function impairment: A randomized controlled trial. PLoS Negl Trop Dis 2017; 11:e0005952. [PMID: 28976976 PMCID: PMC5643133 DOI: 10.1371/journal.pntd.0005952] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 10/16/2017] [Accepted: 09/12/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND While prednisolone is commonly used to treat recent nerve function impairment (NFI) in leprosy patients, the optimal treatment duration has not yet been established. In this "Treatment of Early Neuropathy in Leprosy" (TENLEP) trial, we evaluated whether a 32-week prednisolone course is more effective than a 20-week course in restoring and improving nerve function. METHODS In this multi-centre, triple-blind, randomized controlled trial, leprosy patients who had recently developed clinical NFI (<6 months) were allocated to a prednisolone treatment regimen of either 20 weeks or 32 weeks. Prednisolone was started at either 45 or 60 mg/day, depending on the patient's body weight, and was then tapered. Throughout follow up, NFI was assessed by voluntary muscle testing and monofilament testing. The primary outcome was the proportion of patients with improved or restored nerve function at week 78. As secondary outcomes, we analysed improvements between baseline and week 78 on the Reaction Severity Scale, the SALSA Scale and the Participation Scale. Serious Adverse Events and the need for additional prednisolone treatment were monitored and reported. RESULTS We included 868 patients in the study, 429 in the 20-week arm and 439 in the 32-week arm. At 78 weeks, the proportion of patients with improved or restored nerve function did not differ significantly between the groups: 78.1% in the 20-week arm and 77.5% in the 32-week arm (p = 0.821). Nor were there any differences in secondary outcomes, except for a significant higher proportion of Serious Adverse Events in the longer treatment arm. CONCLUSION In our study, a 20-week course of prednisolone was as effective as a 32-week course in improving and restoring recent clinical NFI in leprosy patients. Twenty weeks is therefore the preferred initial treatment duration for leprosy neuropathy, after which likely only a minority of patients require further individualized treatment.
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Affiliation(s)
- Inge Wagenaar
- Dept. of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Erik Post
- KIT Health, Royal Tropical Institute, Amsterdam, the Netherlands
| | - Wim Brandsma
- Independent Leprosy Consultant, Royal Tropical Institute, Amsterdam, the Netherlands
| | - Bob Bowers
- Rural Health Program, The Leprosy Mission International Bangladesh, Nilphamari, Bangladesh
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Khorshed Alam
- Rural Health Program, The Leprosy Mission International Bangladesh, Nilphamari, Bangladesh
| | | | - Vivek Pai
- Bombay Leprosy Project, Mumbai, India
| | - Sajid Husain
- JALMA institute of Leprosy & Other Mycobacterial Diseases, Agra, India
| | - Cita Rosita Sigit Prakoeswa
- Dermatovenereology Dept., Dr Soetomo Hospital–Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Linda Astari
- Dermatovenereology Dept., Dr Soetomo Hospital–Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Deanna Hagge
- Anandaban Hospital and Mycobacterial Research Laboratories, The Leprosy Mission Nepal, Kathmandu, Nepal
| | - Mahesh Shah
- Anandaban Hospital and Mycobacterial Research Laboratories, The Leprosy Mission Nepal, Kathmandu, Nepal
| | - Kapil Neupane
- Anandaban Hospital and Mycobacterial Research Laboratories, The Leprosy Mission Nepal, Kathmandu, Nepal
| | | | | | - Peter Nicholls
- Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom
| | - Jan Hendrik Richardus
- Dept. of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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17
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Negera E, Walker SL, Girma S, Doni SN, Tsegaye D, Lambert SM, Idriss MH, Tsegay Y, Dockrell HM, Aseffa A, Lockwood DN. Clinico-pathological features of erythema nodosum leprosum: A case-control study at ALERT hospital, Ethiopia. PLoS Negl Trop Dis 2017; 11:e0006011. [PMID: 29028793 PMCID: PMC5656324 DOI: 10.1371/journal.pntd.0006011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 10/25/2017] [Accepted: 10/04/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Leprosy reactions are a significant cause of morbidity in leprosy population. Erythema nodosum leprosum (ENL) is an immunological complication affecting approximately 50% of patients with lepromatous leprosy (LL) and 10% of borderline lepromatous (BL) leprosy. ENL is associated with clinical features such as skin lesions, neuritis, arthritis, dactylitis, eye inflammation, osteitis, orchitis, lymphadenitis and nephritis. ENL is treated mainly with corticosteroids and corticosteroids are often required for extended periods of time which may lead to serious adverse effects. High mortality rate and increased morbidity associated with corticosteroid treatment of ENL has been reported. For improved and evidence-based treatment of ENL, documenting the systems affected by ENL is important. We report here the clinical features of ENL in a cohort of patients with acute ENL who were recruited for a clinico-pathological study before and after prednisolone treatment. MATERIALS AND METHODS A case-control study was performed at ALERT hospital, Ethiopia. Forty-six LL patients with ENL and 31 non-reactional LL matched controls were enrolled to the study and followed for 28 weeks. Clinical features were systematically documented at three visits (before, during and after predinsolone treatment of ENL cases) using a specifically designed form. Skin biopsy samples were obtained from each patient before and after treatment and used for histopathological investigations to supplement the clinical data. RESULTS Pain was the most common symptom reported (98%) by patients with ENL. Eighty percent of them had reported skin pain and more than 70% had nerve and joint pain at enrolment. About 40% of the patients developed chronic ENL. Most individuals 95.7% had nodular skin lesions. Over half of patients with ENL had old nerve function impairment (NFI) while 13% had new NFI at enrolment. Facial and limb oedema were present in 60% patients. Regarding pathological findings before treatment, dermal neutrophilic infiltration was noted in 58.8% of patients with ENL compared to 14.3% in LL controls. Only 14.7% patients with ENL had evidence of vasculitis at enrolment. CONCLUSION In our study, painful nodular skin lesions were present in all ENL patients. Only 58% patients had dermal polymorphonuclear cell infiltration showing that not all clinically confirmed ENL cases have neutrophilic infiltration in lesions. Very few patients had histological evidence of vasculitis. Many patients developed chronic ENL and these patients require inpatient corticosteroid treatment for extended periods which challenges the health service facility in resource poor settings, as well as the patient's quality of life.
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Affiliation(s)
- Edessa Negera
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
- Armauer Hansen Research Institute (AHRI), Addis Ababa, Ethiopia
| | - Stephen L. Walker
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Selfu Girma
- Armauer Hansen Research Institute (AHRI), Addis Ababa, Ethiopia
| | | | | | | | - Munir H. Idriss
- Armauer Hansen Research Institute (AHRI), Addis Ababa, Ethiopia
| | - Yohanis Tsegay
- Armauer Hansen Research Institute (AHRI), Addis Ababa, Ethiopia
| | - Hazel M. Dockrell
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | - Abraham Aseffa
- Armauer Hansen Research Institute (AHRI), Addis Ababa, Ethiopia
| | - Diana N. Lockwood
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
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18
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Walker SL, Sales AM, Butlin CR, Shah M, Maghanoy A, Lambert SM, Darlong J, Rozario BJ, Pai VV, Balagon M, Doni SN, Hagge DA, Nery JAC, Neupane KD, Baral S, Sangma BA, Alembo DT, Yetaye AM, Hassan BA, Shelemo MB, Nicholls PG, Lockwood DNJ. A leprosy clinical severity scale for erythema nodosum leprosum: An international, multicentre validation study of the ENLIST ENL Severity Scale. PLoS Negl Trop Dis 2017; 11:e0005716. [PMID: 28671966 PMCID: PMC5510881 DOI: 10.1371/journal.pntd.0005716] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 07/14/2017] [Accepted: 06/16/2017] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES We wished to validate our recently devised 16-item ENLIST ENL Severity Scale, a clinical tool for measuring the severity of the serious leprosy associated complication of erythema nodosum leprosum (ENL). We also wished to assess the responsiveness of the ENLIST ENL Severity Scale in detecting clinical change in patients with ENL. METHODS Participants, recruited from seven centres in six leprosy endemic countries, were assessed using the ENLIST ENL Severity Scale by two researchers, one of whom categorised the severity of ENL. At a subsequent visit a further assessment using the scale was made and both participant and physician rated the change in ENL using the subjective categories of "Much better", "somewhat better", "somewhat worse" and "much worse" compared with "No change" or "about the same". RESULTS 447 participants were assessed with the ENLIST ENL Severity Scale. The Cronbach alpha of the scale and each item was calculated to determine the internal consistency of the scale. The ENLIST ENL Severity Scale had good internal consistency and this improved following removal of six items to give a Cronbach's alpha of 0.77. The cut off between mild ENL and more severe disease was 9 determined using ROC curves. The minimal important difference of the scale was determined to be 5 using both participant and physician ratings of change. CONCLUSIONS The 10-item ENLIST ENL Severity Scale is the first valid, reliable and responsive measure of ENL severity and improves our ability to assess and compare patients and their treatments in this severe and difficult to manage complication of leprosy. The ENLIST ENL Severity Scale will assist physicians in the monitoring and treatment of patients with ENL. The ENLIST ENL Severity Scale is easy to apply and will be useful as an outcome measure in treatment studies and enable the standardisation of other clinical and laboratory ENL research.
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Affiliation(s)
- Stephen L. Walker
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Anna M. Sales
- Leprosy Laboratory, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, Brazil
| | - C. Ruth Butlin
- Department of Medicine, The Leprosy Mission International, Dhaka, Bangladesh
| | - Mahesh Shah
- Department of Dermatology and Mycobacterial Research Laboratories, The Leprosy Mission Nepal, Anandaban Hospital, Kathmandu, Nepal
| | - Armi Maghanoy
- Department of Dermatology, Leonard Wood Memorial Center for TB and Leprosy Research, Cebu, Philippines
| | - Saba M. Lambert
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Family Medicine, Suisse Clinic, Addis Ababa, Ethiopia
| | - Joydeepa Darlong
- Department of Medicine, The Leprosy Mission Hospital, Purulia, India
| | | | | | - Marivic Balagon
- Department of Dermatology, Leonard Wood Memorial Center for TB and Leprosy Research, Cebu, Philippines
| | | | - Deanna A. Hagge
- Department of Dermatology and Mycobacterial Research Laboratories, The Leprosy Mission Nepal, Anandaban Hospital, Kathmandu, Nepal
| | - José A. C. Nery
- Leprosy Laboratory, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, Brazil
| | - Kapil D. Neupane
- Department of Dermatology and Mycobacterial Research Laboratories, The Leprosy Mission Nepal, Anandaban Hospital, Kathmandu, Nepal
| | - Suwash Baral
- Department of Dermatology and Mycobacterial Research Laboratories, The Leprosy Mission Nepal, Anandaban Hospital, Kathmandu, Nepal
| | - Biliom A. Sangma
- Department of Medicine, The Leprosy Mission International, Dhaka, Bangladesh
| | | | - Abeba M. Yetaye
- Department of Dermatology, ALERT Center, Addis Ababa, Ethiopia
| | | | | | - Peter G. Nicholls
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Diana N. J. Lockwood
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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