[Adverse effects of multidrug therapy in leprosy patients: a five-year survey at a Health Center of the Federal University of Uberlândia]

Adverse reactions induced by MDT/WHO (Rifampicin+Clofazimine+Dapsone) and ROM (Rifampicin+Ofloxacin+Minocycline) regimens used in the treatment of leprosy: a cohort study in a National Reference Center in Brazil

Background: Recommended standard treatment for leprosy is multidrugtherapy (MDT/WHO), consisting Rifampicin+Dapsone+Clofazimine. Other medications are recommended in cases of resistance, adverse reactions and intolerances, including ROM regimen, Rifampicin+Ofloxacin+Minocycline. Therefore, pharmacovigilance is an important tool in understanding these adverse drug reactions (ADRs), supporting pharmacotherapy management and medication safety. This study seeks to evaluate ADRs comparing two therapeutic regimens, MDT and ROM, used in treatment of patients with leprosy, analyzing prognostic factors regarding risk and safety. Methods:A retrospective cohort study was performed by assessing medical records of 433 patients diagnosed with leprosy from 2010 to 2021 at a National Reference Center in Brazil. They were subject to 24 months or more of treatment with MDT or ROM regimens. ADR assessments were analyzed by two experienced researchers, who included clinical and laboratory variables, correlating them with temporality, severity and the causality criteria of Naranjo and WHO. Results: The findings observed an average of 1.3 reactions/patient. Out of individuals experiencing reactions, 67.0% (69/103) were utilizing MDT/MB, while 33.0% (34/103) were using ROM. The median time for ADR of 79 days for MDT and 179 days for ROM. In first reaction, Dapsone was the most frequently involved medication; the most affected system was hematopoietic. As compared to Clofazimine, results indicated that use of Dapsone was associated with 7% increased risk of ADR occurrence (HR: 1.07; p = 0.866). Additionally, Rifampicin was linked to 31% increased risk of ADRs (HR: 1.31; p = 0.602); and Ofloxacin showed 35% elevated risk (HR: 1.35; p = 0.653). Conversely, results for Minocycline indicated 44% reduction in the risk of ADRs (HR: 0.56; p = 0.527), although statistical significance was not reached. The use of MDT conferred 2.51 times higher risk of developing ADRs in comparison to ROM. Conclusion: The comparison between MDT and ROM revealed that MDT caused more ADRs, and these reactions were more severe, indicating less safety for patients. Dapsone was the most common medication causing ADRs, followed by Rifampicin. The combination with Clofazimine was associated with an additional risk of ADRs, warranting further studies to confirm this hypothesis. Given the high magnitude of ADRs, healthcare teams need to monitor patients undergoing leprosy treatment with focus on pharmacovigilance.

Development of a multivariate predictive model for dapsone adverse drug events in people with leprosy under standard WHO multidrug therapy

BACKGROUND

The occurrence of adverse drug events (ADEs) during dapsone (DDS) treatment in patients with leprosy can constitute a significant barrier to the successful completion of the standardized therapeutic regimen for this disease. Well-known DDS-ADEs are hemolytic anemia, methemoglobinemia, hepatotoxicity, agranulocytosis, and hypersensitivity reactions. Identifying risk factors for ADEs before starting World Health Organization recommended standard multidrug therapy (WHO/MDT) can guide therapeutic planning for the patient. The objective of this study was to develop a predictive model for DDS-ADEs in patients with leprosy receiving standard WHO/MDT.

METHODOLOGY

This is a case-control study that involved the review of medical records of adult (≥18 years) patients registered at a Leprosy Reference Center in Rio de Janeiro, Brazil. The cohort included individuals that received standard WHO/MDT between January 2000 to December 2021. A prediction nomogram was developed by means of multivariable logistic regression (LR) using variables. The Hosmer-Lemeshow test was used to determine the model fit. Odds ratios (ORs) and their respective 95% confidence intervals (CIs) were estimated. The predictive ability of the LRM was assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

A total of 329 medical records were assessed, comprising 120 cases and 209 controls. Based on the final LRM analysis, female sex (OR = 3.61; 95% CI: 2.03-6.59), multibacillary classification (OR = 2.5; 95% CI: 1.39-4.66), and higher education level (completed primary education) (OR = 1.97; 95% CI: 1.14-3.47) were considered factors to predict ADEs that caused standard WHO/MDT discontinuation. The prediction model developed had an AUC of 0.7208, that is 72% capable of predicting DDS-ADEs.

CONCLUSION

We propose a clinical model that could become a helpful tool for physicians in predicting ADEs in DDS-treated leprosy patients.

Epidemiological characteristics of leprosy from 2000 to 2019 in a state with low endemicity in southern Brazil

BACKGROUND

Leprosy is an infectious and contagious disease caused by Mycobacterium leprae and is mainly characterized by lesions in the skin and peripheral nerves. In Brazil, it is a public health problem due to its high endemicity. However, the state of Rio Grande do Sul presents low endemicity of this disease.

OBJECTIVE

To characterize the epidemiological profile of leprosy in the state of Rio Grande do Sul from 2000 to 2019.

METHODS

This was a retrospective observational study. Epidemiological data were collected from the Notifiable Diseases Information System (SINAN, Sistema de Informação de Agravos de Notificação).

RESULTS

Among the 497 municipalities in the state, 357 (71.8%) registered cases of leprosy in the assessed period, with an average of 212 (81.5%) new cases per year. The average detection rate was 1.61 new cases per 100,000 inhabitants. The male sex was predominant (51.9%) and the mean age was 50.4 years. Regarding the epidemiological clinical profile; 79.0% of the patients were multibacillary; 37.5% presented the borderline clinical form; 16% had grade 2 physical disability at diagnosis and bacilloscopy was positive in 35.4% of cases. As for treatment, 73.8% of the cases were treated with the standard multibacillary therapeutic regimen.

STUDY LIMITATIONS

There were missing/inconsistent data in the database available.

CONCLUSIONS

The findings observed in this study indicate that the state presents a low endemicity profile of the disease and these results can support adequate health policies relevant to the reality of Rio Grande do Sul, inserted in a national scenario of highly endemic leprosy.

Self-reported clinical history of misdiagnosed leprosy cases in the State of Mato Grosso, Brzil, 2016-2019

This study aimed to analyze the self-reported clinical history of patients misdiagnosed with leprosy in the State of Mato Grosso, Brazil. This is a cross-sectional study of new leprosy cases diagnosed in the State of Mato Grosso from 2016 to 2019, with individuals who were released from multidrug therapy due to misdiagnosis after starting treatment. Data were collected via telephone interviews. Over the study period, 354 leprosy cases were released from treatment due to misdiagnosis, of which 162 (45.8%) could be interviewed. All interviewees expressed dissatisfaction with their treatment, which prompted them to seek a reevaluation of their diagnosis before they were released due to "misdiagnosis". Among them, 35.8% received a final diagnosis of a musculoskeletal or connective tissue disease - mainly fibromyalgia and degenerative changes in the spine - followed by 13.6% with diagnoses of skin and subcutaneous tissue diseases. For 23.5% of the respondents, no alternative diagnosis was established, whereas 7.4% were later re-diagnosed with leprosy. Fibromyalgia and spinal problems were the most common alternative diagnoses for erroneous leprosy. Although the diagnosis of leprosy is usually clinical and does not require access to technical infrastructure in most cases, some more complex situations require diagnostic support via complementary tests, as well as close collaboration between primary care and reference services.

Rifampicin Allergy Leading to Acute Renal Shutdown

Rifampicin is a widely used drug to treat tuberculosis and leprosy. Its toxicity is predominantly hepatic and immunoallergic in character. While hepatic toxicity is dose-related, the immunoallergic effects are unpredictable and usually associated with intermittent therapy. These immunoallergic effects may be minor (a cutaneous, gastrointestinal, or influenza-like syndrome) or major (hemolytic anemia, shock, or acute renal failure). Herein, we report a case of rifampicin allergy in a patient who was on intermittent once monthly rifampicin therapy for neuritic leprosy and was on his 4th month of treatment. Rifampicin exposure led to sudden shock and acute renal failure, which eventually required hemodialysis support. The patient made a complete recovery over the subsequent days and his renal function returned to normal over the next 3 weeks. He continues his multidrug therapy of leprosy without rifampicin.

Effect of Vehicle Composition on the Preparation of Different Types of Dapsone Crystals for Topical Drug Delivery

Topical formulations composed of API-pure crystals have been increasingly studied, especially in regards to the impact of particle size in penetration efficiency. Less attention, however, has been devoted to the solid-state properties of drugs delivered to the skin. In this study, we address the effect of formulation composition on the crystal form existing in topical products. Dapsone (DAP) gel formulations were prepared by mixing an organic solution containing DAP with an aqueous solution containing polymers and preservatives. The organic solvent was chosen as ethoxydiglycol (DEGEE), polyethylene glycol (PEG), or 1-methyl-2-pirrolidone (MPR) to assess the impact of composition on DAP crystal form. Such solvent variations resulted in different particulate matter. In terms of crystalline nature, the presence of DEGEE in formulations induced the crystallization of DAP hydrate, while PEG cocrystal and a mixture of hydrate and MPR solvate crystallized from the same amounts of PEG and MPR, respectively. Microscopic analysis of the gels showed heterogeneous particles with different characteristics. The behavior of gels after application to the skin was also tested. Interestingly, the different formulations seemed to accumulate in different regions of the skin. This could be the result of the effect of vehicle composition/excipients on the characteristics of the skin, such as hydration. The site-specific accumulation, however, was more pronounced in crystal-loaded gels as opposed to blank formulations. These results indicate that future studies should consider the effect of formulation composition on the API crystal form landscape as part of the strategies used to successfully target drug delivery to the skin.

Innovative tracking, active search and follow-up strategies for new leprosy cases in the female prison population

BACKGROUND

Regarding the leprosy transmission through the upper airways, overcrowded locations such as prisons can become a risk to get sick. Like the leprosy hidden endemic demonstrated in male prison population, being interesting to assess the leprosy scene also among confined women.

METHODS

A prospective descriptive study conducted at Female Penitentiary, Brazil. Leprosy Suspicion Questionnaire (LSQ) were applied to the participants, and submitted to specialized dermatoneurological exam, peripheral nerve ultrasonography, and anti-PGL-I serology.

FINDINGS

404 female inmates were evaluated, 14 new cases were diagnosed (LG-leprosy group), a new case detection rate (NCDR) of 3.4%, 13 multibacillary, while another 390 constituted the Non-Leprosy group (NLG). Leprosy cases were followed up during multidrug therapy with clinical improvement. The confinement time median was 31 months in LG, similar to NLG, less than the time of leprosy incubation. Regarding LSQ, the neurological symptoms reached the highest x2 values as Q1-numbness (5.6), Q3-anesthetizes areas in the skin (7.5), Q5-Stinging sensation (5.8), and Q7-pain in the nerves (34.7), while Q4-spots on the skin was 4.94. When more than one question were marked in the LSQ means a 12.8-fold higher to have the disease than a subject who marked only one or none. The high 34% rate of anti-PGL-I seropositivity in the penitentiary, higher levels in LG than NLG. Three additional leprosy cases each were diagnosed on the second (n = 66) and third (n = 14) reevaluations 18 and 36 months after the initial one. Semmes-Weinstein monofilaments demonstrated lower limbs (32.2%) more affected than the upper limbs (25%) with improvement during the follow-up.

INTERPRETATION

The NCDR in this population showed an hidden endemic of leprosy as well as the efficacy of a search action on the part of a specialized team with the aid of the LSQ and anti-PGL-I serology as an auxiliary tracking tools.

Adverse effects of polychemotherapy for leprosy in 13 years of follow-up at a university hospital

Leprosy is one of the neglected diseases in the world and Brazil is the second country with more cases. A retrospective study was conducted based on the medical records of 196 leprosy patients diagnosed during the course of 13 years at a university hospital. The aim was to describe the adverse effects of polychemotherapy, as well the most prevalent and most vulnerable populations. In the study, dapsone was the most implicated drug, especially in women, and the risk increased with age. The authors conclude that with this patient profile, greater vigilance should be taken regarding possible adverse effects, especially anemia.

Development and evaluation of dapsone tablets coated for specific colon release

Objective: Drug release systems based on colonic microbiota have been explored with the use of polysaccharides, which are biodegradable. In order to modulate the release into the colon, dapsone tablets were developed, coated with Surelease^® and chondroitin sulfate (SC).Methods: The formulation was developed using the wet granulation method, in the form of 9-millimetre circular tablets. The coating was applied in a perforated basin-type coating using different proportions of Surelease^® and chondroitin sulfate. The tablets were assessed according to the criteria of mean weight, hardness, and friability. The dissolution test was performed in the dissolver IV apparatus, in media simulating the gastrointestinal system environments (pH 1.2-pH 6.0 and pH 7.2) for 420 min. The results were analyzed by statistical analysis and factorial design.Results: The results of mean weight, hardness, and friability met the pharmacopeial specifications. In the dissolution test, the results obtained demonstrated that Surelease^® is able to offer effective protection to the drug, releasing minimum rates when used at 6% or 10% of the tablet's weight gain. The experiments showed that the drug was not able to spread through the coatings manufactured exclusively with Surelease^® or even when SC was incorporated in different proportions. Only in the formulation where SC was included in the highest proportion (10%), and the weight gain of the tablet was lower (6%), the release of dapsone increased, reaching 9.5% of drug released. Through factorial planning, it was observed that the drug release rate increases when the weight gain of the tablet remains at the lower level (6%), while the amount of polysaccharide is increased (90:10).Conclusions: The data indicate that the proportion of polysaccharide for ethyl cellulose in the film and the thickness of the coating are the key parameters in controlling the release of the drug from the system.

Can different stages of leprosy treatment influence the profile of oral health? Oral status in leprosy

BACKGROUND

The aim of study was to evaluate the oral health status, salivary flow and halitosis among individuals diagnosed with leprosy as compared with healthy subjects.

MATERIAL AND METHODS

A sample of 160 individuals was allocated into four groups, as follows: (G1) individuals with complete leprosy treatment; (G2) individuals diagnosed with leprosy and under multi-drug therapy; (G3) individuals diagnosed with leprosy not yet under treatment; and (G4) healthy individuals. Then individuals were submitted to periodontal clinical examination (visible plaque index, bleeding index, depth of probing and clinical attachment level); DMFT index (decayed-missing-filled teeth index); evaluation of salivary flow and halitosis using a halimeter equipment (Interscan Corp, Chatsworth, CA, USA).

RESULTS

The data were analyzed using Kruskal-Wallis and chi-square tests. The mean DMFT was found to be higher than 6.6, which is considered very high, with no significant difference between groups (P>0.05). As for salivary flow, 76.2% of the subjects presented normal flow rates, while 10% and 13.7% showed low and very low salivary flow rates, respectively, with hyposalivation being mostly observed in Groups 1 and 2. The highest prevalence of noticeable odor was found in healthy individuals (G4), and the most prevalent periodontal diagnosis was gingivitis (63.1%) in Group 3 (individuals with leprosy not yet under multi-drug therapy) followed by periodontitis (25%) in Group 1 (individuals who had completed leprosy treatment).

CONCLUSIONS

It was observed that individuals with a history of leprosy present poor oral health similar to that of systemically healthy individuals.

Leprosy and women

Leprosy has an impact on the physical, social, and psychological health of affected people. Women in developing countries seek health care late for any health-related issues. Leprosy, a disease known for its stigma, adds further to these facts. Also, close contact between women and family members, especially children, increases the chance of transmission to others and thereby increases the disease burden in the society. Hence, leprosy in women is an important issue for the affected patient, their family members, and society as a whole.

History of leprosy in Rio de Janeiro

The record of the first cases of leprosy in Rio de Janeiro dates from the seventeenth century. The first local host of leprosy patients was created from 1741, and the first colonies hospitals were built in the early twentieth century, in order to avoid contagion of the population. The first structures dedicated to research also date from this time: the Leprosy International Institute, the Leprology Institute, and the Leprosy Laboratory of the Oswaldo Cruz Foundation, where the most prestigious leprologists of Rio de Janeiro worked. Currently, investigations are focused on the Oswaldo Cruz Foundation; additionally, leprosy patients are treated at municipal health centers and state hospitals, and former colony hospitals only accept patients with severe disabilities.

Epidemiological profile of leprosy in the Brazilian state of Piauí between 2003 and 2008

BACKGROUND

Leprosy is a chronic infectious disease caused by Mycobacterium leprae. It is considered a major public health issue in developing countries.

OBJECTIVES

To evaluate the clinical and epidemiological profile of leprosy patients between 2003 and 2008 in the state of Piauí, to analyze detection and prevalence rates in the general population and in the population of children under 15 years of age, and to evaluate the predominant clinical forms.

METHODS

Data were obtained from the notifiable diseases database of the State Health Department, Piauí, Brazil. Medical records are retrieved from patients' charts using a specific questionnaire and the collected data is then entered into the database system.

RESULTS

Of the 12,238 cases of leprosy reported in this period, 85% represented new cases. The mean overall annual detection rate was 54 cases/100,000 habitants. The rate for children under 15 years of age was 15.3 cases/100,000 habitants. Overall, 52.18% of the patients were male; 64.66% were between 20 and 59 years of age; and 53.53% had the paucibacillary form of leprosy. Nevertheless, in 88.82% of cases of the paucibacillary form of the disease, more than five lesions were present, while in 10.55% of cases of the multibacillary form of the disease, no lesions were present. Over 20% of patients had some degree of disability.

CONCLUSION

These indicators point to a high circulation of bacilli in the community and highlight the extreme difficulty experienced by the primary healthcare network in organizing itself in order to ensure that patients with this complex disease receive an accurate and early diagnosis.

Polymorphisms in the CYP2E1 and GSTM1 genes as possible protection factors for leprosy patients

Background

The CYP2E1 and GSTM1 genes encode metabolic enzymes that have key functions in drug modification and elimination.

Methodology/Principal Findings

We investigated the possible effects of CYP2E1 and GSTM1 polymorphisms in 71 leprosy patients and in 110 individuals from the general population. The GSTM1*0 null allele and INDEL CYP2E1*1D mutant genotypes were analyzed by conventional PCR, while CYP2E1 SNPs (1053C>T, 1293G>C and 7632T>A) were determined by RT-PCR. In leprosy patients, the GSTM1*0 and CYP2E1*5 alleles and the combined alleles GSTM1*0/CYP2E1*6 and GSTM1*0/CYP2E1*5 were significantly related to a baciloscopic index (BI) (BI<3), while the CYP2E1*6 allele was related to a better clinical evolution in the leprosy spectrum.

Conclusions/Significance

Therefore, GSTM1*0, CYP2E1*5 and CYP2E1*6 may be possible protection factors for leprosy patients.

Clinical spectrum and severity of hemolytic anemia in glucose 6-phosphate dehydrogenase-deficient children receiving dapsone

Drug-induced acute hemolytic anemia led to the discovery of G6PD deficiency. However, most clinical data are from isolated case reports. In 2 clinical trials of antimalarial preparations containing dapsone (4,4'-diaminodiphenylsulfone; 2.5 mg/kg once daily for 3 days), 95 G6PD-deficient hemizygous boys, 24 G6PD-deficient homozygous girls, and 200 girls heterozygous for G6PD deficiency received this agent. In the first 2 groups, there was a maximum decrease in hemoglobin averaging -2.64 g/dL (range -6.70 to +0.30 g/dL), which was significantly greater than for the comparator group receiving artemether-lumefantrine (adjusted difference -1.46 g/dL; 95% confidence interval -1.76, -1.15). Hemoglobin concentrations were decreased by ≥ 40% versus pretreatment in 24/119 (20.2%) of the G6PD-deficient children; 13/119 (10.9%) required blood transfusion. In the heterozygous girls, the mean maximum decrease in hemoglobin was -1.83 g/dL (range +0.90 to -5.20 g/dL); 1 in 200 (0.5%) required blood transfusion. All children eventually recovered. All the G6PD-deficient children had the G6PD A- variant, ie, mutations V68M and N126D. Drug-induced acute hemolytic anemia in G6PD A- subjects can be life-threatening, depending on the nature and dosage of the drug trigger. Therefore, contrary to current perception, in clinical terms the A- type of G6PD deficiency cannot be regarded as mild. This study is registered at http://www.clinicaltrials.gov as NCT00344006 and NCT00371735.

The impact of leprosy on health-related quality of life

INTRODUCTION

Leprosy is a potentially disabling infectious disease that evolves into emotional issues due to the prejudice that persists about the illness. The endemic has declined substantially with multidrug therapy (MDT) in the 80's; however, new demands associated with the reduction of stigma and the improvement of the affected people's quality of life have emerged. In Brazil, leprosy is still a public health problem. Piauí is the second state in the Northeast in prevalence and detection, and Teresina is a hyperendemic city. This study aimed to analyze the health-related quality of life (HRQoL) of people in treatment for leprosy in Teresina/PI.

METHODS

An observational study was conducted using the SF-36 (a specific questionnaire for assessing quality of life), which sought the determinants of poor quality of life among people with leprosy, outlining the sociodemographic, clinical, and epidemiological characteristics of the 107 patients interviewed.

RESULTS

The correlations between the variables showed five determinants of HRQoL: late diagnosis, multibacillary forms, reactions, disability diagnosis grade II, and prejudice. The profile of the participants showed that leprosy still affects the lower social classes in historically endemic areas, causing high percentages of secondary injuries that compromise the work capacity and quality of life of the affected people, perpetuating the stigma associated with the disease.

CONCLUSIONS

The study reinforces the need to implement more effective strategies of disease control, due to the development of severe and disabling forms of leprosy is directly related to poor HRQoL in the same cured patient.

[Epidemiological profile of leprosy in a Brazilian municipality between 2000 and 2006]

INTRODUCTION

Leprosy is considered to be a major public health problem in developing countries. It is estimated that notifications are issued only in relation to 1/3 of the patients and that, among these patients, many undergo irregular treatment or drop out, thus increasing the impact of the disease. The objective this paper was to describe the epidemiological profile of the population with a diagnosis of leprosy in the municipality of Uberaba, State of Minas Gerais, Brazil, between 2000 and 2006.

METHODS

This was a retrospective study using data from notifications of leprosy cases in the Notifiable Disease Information System of the Brazilian Ministry of Health.

RESULTS

There were 455 recorded cases of leprosy, and 55.4% of these were among males. The most affected age group was 34 to 49 years (31.4%), while nine cases of leprosy (2%) were found in children under the age of 15 years. The commonest clinical form was the borderline type (69.1%) and the operational class was multibacillary (87%). These findings are a matter of concern, considering that the age group that is most economically active is potentially the principal group spreading the disease.

CONCLUSIONS

The finding that 87% of the cases were multibacillary indicates that the diagnoses were late. It is therefore necessary to decentralize the leprosy care services and train more professionals to enable earlier diagnosis and treatment.

[Detection of new cases of leprosy in the City of Prudentópolis, PR: the analysis from 1998 to 2005]

The aim of this study was to evaluate the detection of new cases of leprosy in Prudentópolis, State of Paraná, from 1998 to 2005. Additionally, we investigated the age group and predominant clinical form of leprosy cases. Data were obtained from clinical-epidemiological records of confirmed leprosy cases that were notified in the Information System for Notifiable Diseases, between 1998 and 2005. Over this period, 222 leprosy cases were notified, of which 63% presented the multibacillary form, with predominance of the Virchow clinical form, thus indicating a process of intense disease transmission. Among these leprosy cases, 35% of the patients were at an economically active age (31 to 45 years old). These indicators showed that there was a high level of bacillus circulation in the community, considering that one risk factor for infection by the bacillus Mycobacterium leprae is contact with untreated individuals who have the multibacillary form. This is despite the drastic reduction in leprosy prevalence over the last two decades, through the implementation of polychemotherapy and other preventive measures.

Evaluation of incapacity level in leprosy: a strategy to sensitize and train the nursing team

The main problems caused by leprosy are physical incapacities. This study evaluated the level of patients' incapacity in treatment and in discharge in 11 municipal districts of the 14th Regional of Health of Paraná, at the same time it promoted discussion and qualified nursing professionals of local teams. It was verified that 79.8% of the population evaluated presented some degree of incapacity and that some of the professionals ignored the evaluation technique. The percentage of patients with incapacity levels I and II was high, fact that corroborates the late diagnosis of cases. The need of a permanent self-care process associated to polichemotherapy and continuous evaluation of new and old cases in order to avoid the illness physical incapacities is highlighted.