leprosy

Module 3a:

REACTIONS & NEURITIS

Module 3a:

REACTIONS & NEURITIS

The appearance of systemic or localized signs of acute inflammation on patients with leprosy or who have had leprosy.

The appearance of systemic or localized signs of acute inflammation on patients with leprosy or who have had leprosy.

REACTIONS:REACTIONS:

Reactions can occur before diagnosis, during treatment, and even after cure.

Reactions can occur before diagnosis, during treatment, and even after cure.

An effect of increased immune system response to bacilli or fragments of bacilli.

An effect of increased immune system response to bacilli or fragments of bacilli.

2 TYPES OF REACTIONS:2 TYPES OF REACTIONS:

Type 1: Reversal ReactionType 1: Reversal Reaction

This leads to an acute, localized, cell mediated inflammatory response.

This leads to an acute, localized, cell mediated inflammatory response.

Affects both PB and MB patients.Affects both PB and MB patients.

Only affects MB patients.Only affects MB patients.

2 TYPES OF REACTIONS:2 TYPES OF REACTIONS:

Type 2: Erythema Nodosum LeprosumType 2: Erythema Nodosum Leprosum

Results when large numbers of Mycobacterium leprae are killed and decompose.

Results when large numbers of Mycobacterium leprae are killed and decompose.

The proteins from dead bacilli cause an allergic reaction.

The proteins from dead bacilli cause an allergic reaction.

Most impairments occur during reactions.Most impairments occur during reactions. i

This is because of peripheral nerve inflammation which manifests in two (2) ways:


1. The nerve is enlarged and/or very painful.

1. The nerve is enlarged and/or very painful.



2. “Silent neuritis” in which the patient may not complain but there is significant clinical evidence of nerve function impairment by decrease of sensation and/or decrease in muscle strength.

2. “Silent neuritis” in which the patient may not complain but there is significant clinical evidence of nerve function impairment by decrease of sensation and/or decrease in muscle strength.

The onset of any of the signs and symptoms of a reaction warrants immediate and appropriate action to prevent irreversible damage.

The onset of any of the signs and symptoms of a reaction warrants immediate and appropriate action to prevent irreversible damage.

These signs and symptoms are:These signs and symptoms are:

1. Red, swollen skin patches;1. Red, swollen skin patches;

2. Fever, myalgia, body malaise;

3. Acute nerve pain or tenderness;

4. Severe joint swelling and pain;

5. Recent decrease in sensitivity;

2. Fever, myalgia, body malaise;

3. Acute nerve pain or tenderness;

4. Severe joint swelling and pain;

5. Recent decrease in sensitivity;

These signs and symptoms are:These signs and symptoms are:

6. Recent decrease in muscle strength;6. Recent decrease in muscle strength;

7. Lagophthalmos;

8. Redness, sensitivity to light and pain in the eyes;

9. Swelling of the face, hands and feet;

10. Inflammation of the testicles.

7. Lagophthalmos;

8. Redness, sensitivity to light and pain in the eyes;

9. Swelling of the face, hands and feet;

10. Inflammation of the testicles.

Factors that may precipitate reactions:Factors that may precipitate reactions:

1. MDT treatment;1. MDT treatment;

2. Inter-current infections;

3. Anti-bacterial treatment;

4. Mental or physical stress;

5. Puberty;

6. Pregnancy and lactation;

7. Surgery.

2. Inter-current infections;

3. Anti-bacterial treatment;

4. Mental or physical stress;

5. Puberty;

6. Pregnancy and lactation;

7. Surgery.

MEDICAL MANAGEMENT:MEDICAL MANAGEMENT:

When signs of reaction and/or neuritis are found, ACT IMMEDIATELY!

When signs of reaction and/or neuritis are found, ACT IMMEDIATELY!

Management of Mild Reversal or ENL Reaction:Management of Mild Reversal or ENL Reaction:

FeaturesFeatures ManagementManagement• Mildly swollen

lesion.• Mild fever.

• Mildly swollen lesion.

• Mild fever.

• Give only analgesics.• Do Nerve Function

Assessment (NFA) every two (2) weeks.

• Advise bed rest.• Continue MDT.

• Give only analgesics.• Do Nerve Function

Assessment (NFA) every two (2) weeks.

• Advise bed rest.• Continue MDT.

Management of Severe Reversal Reaction:Management of Severe Reversal Reaction:

FeaturesFeatures ManagementManagement• Nerve damage of

less than 12 months (muscle weakness, loss of sensation, and/or nerve pain)

• Nerve tenderness• Swollen lesion(s) in

the face.

• Nerve damage of less than 12 months (muscle weakness, loss of sensation, and/or nerve pain)

• Nerve tenderness• Swollen lesion(s) in

the face.

• Give the prescribed WHO Prednisone treatment.

• Continue MDT• Do NFA every two (2)

weeks.• Refer patients with

persistent, recurrent & non-responding reactions.





Management of Severe ENL Reaction:Management of Severe ENL Reaction:

FeaturesFeatures ManagementManagement• High fever.• Reddish nodules• Painful neuritis.• Joint pain.• Skin ulceration• Orchitis, iritis,

ostitis, nephritis, swollen hands, feet & face.

• High fever.• Reddish nodules• Painful neuritis.• Joint pain.• Skin ulceration• Orchitis, iritis,

ostitis, nephritis, swollen hands, feet & face.









WHO Recommended Prednisone Regimen (for adults)WHO Recommended Prednisone Regimen (for adults)

• 1st & 2nd week:40mg / day (or approx 1mg / kg body

weight)

• 1st & 2nd week:40mg / day (or approx 1mg / kg body

weight)• 3rd & 4th week: 30mg / day• 3rd & 4th week: 30mg / day• 5th & 6th week: 20mg / day• 5th & 6th week: 20mg / day

• 7th & 8th week: 15mg / day• 7th & 8th week: 15mg / day• 9th & 10th week: 10mg / day• 9th & 10th week: 10mg / day• 11th & 12th week: 5mg / day• 11th & 12th week: 5mg / day

Prednisone should be taken in the morning after a full meal.

Prednisone should be taken in the morning after a full meal.

i

Duration of Prednisone treatment is 12 weeks or until patient recovers sensation and muscle force.

Duration of Prednisone treatment is 12 weeks or until patient recovers sensation and muscle force.

Reaction and neuritis may occur for up to 3 years after MDT treatment.

Reaction and neuritis may occur for up to 3 years after MDT treatment.

i

That is why it is often mistaken for cases of relapse.

That is why it is often mistaken for cases of relapse.

In such cases, MDT need not be restarted, but the appropriate treatment of the reaction is essential.

In such cases, MDT need not be restarted, but the appropriate treatment of the reaction is essential.

Contraindications to Prednisone Treatment:Contraindications to Prednisone Treatment:

Absolute:Absolute:

• Peptic ulcer;

• Psychosis or depression;

• Acute or chronic bacterial infection.

• Peptic ulcer;

• Psychosis or depression;

• Acute or chronic bacterial infection.

Contraindications to Prednisone Treatment:Contraindications to Prednisone Treatment:

Relative:Relative:

• Diabetes mellitus;

• Hypertension;

• Glaucoma;

• Pregnancy;

• Ulceration;

• Diabetes mellitus;

• Hypertension;

• Glaucoma;

• Pregnancy;

• Ulceration;

• Lack of cooperation;

• Mature cataract;

• Age below 15 years;

• Age over 60.

• Lack of cooperation;

• Mature cataract;

• Age below 15 years;

• Age over 60.

If Prednisone is contraindicated or insufficient to control recurrence, give:

If Prednisone is contraindicated or insufficient to control recurrence, give:

Clofazimine:Clofazimine:

• 300mg / day during the 1st month.• 200mg / day during the 2nd month.• 100mg / day during the 3rd month.

• 300mg / day during the 1st month.• 200mg / day during the 2nd month.• 100mg / day during the 3rd month.

Distinguishing Features Between Reaction and Relapse:Distinguishing Features Between Reaction and Relapse:

FeatureFeature ReactionReaction

OnsetOnset Sudden (within a few hours)Sudden (within a few hours)

RelapseRelapse

Slow & insidious (weeks or months)Slow & insidious (weeks or months)



Time of OnsetTime of Onset

Generally occurs during chemotherapy, but may occur up to 3 years after stopping treatment.

Generally occurs during chemotherapy, but may occur up to 3 years after stopping treatment.

RelapseRelapse

Generally occurs long after chemotherapy is discontinued, after an interval of at least 6 months, but usually after 2 years.

Generally occurs long after chemotherapy is discontinued, after an interval of at least 6 months, but usually after 2 years.



Old LesionsOld Lesions

Some or all the existing lesions become erythematous, shiny or swollen.

Some or all the existing lesions become erythematous, shiny or swollen.

RelapseRelapse

The margins of some may become erythematous.

The margins of some may become erythematous.



New LesionsNew Lesions

Previously undetected lesions may become visible.

Previously undetected lesions may become visible.

RelapseRelapse

Few, but always in different sites than previous lesions.

Few, but always in different sites than previous lesions.



Ulc

erat

ion

Ulc

erat

ion Sometimes.Sometimes.

RelapseRelapse

Unusual.Unusual.



ScalingScaling Lesions desquamate as they subside.

Lesions desquamate as they subside.

RelapseRelapse

Absent.Absent.



Ner

ve

Invo

lvem

ent

Ner

ve

Invo

lvem

ent Common: many

nerves may rapidly become painful and tender; disturbances develop rapidly.

Common: many nerves may rapidly become painful and tender; disturbances develop rapidly.

RelapseRelapse

A single nerve becomes involved; disturbances develop slowly.

A single nerve becomes involved; disturbances develop slowly.



Gen

eral

C

ondi

tion

Gen

eral

C

ondi

tion

Fever and malaise are common features of Type 2 reaction (Erythema Nodosum Leprosum).

Fever and malaise are common features of Type 2 reaction (Erythema Nodosum Leprosum).

RelapseRelapse

Not affected.Not affected.



Res

pons

e to

P

redn

ison

eR

espo

nse

to

Pre

dnis

one Excellent.Excellent.

RelapseRelapse

Lesions do not subside with Prednisone.

Lesions do not subside with Prednisone.



Dru

g C

ompl

ianc

eD

rug

Com

plia

nce May have been

good.May have been good.

RelapseRelapse

Poor.Poor.

A relapse case should be started on the standard MDT regimen.

A relapse case should be started on the standard MDT regimen.

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