Development of leprosy in a patient with rheumatoid arthritis during treatment with etanercept: a case report.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder. There is a clear association between some disease-modifying drugs used to treat RA and infection. The introduction of the anti-tumor necrosis factor (TNF) therapies has improved the outcome of severe RA. The TNF-antagonism may increase susceptibility to granulomatous pathogens such as Mycobacterium tuberculosis, Listeria monocytogenes, and Histoplasma capsulatum. METHODS: We report the case of a 37-year-old woman with RA receiving an anti-TNF agent, who developed a rash on her back and both legs, which was finally diagnosed as tuberculoid leprosy. RESULTS: This is the first case of leprosy due to anti-TNF therapy reported in Europe. CONCLUSIONS: Clinicians should be aware of this and other types of atypical and serious infections that patients may suffer from when treated with anti-TNF agents.

UVB suscetibilidade como fator de risco para o desenvolvimento da hanseníase virchowiana / UVB susceptibility as a risk factor to the development of lepromatous leprosy

FUNDAMENTOS: A radiação ultravioleta B (RUVB) é o mais importante fator ambiental capaz de modificar a função imunológica da pele humana. OBJETIVO: estudar a associação entre o fenótipo de suscetibilidade ou resistência à radiação RUVB e as formas polares da hanseníase. MATERIAL E MÉTODOS: foram avaliados 38 pacientes com hanseníase virchowiana (MHV) e 87 pacientes com hanseníase tuberculoide (MHT) de acordo com a classificação de Ridley e Jopling (1966). Todos os pacientes foram submetidos ao teste para determinação do fenótipo de suscetibilidade ou resistência à RUVB por meio da aplicação de um disco de dinitroclorobenzeno (DNCB) a 2 por cento em uma área de pele previamente irradiada com duas vezes a dose eritematosa mínima (DEM). Após 21 dias, outra aplicação de um disco similar de DNCB a 0,05 por cento na região escapular (área não exposta à RUVB) foi realizada para avaliar se houve sensibilização, com leitura após 48 horas. Os pacientes que apresentaram reação positiva ao DNCB foram considerados UVB-resistentes e o oposto foi considerado para aqueles que não apresentaram resposta (UVB-suscetíveis). RESULTADOS: A frequência de UVB-suscetíveis foi de 63,2 por cento (24 pacientes) no grupo MHV e 34,4 por cento (30 pacientes) no grupo MHT (OR = 3,26; IC = 1,36-7,87; x² = 7,73; p = 0,005). CONCLUSÃO: Os resultados sugerem que a UVB-suscetibilidade é um fator de risco para o desenvolvimento da MHV.

BACKGROUNDS: Ultraviolet radiation B (UVRB) is the most important environmental factor capable of altering the immune function of human skin. OBJECTIVE: To evaluate the association of the phenotypes of susceptibility or resistance to ultraviolet radiation B (UVRB) and the polar forms of leprosy. MATERIAL AND METHODS: We evaluated 38 patients with lepromatous leprosy (LL) and 87 patients with tuberculoid (TT) leprosy, according to the classification by Ridley and Jopling (1966). All the patients were submitted to a test to determine the phenotypes of susceptibility or resistance to UVRB through the application of a 2 percent dinitrochlorobenzene (DNCB) disc to a previously irradiated area with twice the minimal erythema dose (MED). After 21 days, a similar disc soaked in 0.05 percent DNCB was applied to the scapular area (unexposed to UVRB) to check for sensitiveness, with reading of the results after 48 hours. The patients that showed a positive reaction to DNCB were considered resistant (UVB-R) and those who did not show any reaction were considered susceptible (UVB-S). RESULTS: The frequency of UVB-S individuals was 63.2 percent (24 patients) in the LL group and 34.4 percent (30 patients) in the TT group (OR=3.26; IC=1.36 - 7.87; x²=7.73; p=0.005). CONCLUSION: Our results suggest that UVB-susceptibility is a risk factor to the development of lepromatous leprosy (LL).

UVB susceptibility as a risk factor to the development of lepromatous leprosy.

BACKGROUNDS: Ultraviolet radiation B (UVRB) is the most important environmental factor capable of altering the immune function of human skin. OBJECTIVE: To evaluate the association of the phenotypes of susceptibility or resistance to ultraviolet radiation B (UVRB) and the polar forms of leprosy. MATERIAL AND METHODS: We evaluated 38 patients with lepromatous leprosy (LL) and 87 patients with tuberculoid (TT) leprosy, according to the classification by Ridley and Jopling (1966). All the patients were submitted to a test to determine the phenotypes of susceptibility or resistance to UVRB through the application of a 2% dinitrochlorobenzene (DNCB) disc to a previously irradiated area with twice the minimal erythema dose (MED). After 21 days, a similar disc soaked in 0.05% DNCB was applied to the scapular area (unexposed to UVRB) to check for sensitiveness, with reading of the results after 48 hours. The patients that showed a positive reaction to DNCB were considered resistant (UVB-R) and those who did not show any reaction were considered susceptible (UVB-S). RESULTS: The frequency of UVB-S individuals was 63.2% (24 patients) in the LL group and 34.4% (30 patients) in the TT group (OR=3.26; IC=1.36 - 7.87; x(2)=7.73; p=0.005). CONCLUSION: Our results suggest that UVB-susceptibility is a risk factor to the development of lepromatous leprosy (LL).

Post-traumatic inoculation tuberculoid leprosy after injury with a glass bangle.

A lesion of tuberculoid leprosy in an Indian lady presenting at the site of injury from a broken glass bangle is reported. The diagnosis was by classical clinical features and histopathology. The importance of the skin in leprosy transmission is emphasised.

Borderline tuberculoid leprosy: an immune reconstitution phenomenon in a human immunodeficiency virus-infected person

Two months after starting highly active antiretroviral treatment (HAART), an individual with human immunodeficiency virus type 1 (HIV-1) infection and profound CD4+ T lymphocytopenia developed several erythematous plaques on his face, which were due to borderline tuberculoid leprosy with reversal reaction. The temporal association between the development of these lesions and changes in blood CD4+ lymphocyte count and plasma HIV-1 load observed during HAART strongly suggests that the presentation of leprosy resulted from immune reconstitution.

Borderline tuberculoid leprosy: an immune reconstitution phenomenon in a human immunodeficiency virus-infected person.

Two months after starting highly active antiretroviral treatment (HAART), an individual with human immunodeficiency virus type 1 (HIV-1) infection and profound CD4+ T lymphocytopenia developed several erythematous plaques on his face, which were due to borderline tuberculoid leprosy with reversal reaction. The temporal association between the development of these lesions and changes in blood CD4+ lymphocyte count and plasma HIV-1 load observed during HAART strongly suggests that the presentation of leprosy resulted from immune reconstitution.

Cutaneous granulomas masquerading as tuberculoid leprosy in a patient with congenital combined immunodeficiency.

Combined immunodeficiency disorders are characterized by abnormalities in cellular and humoral immunity. This classification includes common variable immunodeficiency (CVI), a primary immunodeficiency disorder characterized by hypogammaglobulinemia, recurrent bacterial infections, and significant T-cell abnormalities. Associated autoimmune diseases include rheumatoid arthritis, pernicious anemia, idiopathic thrombocytopenic purpura, and systemic lupus erythematous. Granulomatous lesions in lymphoid tissues, solid organs, and skin have been reported. We describe a patient with CVI who developed cutaneous granulomas with perineural invasion; to our knowledge, this is a previously undescribed feature.

Histological changes in the nerve, skin and nasal mucosa of patients with primary neuritic leprosy.

Primary neuritic leprosy (PNL) presents as a peripheral neuropathy with no visible skin patches and skin smears negative for acid fast bacilli. The pathogenesis of PNL is poorly understood. The aim of the study was to document the histological changes in the nerve, apparently normal skin and nasal mucosa in PNL and to study its significance to the pathogenesis of leprosy lesions. The study is based on a cohort of 208 PNL patients registered at the Schieffelin Leprosy Research and Training Centre, Karigiri. All patients had a nerve biopsy, 196 had a skin biopsy and 39 had a nasal mucosal biopsy. The findings reveal that PNL patients exhibit a spectrum of disease histologically in the nerve ranging from lepromatous to tuberculoid leprosy with a significant proportion (46%) manifesting a multibacillary leprosy histology. Findings in the apparently normal skin and nasal mucosa reveal that there are widespread changes due to leprosy in tissues such as the skin and nasal mucosa even when the disease appears clinically confined to a few nerves. PNL may be an early stage in the pathogenesis of the disease before the appearance of skin lesions. The number of nerves enlarged and lepromin status did not give any clue to the nature of underlying disease.

[Leprous neuropathy--observation from the standpoint vasculitis].

Pathogenesis of leprous neuropathy was studied from the standpoint of vasculitis. In vasculitic syndrome, mononeuritis multiplex is the most specific peripheral nerve injury. It occurs most frequently in small vessel vasculitis. Among them, the incidence is highest in microscopic polyangitis (MPO), Churg-Strauss Syndrome (CSS), and Wegener's granulomatosis (WG). All of them are categorized as ANCA associated disease. Because the disease activity is parallel with ANCA titer and ANCA is related directory to the pathogenesis of necrotizing vasculitis as well as the occurrence of peripheral neuropathy. Other small vessel vasculitis, such as lupus or rheumatoid vasculitis which are believed to occur by immune complex mechanism, are accompanied seldom by peripheral neuropathy. In WG, there are granulomatous lesions in upper and lower respiratory tracts which are supposed to be induced by Th1 dominant CD4 T cell infiltration. In cases of leprosy, if peripheral neuropathy were related to small vessel vasculitis, there might be two different pathogenesis. One is granulomatous vasculitis like WG in tuberculoid type. The other is immune complex type necrotizing vasculitis like SLE in lepromatous type, especially ENL. The site of these events may be small vessel in epineurium. Further immunologic studies are needed to clarify detailed mechanisms of leprous neuropathy.

Reaçäo hansênica tipo I na hanseníase borderline tuberculóide durante a poliquimioterapia: época de aparecimento e nervos acometidos / Type I reaction in borderline tuberculoid leprosy under multidrug therapy: time of onset and nerves affected

FUNDAMENTOS - A reaçäo tipo I é pouco estudada na literatura. OBJETIVOS - Descrever a época de aparecimento da reaçäo tipo 1 e os nervos acometidos, nos pacientes portadores de hanseníase borderline tuberculóide (BT), durante a poliquimioterapia(PQT). PACIENTES E MÉTODOS - Estudo longitudinal realizado no Ambulatório de Dermatologia da Faculdade de Medicina da UFMG. Setenta e um pacientes com hanseníase BT foram incluídos no estudo de agosto de 1989 a agosto de 1993. RESULTADOS - 89,3 por cento dos pacientes hansenianos BT com reaçäo tipo 1 apresentaram esse surto atá a sexta dose de tratamento. O nervo ulnar foi o mais acometido nas reaçöes tipo 1 (37,0 por cento). CONCLUSÃO - A reaçäo tipo 1 nos pacientes hansenianos BT ocorre mais frequentemente até a sexta dose de PQT. O nervo ulnar foi o mais acometido

Trombocitopenia associada ao uso de sulfona? / Thrombocytopenia associated with the use of sulfones?

A trombocitopenia tem sido raramente descrita em associaçäo à terapêutica com as sulfonas. Relata-se caso de paciente, portador de hanseníase tuberculóide em tratamento com dapsona que evoluiu com plaquetopenia significativa, obtendo recuperaçäo dos valores próximos aos normais após substituiçäo dessa droga pela clofazimina

Effect of BCG on the risk of leprosy in an endemic area: a case control study.

The effect of BCG on the risk of leprosy was measured using a case-control design in an area endemic for the disease. In this study, 397 newly diagnosed cases and 669 controls matched for age, sex and locality were selected from a defined population. Information on exposure to BCG, contact with another case of leprosy, and relevant socioeconomic variables were obtained from the subjects. Having infectious (multibacillary) and noninfectious (paucibacillary) contacts in the household increased the risk of disease 11.7 times (p less than 0.001) and 2.7 times (p less than 0.001), respectively. Overall, the protection offered by BCG was not significant (odds ratio = 0.8; p = 0.17). However, BCG appeared to increase the risk for indeterminate leprosy (adjusted odds ratio = 2.7; p = 0.09) while protecting against borderline disease (adjusted odds ratio = 0.39; p = 0.03). It is possible that BCG causes a shift in the overall cell-mediated immune response, thus increasing the risk for milder and transient forms of leprosy while protecting against more serious forms. These findings may have important implications for the design and interpretation of vaccine trials. Namely, trials should be designed to measure the protective efficacy of vaccines against the more serious forms of leprosy, which have the greatest public health significance.