Leprosy: Treatment and management of complications.

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.

Erythema leprosum--after treatment of Lepromatous Leprosy.

Leprosy is usually well-controlled by multidrug therapy (MDT). However, in case of noncompliance or leprosy reactions, it may present a therapeutically challenge. A 33-year-old Brazilian woman with lepromatous leprosy was treated with MDT for one year, but then discontinued therapy because she wanted to have children. Eight weeks after stopping her medications, she developed a severe and recalcitrant erythema (nodosum) leprosum (ENL) which presented histologically with thrombosed small veins and neutrophilic inflammation in fat septa, but without arteritis. During her pregnancy and ensuing lactation period, glucocorticoids were the only suitable drug. With the use of the shortened WHO/MDT regimen (one year vs. two years of treatment), ENL will probably be seen more often after the end of leprosy therapy. It needs to be rapidly recognized and treated to avoid damage to eyes or kidneys.

Newer trends in the management of genital herpes.

Management of genital herpes is complex. Apart from using the standard antivirals, an ideal management protocol also needs to address various aspects of the disease, including the psychological morbidity. Oral acyclovir, valacyclovir or famciclovir are recommended for routine use. Long-term suppressive therapy is effective in reducing the number of recurrences and the risk of transmission to others. Severe or disseminated disease may require intravenous therapy. Resistant cases are managed with foscarnet or cidofovir. Genital herpes in human immunodeficiency virus-infected individuals usually needs a longer duration of antiviral therapy along with continuation of highly active anti retroviral therapy (HAART). Genital herpes in late pregnancy increases the risk of neonatal herpes. Antiviral therapy and/or cesarean delivery are indicated depending on the clinical circumstance. Acyclovir appears to be safe in pregnancy. But, there is limited data regarding the use of valacyclovir and famciclovir in pregnancy. Neonatal herpes requires a higher dose of acyclovir given intravenously for a longer duration. Management of the sex partner, counseling and prevention advice are equally important in appropriate management of genital herpes. Vaccines till date have been marginally effective. Helicase-primase inhibitors, needle-free mucosal vaccine and a new microbicide product named VivaGel may become promising treatment options in the future.

Two patients coinfected with Mycobacterium leprae and human immunodeficiency virus type 1 and naive for antiretroviral therapy who exhibited type 1 leprosy reactions mimicking the immune reconstitution inflammatory syndrome.

Two case reports of patients with human immunodeficiency virus type 1 (HIV-1) infection who developed leprosy are presented. Both developed type 1 leprosy reactions in the absence of antiretroviral therapy. Reactions have been described for a number of HIV-1- and Mycobacterium leprae-coinfected patients and have been considered to be part of an immune reconstitution inflammatory syndrome (IRIS) since the reactions were usually linked to the administration of highly active antiretroviral therapy. The reports of our two patients suggest that the type 1 reactions in patients with leprosy and HIV may not always be an IRIS manifestation but may be akin to the classical reactional state described for the natural course of leprosy infection, which occurs in leprosy patients due to the fluctuations of the antimycobacterial immune response, whether they are coinfected with HIV or not.

[Initial manifestation of tuberculoid leprosy in pregnancy. Guidelines for diagnosis and therapy]. / Erstmanifestation einer tuberkuloiden Lepra in der Schwangerschaft. Leitlinien zur Diagnostik und Therapie.

Pregnancy has long been associated with the first presentation of clinical leprosy or aggravation of the existing disease. In Germany leprosy has been diagnosed in 107 patients since 1980. A 27-year-old Singhalese female, gravida 2 at 14 weeks' gestation was admitted with well defined, elevated, erythematous lesions on her cheeks and nose. Clinical examination revealed central anaesthesia in the lesions. No further signs of leprosy in the skin, the mucosae and the peripheral nerves were found. Fite-Faraco staining of the skin biopsy showed sporadic acid-fast bacilli and confirmed an active subpolar tuberculoid leprosy (TTs). Outpatient treatment was immediately initiated with oral rifampin 600 mg monthly and dapsone 100 mg daily. During the 4-month treatment cycle the skin lesions vanished completely. Additional leprosy reactions did not occur and the medication was well tolerated. However, in the 32nd gestational week the patient was readmitted with premature labour and 3 weeks later Caesarean section was performed because of cardiotocographic pathology. Polymerase chain reaction (PCR) for M. leprae of placental tissue was negative. Antibodies against phenolic glycolipid 1 (PGL 1) of M. leprae (IgM-Elisa and Dot-Elisa) from cord blood, maternal and newborn blood were not found. On the fifth postpartal day the healthy mother and her baby were discharged. In conclusion, leprosy in pregnancy can be treated safely and successfully by combined drug therapy.

[Leprosy and pregnancy]. / Hanseníase e gravidez.

UNLABELLED: We followed 20 cases of pregnant women with leprosy: eight lepromatous (L), seven "borderline", four turbeculoid and only one indeterminate (I) and their newborns. Three patients showed the first symptoms during pregnancy and another one in postpartum. One patient was sick during sixteen years and another one was treated during fourteen years. The bacterioscopic examination was positive in thirteen and negative in seven patients. The Mitsuda test was negative in sixteen, positive in two and in two others was not performed. The treatment in fourteen patients was polychimiotherapy (diamino diphenylsulfone, rifampicin and clofazimine). Three patients received dapsone monotherapy. Three women started the treatment postpartum. Reactions states were treated with corticosteroids and acetylsalicylic acid. The therapy was Irregular in nine and Regular in eight cases. Ten patients showed reactions: eight during pregnancy, one in puerperium and one in the lactation period. Eight showed erythema nodosum leprosum and two reversal reaction. One patient showed false positive biologic test for syphilis and another one had positive bacterioscopic examination in the lactation period. One patient showed false positive biologic test for syphilis and another had positive bacterioscopic examination in the lactation period. One newborn showed exfoliative dermatitis in the first hours of life and his mother had used sulfone during pregnancy. Among the twenty babies five had less than 2,500g in weight and four were premature. CONCLUSION: The reaction states of patients and low birth weight of premature babies occurred in lepromatous and "borderline" cases.

Neonatal hyperbilirubinemia after treatment of maternal leprosy.

Leprosy occurs rarely in women of reproductive age. Until this report, the treatment of leprosy with dapsone has not been associated with any adverse fetal or neonatal side effects. We have reported what we believe to be the first case of neonatal hyperbilirubinemia after maternal dapsone therapy for leprosy.

Clofazimine in pregnancy complicated by leprosy.

Little is known of the perinatal consequences of the use of clofazimine (B663, Lamprene) to treat leprosy. Two patients who were treated with the drug throughout pregnancy are presented and the literature is reviewed. Although the 2 current pregnancies ended successfully, 3 neonatal deaths in 15 pregnancies (20%) have been reported. These data suggest that patients taking clofazimine during pregnancy be managed at a perinatal center where adequate neonatal care can be given.