Cutaneous ulceration as a presenting feature of type 1 lepra reaction: A case report.

Reactions in leprosy represent sudden shift in the immunological response and are seen in 11-25% of affected patients. It can be seen before, during or after the completion of multidrug therapy (MDT).1 Two types of reactions are recognized; Type 1 reaction (T1R), seen in borderline leprosy, affecting mainly skin and nerves; type 2 reaction (T2R) or erythema nodosum leprosum (ENL), seen in lepromatous leprosy, characterized by systemic features in addition to cutaneous lesions. Trophic ulcers and ulcerating ENL are well known entities while cutaneous ulceration in T1R is extremely rare; we describe an immune-competent woman with cutaneous ulceration as a presenting feature to highlight the need to recognize this entity at the earliest opportunity.

The challenge of concomitant infections in the coronavirus disease 2019 pandemic era: Severe acute respiratory syndrome coronavirus 2 infection in a patient with chronic Chagas disease and dimorphic leprosy.

Coronavirus disease 2019 (COVID-19) was first officially described in Brazil on February 26th, 2020. The accumulation of reports of concomitant infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and pathogens that cause diseases endemic to tropical countries, such as dengue and chikungunya fever, has started to draw attention. Chagas disease and leprosy remain public health problems in many developing countries, such as Brazil. In this manuscript, we describe a case of concomitant leprosy, Chagas disease, and COVID-19, highlighting the cutaneous manifestations of SARS-CoV-2 infection and the clinical behavior of household contacts who previously received prophylactic Bacillus Calmette-Guérin vaccines.

The challenge of concomitant infections in the coronavirus disease 2019 pandemic era: Severe acute respiratory syndrome coronavirus 2 infection in a patient with chronic Chagas disease and dimorphic leprosy

Abstract Coronavirus disease 2019 (COVID-19) was first officially described in Brazil on February 26th, 2020. The accumulation of reports of concomitant infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and pathogens that cause diseases endemic to tropical countries, such as dengue and chikungunya fever, has started to draw attention. Chagas disease and leprosy remain public health problems in many developing countries, such as Brazil. In this manuscript, we describe a case of concomitant leprosy, Chagas disease, and COVID-19, highlighting the cutaneous manifestations of SARS-CoV-2 infection and the clinical behavior of household contacts who previously received prophylactic Bacillus Calmette-Guérin vaccines.

A case report of erythroderma in a patient with borderline leprosy on reversal reaction: a result of the exacerbated reaction?

BACKGROUND: Erythroderma is characterized by erythema and scaling affecting more than 90% of the body surface area. Inflammatory, neoplastic and, more rarely, infectious diseases may culminate with erythroderma. Diagnosis of the underlying disorder is therefore crucial to institute the appropriate therapy. Leprosy is a chronic infectious disease that is endemic in Brazil. Here we present an unusual case of leprosy and reversal reaction causing erythroderma, and we discuss the underlying immunological mechanisms which could contribute to the generalized skin inflammation. CASE PRESENTATION: We report a case of a patient with reversal reaction (RR) in borderline borderline leprosy presenting with erythroderma and neural disabilities. Histopathology of the skin showed regular acanthosis and spongiosis in the epidermis and, in the dermis, compact epithelioid granulomas as well as grouped and isolated bacilli. This duality probably reflects the transition from an anergic/multibacillary state to a state of more effective immunity and bacillary control, typical of RR. Leprosy was successfully treated with WHO's multidrug therapy, plus prednisone for controlling the RR; the erythroderma resolved in parallel with this treatment. Immunologic studies showed in situ predominance of IFNγ + over IL-4+ lymphocytes and of IL-17+ over Foxp3+ lymphocytes, suggesting an exacerbated Th-1/Th-17 immunoreactivity and poor Th-2 and regulatory T-cell responses. Circulating Tregs were also diminished. We hypothesize that the flare-up of anti-mycobacteria immunoreactivity that underlies RR may have triggered the intense inflammatory skin lesions that culminated with erythroderma. CONCLUSIONS: This case report highlights the importance of thorough clinical examination of erythrodermic patients in search for its etiology and suggests that an intense and probably uncontrolled leprosy RR can culminate in the development of erythroderma.

Clinico-pathological features of erythema nodosum leprosum: A case-control study at ALERT hospital, Ethiopia.

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.

Coinfección VIH- lepra. A propósito de dos casos / No disponible

La lepra, enfermedad milenaria y estigmatizante, sigue estando vigente en nuestros días. Aunque en nuestro país no constituye un problema de salud, a nivel de país ni de provincia, se notifican casos todos los años. La población masculina se ve afectada en mayor cuantía que la población femenina a pesar de que la misma no distingue su aparición por sexo. Es una enfermedad infecciosa, crónica que afecta a la piel y los nervios periféricos, a la mucosa de las vías respiratorias superiores y también a los ojos, además de algunas otras estructuras. Ocurre en personas de cualquier edad, y es causada por el Mycobacterium leprae. A pesar de ser producida por una micobacteria como la Tuberculosis, no contamos con la evidencia de que la misma se comporte de forma oportunista en los casos VIH. Pensar en ella ante la presencia de lesiones de piel con pérdida de sensibilidad, permite el diagnostico precoz, esto reviste gran importancia ya que cura al enfermo, interrumpe la cadena de transmisión y evita las discapacidades. Presentamos los dos únicos casos diagnosticados en nuestra provincia de coinfección VIH/Lepra en los últimos 20 años. Ambos del sexo masculino, los cuales presentaron lesiones en piel después de sus diagnósticos de VIH y al ser estudiados se les diagnóstico lepra y se impuso tratamiento. Logrando la curación del primer caso y encontrándose en estos momentos en observación el segundo caso con evolución satisfactoria de sus lesiones en piel. Los pacientes con diagnóstico de VIH no escapan a la posibilidad de contraer lepra, ante lesiones en piel tanto los pacientes como los médicos deben pensar en ella. Con tratamiento se cura, un enfermo en tratamiento no contagia y las incapacidades se pueden prevenir

Leprosy, a millennial and stigmatizing disease continues is still active in our days. Although it no longer constitutes a problem of health at country or department level, are cases are notified every year. The male population is more affected that the female population. It is an infectious and chronic illness that affects skin and outlying nerves, the mucous of the upper respiratory tract and also the eyes, besides some other structures. It can appear in people of any age and is caused by Mycobacterium leprae. In spite of being caused by mycobacteria like Tuberculosis, we don’t have evidence that leprosy behaves in an opportunist manner in the HIV affected individuals. In the presence of skin lesions with loss of sensibility one should think of leprosy and this can lead to an early diagnosis and treatment, interrupting the transmission chain and avoiding disabilities. We present the only two cases diagnosed in our department of co infection HIV/Leprosy in the last 20 years. Both are males, presenting lesions in skin after their diagnoses of HIV and finally being diagnosed leprosy and treatment was implemented. The first case is cured and in observation and the second case presents a satisfactory evolution of his skin lesions. The patients diagnosed of HIV can contract leprosy, therefore in a case with skin lesions and HIV clinicians should consider leprosy. With treatment the patient can be cured, rendered non-infectious and kept free of disabilities

Estado reaccional leprótico en una paciente con osteosarcoma de tobillo / No disponible

La lepra es una enfermedad infecciosa, poco transmisible, de evolución crónica, causada por el Mycobacterium leprae, que se caracteriza por afectar la piel, los nervios periféricos, la mucosa de las vías respiratorias superiores además de otras estructuras. Se ha subestimado su prevalencia y permanece siendo un problema de salud pública, detectándose aún nuevos casos cada año. Después de la introducción de la multiterapia MDT tanto prevalencia como incidencia han disminuido. En la actual investigación se hace la presentación de un caso clínico, paciente femenina, de 49 años, con diagnóstico de Lepra Dimorfa, que tiene antecedentes de haber sido amputada hace tres años de miembro inferior izquierdo por osteosarcoma de tobillo

Leprosy is an infectious disease with a chronic evolution and its etiological agent is Mycobacterium leprae. The disease affects skin, peripheral nerves, upper respiratory tract and other structures. Its prevalence has been underestimated and continues to be a public health problem in many countries. After the introduction of MDT, both prevalence and incidence declined. This study is a presentation of a clinical case of a 49 year old woman diagnosed of dimorphic leprosy and a history of amputation three years earlier due to osteosarcoma of the ankle

Household costs of leprosy reactions (ENL) in rural India.

BACKGROUND: Erythema nodosum leprosum (ENL) is a common immune-mediated complication of lepromatous (LL) and borderline lepromatous (BL) leprosy. Most patients experience chronic or multiple acute ENL over many years during an economically active period of their lives. Understanding the economic burden of ENL is essential to provide effective patient support, yet this area has not been investigated. METHODS: Ninety-one patients with LL or BL leprosy attending a leprosy hospital in Purulia district of West Bengal, India, were interviewed using a structured questionnaire. Cases (n = 53) were identified as those who had one or more episodes of ENL within the last 3 years. Controls (n = 38) had LL or BL leprosy but no history of ENL. Data were collected on household income, direct and indirect costs, and coping strategies. FINDINGS: The total household cost was Rs 1543 per month or 27.9% (IQR 13.2-52.6) of monthly household income for cases, and Rs 237 per month or 4.9% (IQR 1.7-13.4) of monthly household income for controls. Indirect costs accounted for 65% of total household costs for cases. Direct costs accounted for the remaining 35% of household costs, and resulted almost entirely from treatment-seeking in the private sector. Total household costs exceeded 40% of household income for 37.7% of cases (n = 20) and 2.6% of controls (n = 1) [1 USD = 59 INR]. INTERPRETATION: Households affected by ENL face significant economic burden and are at risk of being pushed further into poverty. Health policy should acknowledge the importance of private sector provision and the significant contribution to total household costs of lost productivity (indirect cost). Further work is needed to explore this area and identify solutions.

Tuberculous lymphadenitis and borderline leprosy in a patient with isolated unconjugated hyperbilirubinaemia.

A 35-year-old man was diagnosed with tuberculous lymphadenitis and multibacillary borderline tuberculoid leprosy. On investigation, isolated unconjugated hyperbilirubinaemia was detected and evaluation led us to conclude that the probable cause was Gilbert's syndrome. He was successfully managed by administration of chemotherapy for the treatment of both the mycobacterial infections, with no adverse effects on liver function tests.

Fulminant hepatic failure in a 15 year old boy with borderline lepromatous leprosy and type 2 reaction.

The liver is the most frequently affected visceral organ in leprosy, particularly in the multibacillary group. Administration of hepatotoxic drugs may also affect liver function. We report the case of a male patient, diagnosed as borderline lepromatous leprosy with Type 2 reaction, who was managed with multibacillary multidrug therapy and steroids, and who then developed acute hepatitis and succumbed to sudden cardiac death. Although erythema nodosum leprosum has been described as a rare cause of death in the literature, such an occurrence in the present era when leprosy has been eliminated needs a special mention.