Leprosy Reactions: Experience in the Puerto Rico Hansen's Disease Population.

OBJECTIVE: Hansen's disease (HD) is a chronic granulomatous infection endemic in the tropics. Its main clinical manifestations involve the cutaneous, nervous, and musculoskeletal systems. Leprosy reactions (LR) are systemic inflammatory and immune-mediated complications of HD. These include reversal reactions (RR), erythema nodosum leprosum (ENL), and Lucio phenomenon. These reactions significantly increase disease-related morbidity and disability. We aimed to determine the number and type of LR, their association to hosts' immune responses (Ridley Jopling classification), timing of development, and treatment of HD patients in Puerto Rico. METHODS: A retrospective medical record review was performed on 291 HD patients containing LR status data available from the Dermatology Service at the Hispanic Alliance for Clinical & Translational Research. RESULTS: Our data revealed that 83 (29%) patients developed LR, of which 31% had RR and 69% had ENL. Most LR were observed in patients in the lepromatous border (97%): Borderline lepromatous leprosy (BL) and Lepromatous Leprosy (LL). Most patients with RR and ENL had a single episode (83% and 62%, respectively), and those that received multi-drug therapy (MDT) had a reaction onset occurring most frequently within the first year of MDT and after the first year of MDT, respectively. Prednisone was the first line treatment used to manage both types of LR. CONCLUSION: Most lepromatous reactions occur within the lepromatous border. ENL was the most common LR. Prompt recognition and management of these immunologic reactions is essential to prevent long term nerve function impairment.

Erythema nodosum leprosum: A rare cause of testicular nodules.

Erythema nodosum leprosum (ENL), characterized by erythematous subcutaneous nodules with multiorgan involvement and systemic manifestations such as neuritis, arthritis, and orchitis, affects approximately 50 % of patients with lepromatous leprosy (LL). It has also been associated with testicular atrophy and adult-onset hypogonadism, but testicular nodules have rarely been reported. We present the case of a 35-year-old male patient with biopsy confirmed LL who completed multidrug therapy and presented for follow-up with a complaint of testicular tenderness. His disease course had been complicated by ENL and polyneuritis. At the time, physical examination revealed a palpable tender nodule in the left testicle. Testicular ultrasound and magnetic resonance imaging showed bilateral intratesticular masses, of which the differential diagnosis included malignancy and inflammatory or postinfectious granulomatous process. Laboratory workup, testicular malignancy markers, and hormone levels were within normal limits. In view of the patient's underlying condition and after Urology evaluation, a diagnosis of granulomatous process was favored. The patient completed a prednisone taper followed by a 3-day prednisone pulse and weekly methotrexate, with sequential testicular ultrasounds to monitor response. After a year of close follow-up and slow tapering of methotrexate, the patient achieved complete resolution of the left intratesticular mass and decrease in size of the contralateral mass, evidenced by both physical examination and imaging. This case highlights the importance of a high index of suspicion in patients with LL and ENL who present with testicular nodules, as awareness of testicular involvement in this population is imperative to avoid life altering procedures such as orchiectomy.

Fatal New-Onset Congestive Heart Failure Related to Adalimumab Use in a Patient with Relapsing Hidradenitis Suppurativa: A Case Report.

BACKGROUND Tumor necrosis factor (TNF)-alpha inhibitors are essential treatments in several inflammatory conditions such as hidradenitis suppurativa (HS). However, they are not without associated risks. In rare cases, new-onset and exacerbations of heart failure have been associated with their use. The purpose of this report is to raise awareness of the need for further study of adalimumab for this adverse effect, as well as to recognize the need for research to find new HS treatment modalities for better care of the broad patient population. CASE REPORT We report the case of a 67-year-old man with a history of severe HS and major depressive disorder who came to our hospital complaining of dyspnea, fatigue upon exertion, and lower-extremity edema of 2 weeks' evolution. Symptoms began after the re-initiation of adalimumab for his severe HS. During hospitalization, he was diagnosed with decompensated congestive heart failure (CHF). Extensive studies, looking for ischemic or infectious etiology, yielded negative results. Being aware of adalimumab's potential adverse effects, the team discontinued the medication as a probable cause of his condition. Unfortunately, the patient died secondary to heart failure and septicemia. CONCLUSIONS The unusual but potentially life-threatening appearance of heart failure secondary to adalimumab use merits thorough attention by primary care doctors and specialists. This adverse event's rare occurrence can underestimate the number of fatalities associated with adalimumab and congestive heart failure.