Steroid Dependent Ulcerated Erythema Nodosum Leprosum 16 Years after Successful Treatment of Leprosy

Leprosy could be best understood as two conjoined diseases. The first is a chronic mycobacterial infection that elicits an extraordinary range of cellular immune responses. The second is lepra reaction, whose course and sequelae often extend many years beyond the cure of the infection and may have severely debilitating physical, social, and psychological consequences. Type-2 lepra reaction is also termed Erythema nodosum leprosum (ENL) regardless of the site of involvement, which is in turn a Coomb and Gell Type III hypersensitivity reaction. The paradox of ENL is that it can be a life-threatening disorder and requires control with immunosuppression which may itself pose life-threatening risks for patients Indian studies found its prevalence rate of almost 50% in those with LL and 9% in BL cases and the mean time to presentation with ENL was 3.7 months after starting multi-drug therapy (MDT). Hitherto we report a severe and steroid dependent case of chronic ulcerated ENL, not only occurred sixteen years after successful treatment of lepromatous leprosy, but also had an unusual initial presentation of arthritis. To the best of our knowledge, ENL for such a prolonged period of 15 years was not reported earlier. Â doi:10.3329/jom.v10i1.2002J Medicine 2009; 10: 31-33

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Unusual non-trophic ulcerations in leprosy: A case series of 17 patients

Tropical Doctor ◽

10.1177/0049475521998499 ◽

2021 ◽

pp. 004947552199849

Author(s):

Prakriti Shukla ◽

Kiran Preet Malhotra ◽

Parul Verma ◽

Swastika Suvirya ◽

Abir Saraswat ◽

...

Keyword(s):

Erythema Nodosum ◽

Case Series ◽

Lepromatous Leprosy ◽

Sweet Syndrome ◽

Erythema Nodosum Leprosum ◽

Leprosy Patients ◽

Atypical Presentations ◽

Neuropathic Ulcers

Non-neuropathic ulcers in leprosy patients are infrequently seen, and atypical presentations are prone to misdiagnosis. We evaluated diagnosed cases of leprosy between January 2017 and January 2020 for the presence of cutaneous ulceration, Ridley–Jopling subtype of leprosy, reactions and histologic features of these ulcerations. Treatment was given as WHO recommended multi-bacillary multi-drug therapy. We found 17/386 leprosy patients with non-neuropathic ulcers. We describe three causes – spontaneous cutaneous ulceration in lepromatous leprosy (one nodular and one diffuse), lepra reactions (five patients with type 1; nine with type 2, further categorised into ulcerated Sweet syndrome-like who also had pseudoepitheliomatous hyperplasia, pustulo-necrotic and necrotic erythema nodosum leprosum) and Lucio phenomenon (one patient). Our series draws attention towards the different faces of non-neuropathic ulcers in leprosy, including some atypical and novel presentations.

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

Tropical Doctor ◽

10.1177/00494755211068661 ◽

2022 ◽

pp. 004947552110686

Author(s):

Pallavi Hegde ◽

Deepti Jaiswal ◽

Varsha M Shetty ◽

Kanthilatha Pai ◽

Raghavendra Rao

Keyword(s):

Case Report ◽

Erythema Nodosum ◽

Immunological Response ◽

Lepromatous Leprosy ◽

Multidrug Therapy ◽

Cutaneous Lesions ◽

Erythema Nodosum Leprosum

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.

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Pentoxifylline therapy for patients with type 2 leprosy reactions: erythema nodosum leprosum in steroid-dependent cases

Vestnik dermatologii i venerologii ◽

10.25208/vdv1196 ◽

2021 ◽

Vol 97 (1) ◽

pp. 46-53

Author(s):

Khairuddin Djawad

Keyword(s):

Peripheral Nerves ◽

Erythema Nodosum ◽

Middle Finger ◽

Erythema Nodosum Leprosum ◽

Steroid Dependent ◽

Tingling Sensation ◽

Membrane Type

Introduction. Morbus Hansen is the infectious disease which causes by bacilli intracellular Mycobacterium leprae which mainly affects the skin and peripheral nerves. The leprosy reaction is an episode an immunologically mediated episode of acute or subacute inflammation which affecting skin; nerve; mucous membrane. Type 2 reactions can be last for months and risk of developing dependence on steroids. Pentoxifylline (PTX) works to hampers the production TNF in vitro and in vivo; are an alternative for ENL treatment. Case Report. One case was reported in a male aged 28 years with complaints of recurring red bumps accompanied by fever and pain. Discussion. On physical examination obtained erythema nodosum; with impaired sensibility in the left leg. The patient experienced improvement after being given therapy of neurodex/24 hours/oral; rifampicin 600 mg; ofloxacin 400 mg; minocycline 100 mg which given 3x for a week; and combination therapy to treat the Leprosy reaction given the combination of methylprednisolone 16mg (3-2-0) and Pentoxifylline 400 mg/8 hours/oral. Conclusion. In the 21 day of treatment; the redness lump improved in the middle finger and left arm was gone. No new reddish bumps appeared and less tingling sensation.

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Case Report: Rapid Response to Low-Dose Thalidomide in a Case of Severe Steroid Recalcitrant Erythema Nodosum Leprosum

American Journal of Tropical Medicine and Hygiene ◽

10.4269/ajtmh.21-0683 ◽

2021 ◽

Author(s):

B. Savitha ◽

Kabir Sardana ◽

Ritu Kumari ◽

Ananta Khurana ◽

Surabhi Sinha ◽

...

Keyword(s):

Low Dose ◽

Erythema Nodosum ◽

Lepromatous Leprosy ◽

High Dose ◽

Effective Treatment Option ◽

Steroid Dependence ◽

Erythema Nodosum Leprosum ◽

Organ Specific ◽

Inflammatory Drugs

Erythema nodosum leprosum (ENL), or type 2 lepra reaction, presents with crops of evanescent, tender erythematous nodules accompanied by fever, arthralgia, weight loss, malaise, and organ-specific manifestations, and is seen in borderline and lepromatous leprosy. The drugs approved for ENL include nonsteroidal anti-inflammatory drugs, systemic steroids, thalidomide, and clofazimine. The management of ENL is challenging because long-term steroid use leads to steroid dependence. Our patient had severe steroid recalcitrant ENL with vesicular and pustular lesions mimicking Sweet’s syndrome, and was treated effectively with a low-dose thalidomide regimen (100 mg/d) as opposed to the high dose (400 mg/d) recommended in the literature. We discuss the patho-mechanics and clinical utility of a low-dose thalidomide regimen as an effective treatment option for ENL.

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A case of concomitant subcorneal pustular dermatosis and erythema nodosum leprosum in borderline lepromatous leprosy-relapses

Case Reports in Clinical Pathology ◽

10.5430/crcp.v4n4p6 ◽

2017 ◽

Vol 4 (4) ◽

pp. 6

Author(s):

Hendra Gunawan ◽

Nina Roslina ◽

Oki Suwarsa

Keyword(s):

Erythema Nodosum ◽

Histopathological Examination ◽

Lepromatous Leprosy ◽

Erythema Nodosum Leprosum ◽

Subcorneal Pustular Dermatosis ◽

Morphological Index ◽

The Face ◽

History Of ◽

Chronic Course ◽

Bacterial Index

Subcorneal pustular dermatosis (SPD) is a rare, chronic, and recurrent pustular eruption characterized histopathologically by subcorneal pustules that contain neutrophils. SPD has been clearly reported conjunction with other diseases. Leprosy reactions are acute inflammatory process that immunologically driven on the chronic course of leprosy. Erythema nodosum leprosum (ENL) is a type II of leprosy reaction putatively can initiate SPD lesions. We report one case of concomitant SPD and ENL in borderline lepromatous leprosy-relapses. A 41-year-old man with the history of using multidrug therapy-multibacillary for leprosy presented with painful erythematous nodules on the trunk and extremities, accompanied by pustules on erythematous base on the face, arms, buttocks, and legs. There were thickening of both ulnar nerves with gloves and stocking hypesthesia. The bacterial index was 3+ and morphological index was 20\%. Histopathological examination on the pustule revealed subcorneal pustules with exocytosis of neutrophils which supported the diagnosis of SPD. A possible immunologic mechanism has been suggested in the induction of the occurence both SPD and ENL.

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