Leprosy mailing list – October 12th, 2006
Ref.: Treatment
of recurrent ENL reaction
From: Ahmad
L., Karachi, Pakistan
Dear Salvatore,
This is in response to Dr
Strahm's query (LML September 27th, 2006). Treatment of ENL reaction in
highly bacilliferous MB leprosy is a very interesting question.
In my experience I have come
to the conclusion that ONE SHOULD AVOID USING PREDNISOLONE
IN ENL UNLESS IT IS LIFE THREATENING.
The painful subcutaneous nodules and peri-osteal pain and
tenderness especially over tibia are most distressing for a patient. MDT with loading doses of
Clofazimine plus Thalidomide (if it is not contra-indicated otherwise)
plus NSAIDs are as effective and I have seen no drug dependence as in
the case of Prednisolone.
The life threatening
conditions like oedema of glottis (seen 2 cases in my life out of
which one survived) needs high doses of parental steroids. The other highly morbid
condition like anterior uveitis in eyes respond well with more
frequent use of local application of steroid drops.
The Lucio phenomenon or
Ulcerative ENL responds well with loading doses of clofazimine (up to
300 mgs daily for 1-3 months) plus Thalidomide 300mg daily plus
antiseptic soaks over skin. The
orchitis of ENL is very puzzling especially in young males who might
blame leprologists for their sterility in later life. It should be respected and
treated well, and followed-up from time to time.
Some leprologists stop
Dapsone during reaction (which is thought to provoke reactions). This needs further
discussions. Theoretically
Bacillary Index is likely to deteriorate under cover of steroids.
I would suggest Dr Strahm
that he should evaluate this patient again; look for anterior uveitis,
orchitis and other concomitant diseases, taper-off prednisolone. MDT with high doses of
clofazimine including thalidomide 100mg tid daily for 1-3 months and
Aspirin 300 mgs tid for 2-4 weeks is worth trying.
Regards,
Dr
Latif Ahmad
