Leprosy Mailing List – May 10th, 2007
Ref.:
BL leprosy in reaction and lagophthalmos.
From: Ahmad
L., Karachi, Pakistan
Dear Dr
Salvatore,
Thank you for presenting this
interesting case of a 19 years old boy with BL leprosy in reversal
reaction and lagophthalmos (LML
May 1st, 2007).
BL leprosy is immunologically
unstable, and may present many surprises as in this case where face
lesions are in reaction and lesions on his trunk are silent. Dr Warren mentioned in her
article (LML Jan.11th, 2007) that both reversal and type 2
reactions could occur at the same time.
A bacillary index of 4.7+ with many globi and a
morphological index of 4.2% raise some doubts that this patient
has downgraded from BT. Oedema
of the lesions on the face with early lagophthalmos indicate a
reversal reaction. Lagophthalmos
occurs when the zygomatic branch of the facial nerve is damaged while
crossing over the zygomatic bone.
I have noticed that in such cases the supra-orbital nerves may
also be enlarged and tender. Since
there is infiltration around both eyes, keratitis and anterior
uveitis should be excluded through examination with slit lamp
microscope.
If such a patient comes to me:
i ) I would not start
MDT immediately, I would rather give him clofazimine 300 - 400 mgs after
high fat meals plus 6 weeks course of prednisolone starting with 40 mg
and tapering it off in 6 weeks time.
ii ) I would closely monitor
his voluntary muscle test (VMT) of orbicularis oculi muscles weekly.
iii) I would admit this case
for a supervised active physiotherapy i.e. ask the patient to
close his eyes gently and then gradually squeeze hard and hold for a
few seconds twice in one minute. Many patients develop a habit of
squeezing in a few weeks (it is much better than developing natural Bell's
phenomenon where patient rotates his eyeballs upwards below upper lid
to moisturise cornea. Such
patients end up as failures when a temporalis muscle transfer is
done).
iii) When VMT becomes stable,
I would start with routine MDT and provide him with moist chambers
which are concave plastic shields over the orbit that protects eyes
while sleeping.
iv ) I would do everything
possible to prevent a 19 year young boy go blind as a blind leprosy
patient is hard to rehabilitate.
With best regards,
Dr Latif Ahmad
