Leprosy Mailing List – August 24th, 2007
Ref.:
Multibacillary leprosy patients and particularly those on
steroids may need periods of treatment longer than the recommended
ones.
From:
Warren G., Sydney, Australia
Dear Salvatore,
Thanks for publishing several letters
of mine. Supplementary to my last two letters referring to the
use of prednisolone (Pred) in erythema nodosum leprosum (ENL)
reaction or in leprosy in general, I am very concerned with the
number of times I hear that a patient has Pred during the 6 or 12
months multi-drug therapy (MDT) course, and MDT is then stopped as
initially scheduled. Then a year or two later we find that
the patient has again active leprosy or active reaction, and returns
for treatment. In many
cases the staff assume that because he finished the one course of MDT
he does not need any more and they just give the steroids.
If skin smears are taken and examined during ENL you will often
find there are many acid fast bacilli
(AFB) present, maybe only granulated forms, but bacilli are there
and they provide the Antigens,
liberated from the broken bacilli, that stimulate the increased levels
of B lymphocytes that cause the ENL. (The pus in
pustular ENL is often just a mass of AFB!)
I stated in a previous letter that
in Hong Kong where we had an excellent laboratory technician and the
patients were under full supervision, we were able to do slit-skin
smears regularly while under treatment and I found that the BI and MI
did not drop when the patients were on Pred even if they were on full
anti-leprosy drug treatment as well.
Once the Pred stopped the skin smear would drop without
changing the anti-leprosy medication.
Not too difficult to understand because Pred reduces
inflammation and the inflammation is part of the means of eliminating
the bacilli.
So, in the LL patients in Hong Kong and elsewhere in Asia, we
determined that the best way of being sure that the patient had
had enough treatment was to give the MDT till the skin smear was
negative. If however skin smears are not available and the clinic
depends on MDT duration, counted by months, and Pred has to be used,
then I would not count the months on Pred in the total number of
months required for treatment with MDT.
So if the patient has 3 months of Pred in the middle of a
6-month course I would give an extra 3 months of MDT after the Pred is
stopped, i.e. a total on 9 months MDT. Even stopping the MDT at that
stage would be dependant on the absence of any symptoms suggesting
continuation of leprosy activity.
In severe ENL I would go as far as to say at
least 6-12 months of full MDT after all ENL is stopped.
This bacillus is a very clever one and hides in
nerves etc. Pred helps it
hide, by reducing the effectiveness of the inflammatory response. Once the MDT is stopped the
bacillus comes out and enjoys itself again and then several months, or
years later new symptoms of active leprosy or new ENL will appear.
Yes, I know that a few long term follow ups of
effectiveness of MDT have been done and it is stated that the new
recommendations regarding shorter duration of MDT courses provide
adequate therapy. One
wonders how many relapses actually occur and are never
recorded as such because the patient attends a different clinic, in
which it is not realized initially he has had previous therapy or not
accepted that he is a true relapse or reaction. There are many variations in
the clinical requirement for examination, diagnosis and classification
in different centres across the world, difference in clinics and
techniques. Also there
are relatively few world centres where this type of follow up has been
done. Many of the patients that I see with these problems are from
areas that no one bothers about!
Even here in Sydney I have a patient initially
treated in India with 6 months MDT for what he was told was a “mild BT”
type leprosy. Then he
moved to USA and 2 years later re-diagnosed and given 6 months MDT and
told “cured”. Then
three years later he came to my clinic in Australia with an active
lesion of his hand, not likely to have been a re-infection from
where he had been, so I must assume twice relapsed! Another patient from the
Pacific Islands was given 12 months MDT and told cured. He migrated to us and 3 years
later he was florid BL with a smear of 4+ and it has taken me 4 years
of full MDT to get him smear negative fortunately with no obvious
deformity as yet. To me
it is highly likely that he was a “diffuse lepromatosis” initially
and ought to have had at least the 24 months previously recommended or
better treated initially till smear negative. I have heard that his type of
management is routine in that area of the Pacific.
I throw this extra note in, if you do not mind publishing it
as a warning that the 6 and 12 months courses may not be enough for
the multibacillary (MB) cases or very long term cases such as the
“diffuse lepromatosis” also called “Lucio leprosy” who usually
have had the disease active for 5-10 years before diagnosis because of
the lack of definite edges and the slow development of any neural
deficit or those who have been on prednisolone during the initial
course of MDT. Nobody
wants relapses, when they occur they do untold harm in the community
making folk expect that everyone will not be healed. So, discouraging them to come at
all!
MDT is the best way to prevent spread of the disease, in that
the treated patient is no longer likely to transmit the disease after
a few days of the first dose of full MDT.
Yes, I
know the expense of the longer courses may not be covered by the
regular free medicine supplied through the W.H.O., but somehow we need
to make provision for this. Some
charitable organizations do provide medication as long as the
prescribing doctor recommends it. Do we need to return to the skin smears as a guide?
Yes, I know lots of technicians are not trained to be reliable in
doing them; do we need to get that changed?
Yes I am concerned I have treated so many relapsed patients
in whom deformity could have been prevented if they had been
adequately treated initially. How
can we improve real permanent cure rates?
Grace Warren
Previously Superintendent Hong Kong Leprosy
Hospital 1960-1974
Adviser in Leprosy and Reconstructive surgery
for the Leprosy Mission in Asia. 1976-95
Consultant, as requested, in Australian and
Asian Centres since 1990.
