Lepra Reactions

It is acute inflammatory response

occurring in the course of the disease
1
This is thought to be due to an alteration in the immunological status
of the patient
It is the major cause of nerve damage and disability in leprosy
It can occur at anytime before, during or after treatment
Occurs in 3040% of leprosy cases.
Risk factors,-
Multiple lesions
Lesions close to peripheral nerve
Lesions on the face
Pregnancy / Postpartum period
Puberty
Alcohol intake
 Principal types of Lepra reactions
1.Type 1 Lepra reaction also known as Reversal
reaction and may occur both in PB and MB
leprosy 2
2.Type 2 Lepra reaction also known as Erythema
Nodosum Leprosum an occurs only in MB leprosy
3.Lucio type II phenomenon--a type of cutaneous
vasculitis,tend to affect people not taken MDT
regularly.It presents as odd shaped red patches and
ulcers on hands,feet,wrist,ankle.It is associated
with fever,arthritis,liver,kidney diseases.
Type 1
Mechanism : antigens from broken bacilli react with T-
lymphocytes resulting in alteration of cell-mediated
immunity (Delayed hypersensitivity
Note : 3
reaction)
May occur all of a sudden and may be repeated
episodes
Existing patches become raised, erythematous and
edematous
Neuritis (silent or overt) with / without sudden onset of
muscle paralysis is a common feature
If the pain and tenderness is severe and if paralysis or
anesthesia threatens to follow the neuritis, reaction is
considered severe
New lesions may appear
Systematic complaints are uncommon
Necrosis and ulcerations are seen rarely in severe
reactions
 Lepra reaction Type 1 (Reversal reaction)
Features Type 1 4
Existing lesions suddenly becomes
red, swollen, warm and tender. New
lesions may appear
Skin
Lesions when subsiding may show
scales

Nerves close to the skin may

Nerves become enlarged, tender and painful
(neuritis) with loss of nerve function

Other Organs Rarely affected

General Not common

Symptoms
Type 2
Mechanism : Circulating antibodies against M.leprae react with
the M.leprae antigens (Antigen-antibody reaction) 5
Note :
It may be intermittent or continuous
New erythematous, tender nodules
ENL appear in crops
Bilateral, symmetrical in distribution
Existing skin patches do not show any
change
ENLs may be ulcerated in severe
reaction
Swelling of joints with systematic
complaints like fever, chills are
common
Other organs e.g. nerve, muscle, bone,
eye, liver, testis, spleen may be
involved. D/D.
Lepra reaction Type 2 ( ENL reaction)
Features 6 Type 2
Red, painful, tender, subcutaneous
deep) nodules (ENL) appear
commonly on the face, arms and legs
Skin
They appear in groups and subside
within a few days even without
treatment
Nerves may be affected but not as
Nerves common or severe as in Type 1

Other organs like eyes, joints, bones,

Other testis, kidney may be affected
Organs
General Fever, joint pains, fatigue
Symptoms
 Silent neuritis 7
Van Brakel and Khawas proposed the term
Silent Neuropathy (SN) to described the
phenomenon of Nerve function in patient
occurring in the absence of symptoms. It is
therefore only detected if Medical Officer
perform a careful examination of the
peripheral Nervous system otherwise it may
cause disability. Treatment is same as type
I reaction.
 Treatment of Lepra reaction Type 1
I. If the reaction is mild with no nerve involvement the reaction can be controlled by rest
and analgesics (aspirin or paracetamol) (8)
II. If there are signs of severe reversal reaction then in addition to rest and analgesics
corticosteroids e.g. prednisolone is given. Rest to the affected Nerve using splint.
III. In both the cases MDT is to be continued.

Schedule for Prednisolone therapy for an adult patient Type 1

- 40 mg once a day for first 2 weeks then
- 30 mg once a day for weeks 3rd and 4th
- 20 mg once a day for weeks 5th and 6th
- 15 mg once a day for weeks 7th and 8th
- 10 mg once a day for weeks 9th and 10th
- 5 mg once a day for weeks 11th and 12th

[Daily dose should not exceed 1 mg per Kg body weight]

Note : For neuritis (involvement of peripheral nerve trunk) period of treatment prolonged
according to response each period would be for 4 weeks from 20 mg
Enquire for the following before starting steroids (precautions)
# Hypertension # Peptic ulcer # Tuberculosis #
Diabetes # Inter-current infections
 Treatment of Lepra reaction (ENL) Type 2
I. If the reaction is mild with no nerve involvement and having few
nodules and mild fever the reaction can be controlled by rest and
analgesics (aspirin or paracetamol) (9)
II. If there are signs of ENL reaction then in addition to rest and
analgesics corticosteroids e.g. prednisolone is given
Drugs used in type II reaction :-
1. Prednisolone already mentioned.
2. Clofazimine therapy it is also effective for type II reaciton but less
potent then corticosteroid, 300 mg daily (max. 1 month) in three
divided doses and tappered gradually to 100mg daily, can be given
max. upto 12 months.
3. Thalidomide therapy 200 mg twice daily / 100 mg 4 times daily and
then gradually tapered off. Must be used cautiously.
4. Chloroquine 250mg 3 times daily for 1 week then 250mg 2 times daily
for 1 week then 250mg once daily for 1 week
Indications for referral 10

Failure to respond after 4 weeks of steroid treatment

Eye involvement
Other systemic involvement
Recurrent lepra reactions
 Distinguishing Relapse from Reaction (11)

Criteria Relapse Reaction

Time since completion Usually more than 3 Usually less than 3
of treatment years years
Progression of signs & Slow Fast
symptoms
Site of lesions In new places Over old patches
Pain, tenderness or Usually No Usually Yes skin &
swelling nerves
Damage Occurs slowly Sudden onset

General condition Not affected Inflammation

Role of Medical Officer 12

Medical Officer should know to diagnose lepra reaction in

early stage
Medical Officer should know treatment of lepra reaction.
MDT should not be suspended during reactions
MDT significantly reduces the frequency and severity of
reactions
During counseling possible occurrence of reactions should be
explained since signs and symptoms of reactions could be
misunderstood as adverse effects of drugs
 THANK YOU

DR. SWAPAN KUMAR SARKAR

ZONAL LEPROSY OFFICER
BANKURA
MDT should be continued without interruption
along with anti-reaction treatment in patients
taking MDT and MDT need not be started for
those having completed MDT
Review progress every two weeks
If treatment not responding same dose may be
continued for further two weeks (if not
responding even after four weeks or condition
worsening then refer)
In severe conditions rest is provided by applying
a padded splint / any suitable alternative material
to immobilize joints near affected nerves
 Schedule for Prednisolone therapy for an adult
patient Type 2
Type 2 reaction Treatment
Mild few nodules, mild Analgesics
fever
Severe severe pain over Steroid Prednisolone whole
nodules, tendency for course not exceeding 2 to 3 weeks
ulceration, high fever, ( same dose as for Type 1 reactions
involvement of internal but tapering should be done fast
organs based on response )
Neuritis Prednisolone regimen as for
neuritis in Type 1
Iridocyclitis pain, redness Mild cases application of atropine
and watering of eyes and steroid eye drops/ointments
Severe referred to eye specialist
Clofazimine in the treatment of Type 2 Lepra reaction
Less potent than corticosteroids
Often takes 4-6 weeks to develop full effect
Should not be started as the sole agent for
treatment of Type 2 reaction
Useful for reducing or withdrawing corticosteroids
on corticosteroids dependant patients
Dose is 300 mg daily (max. of 1 month) given in
three divided doses to minimize gastro intestinal
side effects
Tapered to 100 mg daily
Total duration should not exceed 12 months
Response seen after 2-4 weeks of starting
 Peripheral Level Signs indicating that a reaction
is severe and patient must referred
Red, painful, single or multiple nodules in the skin with / without
ulceration
Pain / tenderness in one / more nerves, with / without loss of
function
Silent neuritis nerve function impairment, without skin
inflammation
A red, swollen skin patch on the face, overlying another major
nerve trunk
A skin lesion that becomes ulcerated, or that is accompanied by
a high fever
Marked edema of hands, feet or face
Pain / redness of eyes, with / without loss of visual acuity
Painful swelling of joints with fever

[Reactions which show none of these signs of severity but limited

to mildly inflamed skin lesions may be treated symptomatically
with analgesics]
Assessment of patient previously treated for leprosy
Take full history of current problem including -

The duration of previous treatment and the onset of new

symptoms
Did new lesions appear quickly or over a long period ?
What is the relationship with the old skin patches ?
Has there been any pain, tenderness or swelling ?
Has there been any recent loss of function in any nerves ?

[ Carry out full examination of the skin and of

nerve function, in order to identify any signs of
a recent reaction ]
 Key messages for persons completing treatment
successfully

If the person suspects the disease (relapse) has

returned, they should come for further examination if
leprosy reoccurs it can be treated
If any unusual (reactions) symptoms occur ( including
weakness, numbness or pain in the limbs, or loss of
vision or other eye problems ) the person should come
back for examination and treatment especially
important for MB patients
If some disability is already present the person should
know what they need to do at home to manage the
problem
Relapse
Def :The re-occurrence of the disease at any
time after the completion of a full course of
treatment
There is reappearance or increase in the number of lesions

In case of MB relapse confirmed by skin smear examination .

(If skin smear has been done at RFT then usually two log
increase is seen in bacteriological index BI (e.g. 1+ at RFT
and 3+ at recurrence)

Patients who start treatment with high BI are more likely to

suffer relapse later

Most relapse occur long after the treatment is given

sometimes over 10 years
Lepra reaction can also occur after RFT and can be
usually distinguished from relapse
In lepra reaction
a. time of onset usually within 3 years of RFT.
b. If there is signs of recent nerve damage a reaction is very
likely
c. its favorable response to steroid therapy

(A reaction may be treated with steroids while relapse

will not be greatly affected by a course of steroids, so
using steroids as a therapeutic trial can help clarify
thee diagnosis)
Treatment:
MB patients given another course of standard MDT
regimen for MB
PB patients should be treated with MDT regimen of PB
if the disease is PB but if MB is diagnosed at relapse
then a course of MDT regimen of MB
 Cell Mediated Immunity
Is the reaction to the protein of the
organism physiologically
capable of altering the histiocytes
to improve their capacity to lyse
bacteria
1 Localized, well defined,
circumscribed lesion
2 Few bacilli demonstrated
Intense macrophage (epitheloid)
3 cell response effective
phagocytosis and disposal of
bacilli
4 Lepromin +ve
5 Granulomatous inflammation
Humoral Antibodies
Humoral antibodies appear in
response to polysaccharide fraction of
organism macrophages not
influenced and organisms multiply in it
Extensive, diffuse poorly delimited
lesions
Myriads of bacilli
Abundant macrophage (foam cell)
response with efficient phagocytosis
but ineffectual disposal of bacilli
Lepromin -ve
True granuloma absent
 Cell Mediated Immunity Humoral Antibodies

6 Circulation (humoral) Humoral antibodies readily

antibodies insignificant demonstrable

7 Immunological reactional Immunological reactions

exacerbation characterized exacerbation (ENL)
primarily by reactions of characterized primarily by
cellular hypersensitivity reactions of immediate type
(anaphylactoid) hypersensitivity
8 Effective accelerated Sluggish therapeutic response
therapeutic response