Type 1 Leprosy Reaction in Multibacillary (MB) Leprosy Patient

That Have Not Received MDT-MB Therapy

Donna Partogi

, Cut Putri Hazlianda

, Dina Arwina Dalimunthe

Department of Dermatovenereology, Universitas Sumatera Utara, Jalan Dr. Mansyur Kampus USU 20155, Medan,

Keywords: Leprosy, type 1 leprosy reaction, multibacillary leprosy.

Abstract: Leprosy reaction is a variety of symptoms and signs of acute inflammation of leprosy reactions, which can be

considered as part of journey of leprosy. In the type 1 reaction that plays a role is cellular immunity. A 31-

year-old man complaint of reddish skin thickness on the face, body, back, hands, and feet experiences since

2 weeks ago. On dermatological examination, erythematous plaque is found in the facial region, thoracic,

abdominal and posterior trunk, erythematous macules of the superior extremity and the inferior extremity, the

right side of the sinus. On examination of the peripheral nerve, left and right N. Auricularis Magnus are found

enlarged, N. Ulnaris, N. Popliteal lateralis and N. posterior tibialis tenderness are present. Bacterial

examination (BTA) +1. Diagnosis in this patient was multibacillary leprosy who had type 1 reactions that had

not received MDT-MB therapy. the patient was given Prednison 40 mg/day and was reduced gradually every

2 weeks as much as 5-10 mg. leprosy reactions can occur becfor, during, and after treatment. Various factors

that are considered to cause leprosy reactions. In this case, stress was the trigger factor.

1 INTRODUCTION

Leprosy is one of chronic infection disease, caused by

Mycobacterium leprae, mainly affect peripheral

nerve but can also affect skin, mucosa and other tissue

organ, except central nerve system (Bryceson and

Pfaltzgraff, 1990).

The prevalence of leprosy worldwide is estimated

less than 1 case per 10.000 populations. Nevertheless,

leprosy is still one of health problems in Indonesia.

There are still many provinces and districts in

Indonesia that have not achieved leprosy elimination

that was targeted in 2000 (Lewis et al, 2012; Hernani

et al 2004).

Diagnosis of leprosy is based on cardinal signs

that consist of anesthetic skin lesion, thickened

peripheral nerve with impaired nerve function, and

positive acid-fast bacilli (AFB) from slit skin smears

(Hernani et al, 2004; Amirudin et al, 2003).

According to WHO classification in 1981 that was

modified in 1988, leprosy can be classified into

Paucibacillary (PB) and Multibacillary (MB)

(Amirudin et al, 2003; Noordeen 1994; Kosasih et al,

2008). This classification was based on clinical

features and AFB from slit skin smear examination

(Amirudin et al, 2003).

Leprosy treatment in Indonesia was based on

WHO classification, using Multi Drug Therapy

(MDT). MDT-PB consists of Rifampicin and

Dapsone, while MDT-MB consists of Rifampicin,

Dapsone and Clofazimine (Hernani et al, 2004).

Leprosy reaction is a group of acute inflammatory

sign and symptoms on leprosy skin lesions that were

considered as part of leprosy. There are two types

leprosy reaction. In type 1 reaction, cellular immunity

takes the main role, whereas there are shifting toward

tuberculoid pole (reversal/upgrading) or lepromatose

(downgrading). The clinical manifestations of type 1

reaction are skin lesion become more erythematous,

thickened peripheral nerve with tenderness and

function disorder, with minimal systemic

manifestations (Hernani et al, 2004). Type 2 reaction,

also known as erythema nodosum leprosum, is type

III reaction according to Coomb and Gell with

clinical manifestations such as bright red, painful and

tender nodules, on normal looking skin. It can be

found in skin or subcutaneous tissue on any body part,

especially on the face, hands, and limbs with systemic

symptoms (Bryceson and Pfaltzgraff, 1990;

Martodihardjo and Susanto, 2003).

The principle treatment of leprosy reaction consist

of antireaction medication, rest or immobilization,

analgetic or sedative to treat the pain and continue

Partogi, D., Hazlianda, C. and Dalimunthe, D.

Type 1 Leprosy Reaction in Multibacillary (MB) Leprosy Patient That Have Not Received MDT-MB Therapy.

DOI: 10.5220/0010097108710875

In Proceedings of the International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches (ICOSTEERR 2018) - Research in Industry 4.0, pages

871-875

ISBN: 978-989-758-449-7

871

antileprosy medication (Martodihardjo and Susanto,

2003).

We report a case of multibacillary leprosy with

type 1 reaction in 31 years old male patient.

2 CASE

A male, age 31 years old, Bataknese, entrepreneur,

came to Dermatology and Venereology Policlinic H.

Adam Malik General Hospital on March 2

2009

with reddish thickened skin without itchiness on his

face, body and back with reddish patch, also without

itchiness on his hand and leg since 2 weeks ago. At

first, the reddish patches were seen in his body and it

got bigger. There is history of white patches that were

not itchy on his back since 2 years ago. His body felt

unwell and he also had family problem. He never

went to seek medical advice for his condition. There

was no similar family history.

Physical examination showed his general

condition was good with good nutritional status.

Dermatological examination showed erythematous

plaques on facial, thorax, abdomen, and trunk

posterior region, erythema maculae on both superior

and inferior extremities. Examination on peripheral

nerve showed thickened auricularis magnus nerve,

there were no thickened and tenderness on ulnar

nerve, lateral popliteal nerve, and tibial posterior

nerve. There were anesthesia found in the lesion and

both inferior extremities. There were no anomalies in

motoric nerve function test.

The differential diagnoses for this patient are

multibacillary leprosy with type 1 reaction that have

not received MDT-MB, paucibacillary leprosy with

type 1 rection that have not received MDT-MB, and

urticaria. The temporary diagnosis for this patient is

multibacillary leprosy with type 1 reaction that has

not received MDT-MB.

The patient was then referred to dr. Pirngadi

General Hospital Medan to have AFB examination

and get appropriate treatment.

Bacteriological examination (AFB) from right

earlobe showed (+) 1, left earlobe showed 1(+), and

back (+) 1. The patient refused to undergo biopsy

examination. Laboratorium examination of blood and

urine sample is within normal range.

Working diagnosis for this patient is

multibacillary leprosy with type 1 reaction that has

not received MDT-MB.

The patient was advised to rest and was given

MDT-MB, which consist of Rifampicin 600

mg/month, Clofazimine 300 mg/month, and continue

with Clofazimine 50 mg/day and Dapsone 100

mg/day. For his reaction, the patient was given

Prednisone 40 mg/day (1x8 tablet/day) and the

dosage was planned to be reduced 5-10 mg every 2

weeks, Paracetamol 3x500 mg.

After 2 weeks, erythematous plaques are become

less thick and reduced; there were no new

erythematous maculae and plaques. There was no

fever. From peripheral nerve examination, we found

Figure 1. a-e First visit of the patient. (a,b,c) erythematous plaques on facialis, thorax, abdomen and posterior trunk; (d,e)

erythematous maculae on superior and inferior extremities.

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

872

Figure 2. (a) First Control, (b) erythematous plaques were reduced and less thick on facial, thorax, abdomen, and posterior

trunks region, (c) erythematous maculae were also reduced on superior extremities (d) erythematous maculae were reduced

in the inferior extremities.

Figure 3. (a,b,c) Erythematous plaques were less thick on facial, thorax, abdomen, posterior trunk; previous erythematous

maculae were not seen on superior extremities (d) erythematous maculae became less on inferior extremities.

thickened both auricularis magnus nerve, tenderness

in ulnar nerve was not found anymore, but it still can

be found on popliteal lateral nerve. Sensory function

test showed anesthesia is decreased in both inferior

extremities. Motoric nerve function test showed no

anomalies.

Prednisone dose was reduced to 30 mg/day (1x6

tablet/day). We still continue MDT-MB treatment

until 12-18 months.

After 2 weeks, in the next control, the

erythematous plaque and erythematous maculae had

reduced, and there were no new lesion were found.

The peripheral nerve examination found that there

were no thickened peripheral nerve on both

auricularis magnus, no tenderness on ulnar and lateral

popliteal, but tenderness can still be found on

posterior tibial nerve. Sensory nerve function showed

that less anesthesia on both inferior extremities. There

were no anomalies in motoric nerve function.

The prednisone dosage was lowered to 20 mg/day

(1x4 tablet/day). We continue the MDT-MB

treatment and hopefully it will be finished in 12-18

months.

The prognosis of this patient is quo ad vitam ad

bonam, quo ad functionam ad bonam, quo ad

sanationam dubia.

3 DISCUSSION

Diagnosis of leprosy can be concluded based on

cardinal signs, such as numb skin lesion, thickened

peripheral nerve lesion with tenderness and positive

Type 1 Leprosy Reaction in Multibacillary (MB) Leprosy Patient That Have Not Received MDT-MB Therapy

873

AFB examination (Hernani et al, 2004; Amirudin et

al, 2003).

From anamnesis, there are erythematous plaque

without itchiness on his face, body, and back with

erythematous patch without itchiness on his hand and

legs since 2 weeks ago. At first, the reddish patch was

seen on his body and slowly spreading. The patient

also felt feverish. The patient also said that he had

family problem and never seek medical advice for his

skin condition. Leprosy reaction is a group of acute

inflammatory sign and symptoms on leprosy skin

lesions that were considered as part of leprosy

(Martodihardjo and Susanto, 2003). Leprosy reaction

can happen to leprosy patient before, during, and after

treatment (Bryceson and Pfaltzgraff, 1990; Hernani et

al, 2004). Various factors that contributed to this

condition is physical stress caused by pregnancy or

after labor, after vaccination, infection, anaemia,

malnutrition, fatigueness, and psychological stress

that caused by shame, also drug that enhance

immunity (Hernani et al 2004, Rea and Modlin,

2008). In this case, leprosy reaction probably caused

by stress.

Dermatological examination showed

erythematous plaques on facial, thorax, abdomen, and

posterior trunk; erythematous macules on both

inferior and superior extremities. Peripheral nerve

examination showed thickened both auricularis

magnus and tenderness also shown in ulnar, lateral

popliteal, and posterior tibial nerve. Sensory nerve

function test showed anesthesia on skin lesion and

both inferior extremities. Clinical manifestation of

type 1 leprosy reaction is erythematous and

edematous skin lesion that sometimes with ulceration

and followed by tenderness and nerve disorder with

minimal systemic manifestation such as fever,

malaise, and joint pain

(Bryceson and Pfaltzgraff,

1990; Hernani et al, 2004).

Bacteriological examination (AFB) on right

earlobe is (+) 1, on left earlobe (+) 1, and back (+) 1.

This examination support MB leprosy diagnosis.

According to WHO classification in 1988, positive

AFB examination is classified as MB leprosy

(Kosasih et al, 2008).

The differential diagnoses for this patient are

multibacillary leprosy with type 1 reaction that have

not received MDT-MB, paucibacillary leprosy with

type 1 rection that have not received MDT-PB, and

urticaria. The diagnosis of paucibacillary leprosy with

leprosy reaction that have not received MDT-PB can

be removed because we found AFB (+)1 (Hernani et

al, 2004). Differential diagnosis of urticaria can be

removed based on clinical manifestation. Usually in

urticaria, the skin lesions suddenly appear and

disappear gradually. In urticaria, we will not found

AFB and sensory disorder (Aisah S, 2008).

For his treatment, the patient was given MDTMB

that consist of Rifampicin 600 mg/month,

Clofazimine 300 mg/month followed by Clofazimine

50 mg/day and Dapsone 100 mg/day with prednisone

40 mg/day (1 x 8 tablet/day, taken every morning)

with reduced dosage every 2 weeks and paracetamol

3x500 mg. The principle treatment of leprosy reaction

consist of antireaction medication, rest or

immobilization, analgetic or sedative to treat the pain

and continue antileprosy medication (Kosasih et al,

2008).

Prednisone should be started at high dose,

which is 40-80 mg/day depending on the reaction

degree of severity and taken in the morning. The

dosage is decrease gradually, 5-10 mg every 2 weeks

until reaching 5 mg. If there are no clinical

improvement, the dosage should be increase and

reevaluate (Bryceson and Pfaltzgraff, 1990; Hernani

et al, 2004).

Generally, the prognosis of this patient is good,

but there are possibilty of recurrence. After finishing

antileprosy medication for 12 weeks and avoid factors

that caused the reaction, it is hoped that the patient is

going to recover from reaction.

Nevertheless, recurrence can happen if the patient

is exposed to predispose factor (Rea and Modlin,

2008; James, 2006).

4 CONCLUSIONS

Type 1 leprosy reaction can occur before, during and

after completed MDT therapy. In this case, the type 1

leprosy reaction occurred before MDT therapy and

the trigger factor was stress.

ACKNOWLEDGEMENTS

Author wishing to acknowledge financial assistance

from Universitas Sumatera Utara.

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