Module 3 a REACTIONS NEURITIS REACTIONS The appearance

Module 3 a: REACTIONS & NEURITIS

REACTIONS: The appearance of systemic or localized signs of acute inflammation on patients with leprosy or who have had leprosy. Reactions can occur before diagnosis, during treatment, and even after cure.

2 TYPES OF REACTIONS: Type 1: Reversal Reaction An effect of increased immune system response to bacilli or fragments of bacilli. This leads to an acute, localized, cell mediated inflammatory response. Affects both PB and MB patients.

2 TYPES OF REACTIONS: Type 2: Erythema Nodosum Leprosum Only affects MB patients. Results when large numbers of Mycobacterium leprae are killed and decompose. The proteins from dead bacilli cause an allergic reaction.

Most impairments occur during reactions. i

This is because of peripheral nerve inflammation which manifests in two (2) ways: 1. The nerve is enlarged and/or very painful.

This is because of peripheral nerve inflammation which manifests in two (2) ways: 2. “Silent neuritis” in which the patient may not complain but there is significant clinical evidence of nerve function impairment by decrease of sensation and/or decrease in muscle strength.

The onset of any of the signs and symptoms of a reaction warrants immediate and appropriate action to prevent irreversible damage.

These signs and symptoms are: 1. Red, swollen skin patches; 2. Fever, myalgia, body malaise; 3. Acute nerve pain or tenderness; 4. Severe joint swelling and pain; 5. Recent decrease in sensitivity;

These signs and symptoms are: 6. Recent decrease in muscle strength; 7. Lagophthalmos; 8. Redness, sensitivity to light and pain in the eyes; 9. Swelling of the face, hands and feet; 10. Inflammation of the testicles.

Factors that may precipitate reactions: 1. MDT treatment; 2. Inter-current infections; 3. Anti-bacterial treatment; 4. Mental or physical stress; 5. Puberty; 6. Pregnancy and lactation; 7. Surgery.

MEDICAL MANAGEMENT: When signs of reaction and/or neuritis are found, ACT IMMEDIATELY!

Management of Mild Reversal or ENL Reaction: Features • Mildly swollen lesion. • Mild fever. Management • Give only analgesics. • Do Nerve Function Assessment (NFA) every two (2) weeks. • Advise bed rest. • Continue MDT.

Management of Severe Reversal Reaction: Features • Nerve damage of less than 12 months (muscle weakness, loss of sensation, and/or nerve pain) • Nerve tenderness • Swollen lesion(s) in the face. Management • Give the prescribed WHO Prednisone treatment. • Continue MDT • Do NFA every two (2) weeks. • Refer patients with persistent, recurrent & non-responding reactions.

Management of Severe ENL Reaction: Features • • • High fever. Reddish nodules Painful neuritis. Joint pain. Skin ulceration Orchitis, iritis, ostitis, nephritis, swollen hands, feet & face. Management • Give the prescribed WHO Prednisone treatment. • Continue MDT • Do NFA every two (2) weeks. • Refer patients with persistent, recurrent & non-responding reactions.

WHO Recommended Prednisone Regimen (for adults) • 1 st & 2 nd week: 40 mg / day (or approx • • • 1 mg / kg body weight) 3 rd & 4 th week: 30 mg / day 5 th & 6 th week: 20 mg / day 7 th & 8 th week: 15 mg / day 9 th & 10 th week: 10 mg / day 11 th & 12 th week: 5 mg / day

Prednisone should be taken in the morning after a full meal. i Duration of Prednisone treatment is 12 weeks but taper only until patient recovers sensation and muscle force.

Reaction and neuritis may occur for up to 3 years after MDT treatment. i That is why it is often mistaken for cases of relapse. In such cases, MDT need not be restarted, but the appropriate treatment of the reaction is essential.

Contraindications to Prednisone Treatment: Absolute: • Peptic ulcer; • Psychosis or depression; • Acute or chronic bacterial infection.

Contraindications to Prednisone Treatment: Relative: • Diabetes mellitus; • Lack of cooperation; • Hypertension; • Mature cataract; • Glaucoma; • Age below 15 years; • Pregnancy; • Age over 60. • Ulceration;

If Prednisone is contraindicated or insufficient to control recurrence, give: Clofazimine: • 300 mg / day during the 1 st month. • 200 mg / day during the 2 nd month. • 100 mg / day during the 3 rd month.

Distinguishing Features Between Reaction and Relapse: Feature Onset Reaction Relapse Sudden Slow & insidious (within a few hours) (weeks or months)

Distinguishing Features Between Reaction and Relapse: Feature Reaction Time of Generally occurs Onset during chemotherapy, but may occur up to 3 years after stopping treatment. Relapse Generally occurs long after chemotherapy is discontinued, after an interval of at least 6 months, but usually after 2 years.

Distinguishing Features Between Reaction and Relapse: Feature Old Lesions Reaction Some or all the existing lesions become erythematous, shiny or swollen. Relapse The margins of some may become erythematous.

Distinguishing Features Between Reaction and Relapse: Feature New Lesions Reaction Previously undetected lesions may become visible. Relapse Few, but always in different sites than previous lesions.

Distinguishing Features Between Reaction and Relapse: Ulceration Feature Reaction Sometimes. Relapse Unusual.

Distinguishing Features Between Reaction and Relapse: Feature Scaling Reaction Lesions desquamate as they subside. Relapse Absent.

Distinguishing Features Between Reaction and Relapse: Nerve Involvement Feature Reaction Common: many nerves may rapidly become painful and tender; disturbances develop rapidly. Relapse A single nerve becomes involved; disturbances develop slowly.

Distinguishing Features Between Reaction and Relapse: General Condition Feature Reaction Relapse Fever and malaise Not affected. are common features of Type 2 reaction (Erythema Nodosum Leprosum).

Distinguishing Features Between Reaction and Relapse: Response to Prednisone Feature Reaction Excellent. Relapse Lesions do not subside with Prednisone.

Distinguishing Features Between Reaction and Relapse: Drug Compliance Feature Reaction May have been good. Relapse Poor.

A relapse case should be started on the standard MDT regimen.