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ORIGINAL ARTICLE

RETROSPECTIVE STUDY OF LEPROSY REACTIONS IN DERMATOLOGY UNIT DR.WAHIDIN SUDIROHUSODO HOSPITAL

MAKASSAR PERIOD JANUARY 2010-DECEMBER 2012

Sari Handayani Pusadan, Andi Muhammad Adam, Sitti Nur Rahmah

Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin

Sudirohusodo Hospital Makassar

ABSTRACT

Background: Leprosy reactions are immunological phenomenon that occurs before, during and after treatment of multidrug therapy (MDT) for leprosy. Leprosy reactions triggered by the onset of hypersensitivity, increased number of basil, basil or hidden appearance. Although much improved in the last 25 years, knowledge about the disease is especially common reaction is continuously developed.

Objective: To determine the profile leprosy reactions before or during treatment and after treatment at the Outpatient Unit of Dermatology Health Sciences Dr.Wahidin Sudirohusodo hospital Makassar during the period of 3 years, from January 2010 to December 2012, including number of new cases of leprosy reactions, type of leprosy, leprosy reactions type, neutrophils value , laboratory examination, level of disability.

Methods: Retrospective study by collecting data from medical records department Dr.Wahidin Sudirohusodo hospital Makassar, starting from January 2010 to December 2012.

Results: In the period 2010-2012, the number of new cases of leprosy reactions are 71 cases. Most people with leprosy reaction are LL type of leprosy by 29 people (40.85%) and ENL as many as 24 people (33.80%). The number of outpatient cases compare with hospitalization are outpatient ratio 78.88% for 56 people and hospitalized 15 people (21.15%). Increased number of neutrophils occurs in most patients by 20 people (28.17%). Based on the results of laboratory tests during treatment with MDT there were 15 people (21.13%) were anemic. Patients with impaired liver function during treatment were 8 people (11.27%) with increased SGOT and 10 men (14.08%) with an increase in SGPT. The level of disability that occurred as many as 62 cases (87.33%) have 0 degrees or mild degrees, 9 cases (12.68%) have 1 degrees.

Keywords: leprosy reactions, retrospective study

Address for correspondence : Sari Handayani Pusadan, dr., Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar Blok D.2 . Komp Perumahan Graha Mapala Permai Jl. Mapala, Makassar, South Sulawesi, Indonesia [email protected]

mailto:[email protected]

25

Sari Handayani Pusadan retrospective study of leprosy reactions in dermatology unit dr.wahidin sudirohusodo hospital

makassar period january 2010-december 2012

INTRODUCTION

Leprosy is a chronic granulo-

matous disease primarily affects the skin

and peripheral nervous system. Leprosy is

caused by Mycobacterium leprae infection.

Despite a rise in the last 25 years,

knowledge about the disease is especially

common reaction is continuously deve-

loped. (1.2).

Leprosy reactions are with episodes of

acute interruptions in the actual course of

the disease is very chronic. The reaction

can be beneficial, but can also be

detrimental called pathological immune

reaction, and the leprosy reactions

including pathological reactions. (4) There

are three types of leprosy reactions, the

RR of type 1 leprosy reaction and type 2

leprosy reaction is erythema leprosum

nodusum (ENL), and leprosy reaction type

3 lusio phenomenon. (2.3) ENL mainly

occurs in polar lepromatous and can also

be on the BL. ENL reaction is clinically

characterized by a collection of

subcutaneous and dermal nodules on the

skin that are clinically normal, pain and

soft pink light followed by fever, anorexia,

and malaise. ENL involving upper and

lower extremities and often there is a

lesion in the facial area. Lesions can

targetoid form, vesicular, pustular,

ulcerative, or necrotic. ( 4 , 5 ) Reversal

reaction (RR) is also called Type 1

reaction is known as up-grading if it leads

to a form of tuberculoid and down-grading

when it leads to the lepromatous form. RR

is more common in cases that are

undergoing treatment. Clinical features

such as RR expansion of existing lesions

but not a nodule without or with neuritis

symptoms from mild to severe. (2) Leprosy

reaction type 3, namely the phenomenon

lusio severe than reaction type 2 which is

almost similar type of reaction. Lusio

phenomenon is a vascular reaction

caused by the presence of M. Leprae in

the vascular endothelium. (1.2) There are

several factors that are considered as

factors of precipitation, such as

intercurrent infections (viral, malaria or

tuberculosis, etc.), anemia, physical and

mental stress, protective immunization

(especially vaccination against small pox),

a strong positive Mantoux test, drug use

potassium iodide and leprosy drugs,

puberty, pregnancy, childbirth or surgery.

But the precipitation factor is not known for

sure about its mechanism of action. Other

literature explains that leprosy reactions

caused by the presence of

hypersensitivity, increased number of

basil, basil or hidden appearance. (7,8)

RESEARCH OBJECTIVES

The purpose of this study was to

determine the profile of leprosy patients

who had leprosy reactions during

treatment and after treatment at the

Outpatient Unit of Dermatology

Dr.Wahidin Sudirohusodo hospital

Makassar during 3 years, from January

2010 to December 2012 which includes

number of new cases of leprosy reactions,

type of leprosy, leprosy reactions type,

neutrophils value , laboratory examination,

level of disability.

MATERIAL AND METHOD OF

RESEARCH

The research material was taken from the

medical records of new patients who have

leprosy reactions during and after

treatment in Morbus Hansen clinic Dr.

Wahidin Sudirohusodo Makassar over 3

years, starting from January 2010 -

December 2012. Cases included are new

cases ENL and RR, while the recurrent

cases and controls were not included into

it and only counted one time when the

patient first came.

http://translate.googleusercontent.com/translate_f#_ENREF_4

http://translate.googleusercontent.com/translate_f#_ENREF_5

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IJDV Vol.2 No.2 2013

RESULTS

Based on records of patients visited,

number of new cases of leprosy reactions

in the outpatient unit dermatology clinic Dr.

Wahidin Sudirohusodo Makassar during

the period January 2010 to December

2012 was 71, whereas in 2010 the number

of patients was 34, in 2011 there were 10

people and in 2012 there were 27 people

(table 1 and Chart 1).

Table 1. Number of new cases of leprosy

reactions at outpatient unit dermato-

venereology clinic Dr.Wahidin Sudiro-

husodo hospital Makassar period January

2010-December 2012.

Year Number of new cases

%

2010 34 47.89

2011 10 14.08

2012 27 38.03

Number 71 100

Chart 1. Distribution of new cases of

leprosy reactions at outpatient unit

dermatovenereology clinic Dr. Wahidin

Sudirohusodo Makassar period January

2010-December 2012.

Comparison number of leprosy

reactions based on biopsy results showed

that the majority of people with leprosy

reaction is LL type leprosy patients who

visited the outpatient unit dermato-

venereology clinic DR. Wahidin Sudiro-

husodo in 2010-2012. LL type leprosy

patients with RR were 4 cases (5.63%)

and with ENL as many as 24 cases

(33.80%), but unknown type leprosy

patients with RR were 9 cases(12.68%)

and 15 cases (21.13%) ENL (Table 2 and

Chart 2).

Table 2. New cases of leprosy reactions in

leprosy patients at outpatient unit



2010-December 2012.

Type of

reaction

LL BL BB BT TT Not

known

%

Reversal 4 3 3 1 1 9 29.58

ENL 24 6 4 - - 15 69.01

Lusio

phenomenon

1 - - - - - 1.41

Number 29 9 7 1 1 24 100

Chart 2. New cases of leprosy reactions in

leprosy patients at outpatient unit



2010-December 2012

Leprosy reactions in outpatient cases were

56 people (78.88%) and in inpatient cases

were 15 people (21.15%). Hospitalization

in leprosy reaction patients due to primary

reaction or concomitant systemic disease.

(Tables 3 and chart 3).

0

20

40

2010 2011 2012

Number of new cases

Number of new cases

0 5

10 15 20 25 30

LL

BL

BB

BT

TT

27



Table 3. Number of new cases of leprosy

reactions in outpatient and inpatient

department of Dr.Wahidin Sudirohusodo

hospital Makassar period January 2010-

December 2012.

Leprosy reactions

Outpatient Inpatient n (%)

RR 20 1 29.58

ENL 36 13 69.01

Phenomenon lusio

- 1 1.41

Number 56 15 100

Chart 3. Number of new cases of leprosy

reactions in outpatient and inpatient

department of Dr.Wahidin Sudirohusodo


December 2012.

Increased number of neutrophils occured

in most patients were 19 cases (26.76%),

while neutrophils decreased only occurred

in 1 patient (1.41%) with ENL reaction and

there are many patients who were not

examined as many as 39 people (54.93%

). Nomal neutrophil values are also

present in some patients as many as 12

people (16.91%) (Table 4 and chart 4).

Table 4. Number of neutrophils in patients

with leprosy reactions at Dr.Wahidin

Sudirohusodo hospital Makassar period

January 2010-December 2012.

Leprosy reaction

Neutrophil value n

(%) Nor-mal

Increas-ed

Decreas-ed

Not checked

RR 2 4 - 15 29,5

8

ENL 8 16 1 24 69,0

1

Lusio phenome

-non - 1 - - 1,41

Total 10 21 1 39 100

Chart 4. Comparison of neutrophils

number in leprosy reaction cases in

outpatient and inpatient department of


Makassar period January 2010-December

2012.

Results of laboratory tests during

treatment with MDT according to the type

of leprosy reactions and there were 15

anemic cases (21.13%) . Patients with

impaired liver function during treatment

there were 8 cases (11.27%) with

increased SGOT and 10 cases (14.08%)

with increased SGOT. Kidney function in

some patients were not impaired

Increased in urea and creatinine level

occurred in one patient RR with

nephrolithiasis. (table 5 and chart 5).

0 5

10 15 20 25 30 35 40

Outpatient

Inpatient

0

5

10

15

20

25

30

normal

Increased

Decreased

Not Checked

28


Table 5. Laboratory findings in patients

with leprosy reactions received MDT-MB

treatment at Dr.Wahidin Sudirohusodo


December 2012.

Chart 5. Laboratory results in patients with

leprosy reactions during treatment with

MDT-MB leprosy reaction type at



2012.

The level of disability in leprosy reactions

patients were 62 cases (87.33%) who

have mild degree disability or degree 0 .

Degree I were 9 cases (12.68). (Table 6

and chart 6).

Table 6. Level of disability in leprosy

reactions patients according to WHO at



2012.

Leprosy reactions

Degree %

0 I II

RR 19 2 - 21

ENL 42 7 - 49

Phenomenon lusio 1 0 - 1

total 62 9 - 100

Chart 6. Level of disability in leprosy

reactions patients according to WHO at



2012.

DISCUSSION

Number of visited patients were

classified as leprosy reaction in new cases

during January 2010-December 2012

were based on medical record as many as

71 new cases. Based on the results of the

biopsy showed that the majority of patients

who visited outpatient unit

dermatovenereology clinic DR. Wahidin

Sudirohusodo in 2010-2012 largely LL

type of leprosy followed by the number of

cases with BL type. Biopsy performed in

almost all patients. But there were 24

cases with unknown type of leprosy,

0

2

4

6

8

10

12

RR ENL Lusio

SGOT

SGPT

Ureum

Kreatinin

Anemia

0

10

20

30

40

50

RR ENL Lusio

Degree 0

Degree I

Degree II

Type of Leprosy

Laboratory Results

Anemia SGOT SGPT Ureum

Kreati-nin

RR 2 2 1 1 2

ENL 6 8 - - 6

Lusio - - - - -

Number 8 10 1 1 8

29



because not listed in the patient's medical

record. Diagnosis was based on clinical

manifestations, slit skin smear and biopsy

confirmation. Literature said that ENL

reactions often occured in BL leprosy type

and LL types. In our study, we found that

ENL reactions more often occurred in LL

type dan BL type leprosy patients. (5.6)

The number of cases in outpatient clinic

were 56 cases(78.88%) and in inpatient

unit were 15 cases (21.15%).

Hospitalization in leprosy reaction patients

were due to primary reaction or

concomitant systemic disease. Literature

said leprosy patients with the reaction

should be treated at the hospital for better

management . (7,9)

Based on the results of laboratory tests

neutrophils value in patients who came to

the dermatology clinic Dr. Wahidin

Sudirohusodo hospital Makassar during

the period January 2010 to December

2012 there were 21cases (29.58) had

increased neutrophils, whereas

decreased neutrophils occured only in 1

patient (1.41%) with ENL reaction and

many patients did not examined as many

as 39 people (54.93%). Nomal neutrophils

values were also present in 10 cases

(14.08%). From the literature it is said that

the ENL reaction is a reaction in which

leprosy bacilli intact and non-intact into

the body to form antibodies to the antigen,

and then forming immune complexes

which can precipitate in vascular. Antigen-

antibody complexes and complement it

with neutrophils release enzymes that

destroy tissue.(3.10) Results of laboratory

tests during treatment with MDT according

to the type of leprosy reactions and there

were 15 cases (21.13%) were anemic.

Patients with impaired liver function during

treatment there were 8 cases (11.27%)

with increased SGOT and 10 cases

(14.08%) with increased SGOT. Kidney

function nearly not impaired in all patients.

Increased in urea and creatinine occurred

in one patient RR with nephrolithiasis.

MDT is a combination of several

antibiotics that can affect the normal

functions of the organs, especially the liver

function so that the patients who received

MDT should always be controlled. (7,11)

Highest disability rate of our study were

obtained degree 0 or mild degrees of

disability as many as 62 cases (87.33%),

whereas degree I were found in 9 cases

(12.68%). Disability in leprosy occurs due

to damage of sensory nerves, motoric and

autonomic . (5.7)

REFERENCES

1. Lockwood DNJ. Leprosy. In: Burns T,

Breathnach S, editors. Rook's

Textbook of Dermatology. New York:

Wiley-Blackwell; 2010. p. 1469-88.

2. Amiruddin MD. Leprosy: A Clinical

Approach. New York: International

Brillian; 2012.

3. Feuth M, Brandsma JW, Faber WR,

Bhattarai B, Feuth T, Anderson AM.

Erythema nodosum leprosum in

Nepal: A retrospective study of clinical

features and response to treatment

with prednisolone or thalidomide. Lepr

Rev. 2008; 79:254-69.

4. Lee DJ, Rea TH, Modlin RL. Leprosy.

In: Goldsmith LA, Katz SI, Gilchrest

BA, Paller AS, Leffel DJ, Wolff K,

editors. Fitzpatrick's Dermatology in

General Medicine. New York: McGraw

Hill; 2012. p. 2253-62.

5. Walker SL, Lockwood DNJ. Leprosy.

Clin Dermatol. 2007; 25:165-72.

6. Rahmah SN, SV Mochtar, Iskandar F,

Amiruddin MD. Erythema nodosum

leprosum accompanied by side effects

corticosteroid use. Journal of Health

Sciences Dermatology. 2005; 2:1-3.

30


7. Brycesson A, Pfaltzgraft RE. Leprosy.

Edinburgh: Churchill Livingstone;

1990.

8. Burdick AE, Capo VA, Frankel SJ.

Leprosy. In: tyring SK, Lupi O, Hengge

UR, editors. Tropical Dermatology.

London: Churchill Livingstone; 2006.

p. 251-77.

9. Contin LA, Fogagnolo L, Barreto JA,

Nogueira ME, Alves CJM. Use of the

ML-Flow test as a tool in classifying

and treating leprosy. An Bras

Dermatol. 2011; 86:91-5.

10. Lyon S, Silva RC, AC Lyon, Grossi

MAF. Association of the ML Flow

serological test with slit skin smear.

Rev. Soc Trop Med Brazil. 2008;

41:23-6.

11. Lucas S. Bacterial diseases. In: Elder

DE, Elenitsas R, Johnson BL, Murphy

GF, editors. Lever's Histopathology of

the Skin. New York: Lippincott

Williams & Wilkins; 2005.

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