File Presentation Type i Leprosy Reaction Khunadi Hubaya

TYPE I LEPROSY REACTION

KHUNADI HUBAYADERMATOVENEREOLOGY DEPARTMENT OF

TUGUREJO GENERAL HOSPITAL, SEMARANG, CENTRAL JAVA, INDONESIA

PRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011

INTRODUCTION

• Leprosy Reaction

State of symptoms and signs of acute inflammation in the lesions

of leprosy

patients immunological disorder caused by hypersensitive reaction of M.leprae antigens.

Fifty percent (50%) of treated leprosy patients reactionsPRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011

Reaction occurs :• Leprosy occurs • Occur due to of immunological changes

as a result of anti–leprosy treatment • Occur spontaneously other infectious dis-

eases, anemia, mental and physical stress, puberty, pregnancy, childbirth, surgery.

Anti-leprosy treatment most frequent trig-ger factors


TYPE I LEPROSY REACTION • T I LR = upgrading reaction, borderline reac-

tion, tuberculoid reaction, leprosy non-lepromatous reaction

• Occurs in 30% of patients with borderline lep-rosy (BT, BB, BL)

• Appears in: - First 6 months of treatment - Occur 2 years af-ter the first treatment - Not received therapy

• Jopling : delayed hypersensitivity reaction (type IV hypersensitivity reactions Coombs and Gell )PRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011

• Antigens from dead bacilli will react with T lymphocytes changes in cel-luler immune system.

• Result : upgrading/reversal to tubercu-loid form ( increase cellular immune system )

down grading to lepromatous form ( decrease cellular immune sys-tem)

• In fact, the type 1 reaction = reversal reaction most often encoun-tered, down grading reaction is rarer


CINICAL FEATURES

• Prominent and shiny erythematous plaques, few days later, the color can change to purplish or brown-ish. The firm edge of the lesion, pressurized pain or feels hot when touched.

• In severe reactions desquamation or ulceration due to necrosis.


• New lesions may show subclinical le-sions

Neuritis of the nerves are located super-ficially.

Mild neuritis, painless enlarged nerves, anesthesia , paralysis.

• In severe cases nerve enlargement, spontaneous or pressurized pain, anesthesia on the dermatomes.


• The biggest cause nerve function damage (30% patients) claw hand, drop foot, facial palsy with or without lagoph-talmus , keratitis.

• Mild systemic symptoms : facial and leg edema.

• Severe symptoms: malaise, fever, face hands and leg edema

Histopathological: epitheloidcell granuloma edema, dermal edema, plasma cells and granuloma fraction PRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011

INFLUECE OF ANXIETY ON THE IMMUNE SYSTEM (WEBSTER, 1998)

Person experiences excessive anxiety symptoms CRH (Cortico Releas-ing Hormone) release catecholamin hormone more than the glucocorti-coid.

Catecholamin hormone stimulate macrophages stimulate IL – 1O


increasing the formation of T-helper cell (Th-2) more humoral immu-nity will be formed Manifesta-tion type 2 leprosy reaction.

Minute glucocorticoid macrophage to slightly stimulate IL - 12 to secrete Th-1 cells the formed cellular immunity will be small Manifestation type 1 leprosy reaction


MANAGEMENT

• Rest or immobilization• Elimination of triggering factor• Continuing treatment of anti-leprosy

drugs• Analgesic sedatives to cope with pain• Provision of anti reaction drugs


Mild reaction •Nonmedicamentosa: rest, immobiliza-tion

•Medicamentosa: paracetamol, mefe-namic acid, aspirin, piroxicam, di-clofenac sodium,cyclooxygenase 2 (COX 2)

Severe reaction• Improvement of general condition by im-proving fluid/electrolyte balance

• Must be given corticosteroid PRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011

Provision of Corticosteroid

• Prednisone 40-60 mg/day single morning dose, tapering slowly until a few months/ years.

• Corticosteroid > one month, required minimum dose and alternate-day treat-ment

• Prednisone or prednisolone of 0.5 to 1.0 mg/BB kg/day single morning dose, tapering slowly and alternate-day treatment is more tolerated. PRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011

• Hospital for Tropical Diseases in Lon-don: prednisolone 30-40 mg taper-ing to zero over a period of 5-6 months.

• Prednisolone 30 mg/day, slowly ta-pered to zero up to 20 weeks is better than 60mg/day tapered up to 12 weeks.

• Cyclosporin 5-10 mg/BB kg/day used if steroid fail,or as a steroid sparing agent.


• Reported that a case of borderline lepromatous

leprosy with type 1 leprosy reaction

treated with prednisolone 1 mg/BB kg/

day for 4 weeks treatment condition

did not improve and the skin lesions re-

mained painful given topical therapy of

0.1% tacrolimus ointment twice daily

healing of all skin lesions after 2 weeks and

prednisolone dose become zero over a period

of 12 weeks of treatment


• Tacrolimus: immunomodulatory and immuno suppressive agent

• Surgery

During the treatment failure in the repair of some nerve function ex-ploratory surgery to relieve me-chanical compression


Tugurejo General Hospital Semarang

Uses corticosteroid treatment :methylprednisolone dose = prednisone/prednisolone dependence and the side effect is smaller.

Astaxanthin 4 mg, twice a day orally, astaxanthin a strong antioxidant po-tential against strong free radicals and having anti inflammatory effects by inhibiting cytokin and chemokin

• 10


• Zinc 200 mg a day orally stabilizing the cell membrane, machrophage and mast cells that play a role in the immune system.

Changes in zinc metabolism function of immune cells to become abnormal.

Zinc supplementation improve of zinc metabolism increasing immune re-sponse against M.Leprae.


Tgl 9 Oktober 2009 hari pertama


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Tgl tgl 26 Oktober 2009 (hari ke17)


Tgl 24 November 2009 (hari ke 45)


“leprosy work is not merely medical relief; it is transforming frustration of life into joy of dedication, personal ambition into selfless service”Mahatma Gandhi

Sandra Dewi, Duta Lepra Indonesia


File Presentation Type i Leprosy Reaction Khunadi Hubaya

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