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Type 2 lepra reaction in an immunocompromised patient precipitated by filariasis.

Singh SK, Sharma T, Rai T, Prabhu A - Indian J Sex Transm Dis (2014)

Bottom Line: We are presenting a case report of 35-year-old male affected with AIDS, tubercular lymphadenitis, and lepromatous leprosy with recurrent episodes of type 2 lepra reaction manifesting as erythema nodosum leprosum (ENL).The patient was treated with 100 mg thalidomide daily, 300 mg diethylcarbamazine, and modified multidrug therapy (MDT) for leprosy.He responded well and has not had any further reaction in the last 6 months.

View Article: PubMed Central - PubMed

Affiliation: Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.

ABSTRACT
Though patients affected with both acquired immuno deficiency syndrome (AIDS) and leprosy commonly present with type 1 lepra reaction, there are few isolated reports of type 2 lepra reaction in retropositive patients affected with leprosy. We are presenting a case report of 35-year-old male affected with AIDS, tubercular lymphadenitis, and lepromatous leprosy with recurrent episodes of type 2 lepra reaction manifesting as erythema nodosum leprosum (ENL). Dipstick enzyme-linked immunosorbent assay (ELISA) for filarial antigen was also positive. The patient was treated with 100 mg thalidomide daily, 300 mg diethylcarbamazine, and modified multidrug therapy (MDT) for leprosy. He responded well and has not had any further reaction in the last 6 months.

No MeSH data available.


Related in: MedlinePlus

Skin-slit smear examination showing 6+ acid-fast bacilli
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Figure 3: Skin-slit smear examination showing 6+ acid-fast bacilli

Mentions: Patient was on antiretroviral therapy (ART) for past 1 year with zidovudine, lamivudine, and efavirenz. He had inguinal lymphadenitis 7 months ago for which fine needle aspiration cytology was done which showed tubercular lymphadenitis, and antitubercular treatment (ATT) was instituted. He is now taking isoniazid 300 mg, rifampicin 450 mg, and ethambutol 825 mg. He had taken MDT twice in the past year for multibacillary leprosy and was a defaulter. On examination, patient was febrile on presentation and emaciated with body mass inde ×18.5 kg/m2. Severe pallor with bilateral pitting pedal edema was noted. There was glove and stocking anesthesia on bilateral hands and feet with thickening of right superficial radial, bilateral ulnar, and common peroneal nerve. Patient had tender erythematous nodules on his face, upper limbs, upper trunk, and ears [Figures 1 and 2]. There was no associated nerve tenderness, testicular swelling, lymphadenopathy, ocular pain, or photophobia. His investigations showed severe anemia with hemoglobin (Hb) 4.4 g% and mean corpuscular volume (MCV) 77 fl, and total count was 3,700 cells/mm3, but his differential count was normal. Absolute CD4 lymphocyte count was 90 cells/μl and dipstick enzyme-linked immunosorbent assay (ELISA) for filarial antigen was positive. His liver and renal function tests, chest X-ray, X-ray of bilateral knee joints, and urine routine were within normal limits. Blood and stool culture and streptococcal throat swab showed no growth of organisms and his Widal test for typhoid and microscopy for malarial parasite was negative. Skin-slit smear was 6+ for acid-fast bacilli (AFB) [Figure 3]. Biopsy from a nodule showed superficial and deep periadnexal granulomatous inflammation with neutrophils and nuclear debris around vessels [Figure 4]. Lepra stain showed fragmented AFB. Based on the above, a diagnosis of AIDS, lepromatous leprosy with type 2 lepra reaction manifesting as ENL, tubercular lymphadenitis, and filariasis was made. The patient was started on clofazimine 50 mg daily and monthly 300 mg supervised dose, rifampicin 150 mg monthly, ofloxacin 200 mg twice daily, thalidomide 100 mg daily, and diethylcarbamazine 100 mg thrice daily with iron supplements. Dapsone was stopped due to fear of further hemolysis and zidovudine was stopped for suspicion of bone marrow suppression. The patient improved dramatically and his lesions resolved within 1 week. The patient is on our follow-up and free from any reaction.


Type 2 lepra reaction in an immunocompromised patient precipitated by filariasis.

Singh SK, Sharma T, Rai T, Prabhu A - Indian J Sex Transm Dis (2014)

Skin-slit smear examination showing 6+ acid-fast bacilli
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4066596&req=5

Figure 3: Skin-slit smear examination showing 6+ acid-fast bacilli
Mentions: Patient was on antiretroviral therapy (ART) for past 1 year with zidovudine, lamivudine, and efavirenz. He had inguinal lymphadenitis 7 months ago for which fine needle aspiration cytology was done which showed tubercular lymphadenitis, and antitubercular treatment (ATT) was instituted. He is now taking isoniazid 300 mg, rifampicin 450 mg, and ethambutol 825 mg. He had taken MDT twice in the past year for multibacillary leprosy and was a defaulter. On examination, patient was febrile on presentation and emaciated with body mass inde ×18.5 kg/m2. Severe pallor with bilateral pitting pedal edema was noted. There was glove and stocking anesthesia on bilateral hands and feet with thickening of right superficial radial, bilateral ulnar, and common peroneal nerve. Patient had tender erythematous nodules on his face, upper limbs, upper trunk, and ears [Figures 1 and 2]. There was no associated nerve tenderness, testicular swelling, lymphadenopathy, ocular pain, or photophobia. His investigations showed severe anemia with hemoglobin (Hb) 4.4 g% and mean corpuscular volume (MCV) 77 fl, and total count was 3,700 cells/mm3, but his differential count was normal. Absolute CD4 lymphocyte count was 90 cells/μl and dipstick enzyme-linked immunosorbent assay (ELISA) for filarial antigen was positive. His liver and renal function tests, chest X-ray, X-ray of bilateral knee joints, and urine routine were within normal limits. Blood and stool culture and streptococcal throat swab showed no growth of organisms and his Widal test for typhoid and microscopy for malarial parasite was negative. Skin-slit smear was 6+ for acid-fast bacilli (AFB) [Figure 3]. Biopsy from a nodule showed superficial and deep periadnexal granulomatous inflammation with neutrophils and nuclear debris around vessels [Figure 4]. Lepra stain showed fragmented AFB. Based on the above, a diagnosis of AIDS, lepromatous leprosy with type 2 lepra reaction manifesting as ENL, tubercular lymphadenitis, and filariasis was made. The patient was started on clofazimine 50 mg daily and monthly 300 mg supervised dose, rifampicin 150 mg monthly, ofloxacin 200 mg twice daily, thalidomide 100 mg daily, and diethylcarbamazine 100 mg thrice daily with iron supplements. Dapsone was stopped due to fear of further hemolysis and zidovudine was stopped for suspicion of bone marrow suppression. The patient improved dramatically and his lesions resolved within 1 week. The patient is on our follow-up and free from any reaction.

Bottom Line: We are presenting a case report of 35-year-old male affected with AIDS, tubercular lymphadenitis, and lepromatous leprosy with recurrent episodes of type 2 lepra reaction manifesting as erythema nodosum leprosum (ENL).The patient was treated with 100 mg thalidomide daily, 300 mg diethylcarbamazine, and modified multidrug therapy (MDT) for leprosy.He responded well and has not had any further reaction in the last 6 months.

View Article: PubMed Central - PubMed

Affiliation: Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.

ABSTRACT
Though patients affected with both acquired immuno deficiency syndrome (AIDS) and leprosy commonly present with type 1 lepra reaction, there are few isolated reports of type 2 lepra reaction in retropositive patients affected with leprosy. We are presenting a case report of 35-year-old male affected with AIDS, tubercular lymphadenitis, and lepromatous leprosy with recurrent episodes of type 2 lepra reaction manifesting as erythema nodosum leprosum (ENL). Dipstick enzyme-linked immunosorbent assay (ELISA) for filarial antigen was also positive. The patient was treated with 100 mg thalidomide daily, 300 mg diethylcarbamazine, and modified multidrug therapy (MDT) for leprosy. He responded well and has not had any further reaction in the last 6 months.

No MeSH data available.


Related in: MedlinePlus