Case report : A Doubt Case Between Relapse of Borderline Tuberculoid Type

Leprosy and Reversal Reaction Post Multi Drugs Therapy-

Paucibacillary
Hari / Tanggal : Kamis, 8 Januari 2009
Moderator : dr. Rina Gustia, pKK
!arasum"er : dr.at#a $#d#a %enn#, pKK
&pponents : dr. %osse Ri'al, dr. $a(#u )estari
Tau*i+ Hida#at
,,- .K Kulit dan Kelamin
/K 0!1!- / R dr M -2amil ,adang
A Doubt Case between Relapse of Borderline Tuberculoid Type Leprosy and
Reversal Reaction Post Multi Drugs Therapy-Paucibacillary
Abstract
3a4+grounds: .t 5as di**i4ult to distinguis( "et5een relapse and re6ersal rea4tion a*ter 4ompleted
multi drugs t(erap#7pau4i"a4illar# 8M-T7,39 in tu"er4uloid lepros#.
:
Re7treated patients 5it( M-T
are 2usti*ied "# t(e di**i4ult# in di**erential diagnosis "et5een relapse and re6ersal rea4tion due to
limitation o* 4lini4al and la"oratorial 4riteria to distinguis( t(em.
2
$H& suggested a trial 4ourse o*
4orti4osteroids in dou"t 4ase "et5een relapse and re6ersal rea4tion.
:
Case report: $e reported one 4ase o* distinguis(ed "et5een relapse and re6ersal rea4tion a*ter
4ompleted M-T7,3 in :9 #ears old girl. .nitiall# patient diagnosed as relapse o* tu"er4uloid lepros#
"ase on anamnesis and p(#si4al e;amination. 14id *ast "a4illi 81/39 e;amination did not *ound an#
Mycobacterium leprae. Histopat(olog# e;amination result in tu"er4uloid lepros#.
!ey words" relapse, reversal reaction, tuberculoid leprosy
#ntroduction
T(ere 5as di**i4ult# to distinguis( "et5een relapse and re6ersal rea4tion a*ter
4ompleted multi drugs t(erap#7pau4i"a4illar# 8M-T7,39 in tu"er4uloid lepros#.
:
Re7treated
patients 5it( M-T are 2usti*ied "# t(e di**i4ult# in di**erential diagnosis "et5een relapse and
re6ersal rea4tion due to limitation o* 4lini4al and la"oratorial 4riteria to distinguis( t(em.
2
Re6ersal rea4tions o44urring a*ter treatment are sometimes mista+en *or a lepros# relapse,
5(i4( is a return o* t(e disease it sel*.
<

-iagnosis o* relapse a*ter M-T "ase on "ot( suspi4ion and 4on*irmation 4riteria.
Criteria *or pau4i"a4illar# 8,39 patients 5ere a*ter dis4(arge "# 4ompleted t(erap#. uspi4ion
and 4on*irmation 4riteria are stri4tl# 4lini4al 5it( slo5l# appearan4e o* ne5 lesions or
e;a4er"ation o* old lesions.
2
Completel# ne5 s+in lesions o44urring in di**erent pla4es *rom
:
t(e original lesions, parti4ularl# i* t(e# s(o5 no signs o* in*lammation, 4an suggest a relapse.
3iopsies are use*ul *or assessing possi"le relapses.
<

T(e 4riteria diagnosing relapse among t(ese 4ompleted treated patients 5as:
a9 T(e appearan4e o* ne5 s+in lesions or ne5 a4ti6it# in pre6iousl# e;isting s+in lesions or
ne5 ner6e *un4tion loss or ne5 paral#sis o* mus4les. "9 T(e *inding o* a ne5 s+in lesion or
pre6ious lesion 5it( a (ig( s+in smear "a4terial inde; 4ontaining solid7staining "a4illi. 49
Histologi4al e6iden4e o* relapse in a s+in or ner6e "iops#, 5(ere spe4i*i4 4(anges o* lepros#
5ere *ound. .* t5o o* t(e a"o6e 4riteria 5ere met, a relapse in lepros# 5as diagnosed.
=
Relapse rate in M-T "ase on data "# t(e 14tion ,rograms *or t(e >limination o*
)epros#, $H&, is 6er# lo5 80.:? per #ear *or ,3 and 0.@? per #ear *or M3 on t(e
a6erage9.
A
Relapse rate during *ollo5 up post M-T 5ere 0,0B? in t(e *irst < #ears, 0,09?
during =7@ #ears and 0,0B during B79 #ears.
@
1 stud# in Gu2arat, .ndia on :990 s(o5s a mean
relapse rate o* 0.:9? a*ter multi drug t(erap# in pau4i"a4illar# lepros#.
B
Re6ersal rea4tion o44urs in patient 5it( unsta"le "orderline diseases 8i.e.: 3T, 33 and
3)9. Clini4al *eature o* a re6ersal rea4tion is a rapidl# de6eloping in t(e appearan4e o* some
or t(e entire s+in lesion 5it( in*lammation, s5elling, redness and 5armt(.
8
T(e pat4(es are
not usuall# pain*ul, "ut t(ere ma# "e some dis4om*ort. T(e in*lammation is lo4ali'ed in t(e
s+in and t(e ner6es, t(e person does not *eel too ill and t(ere is usuall# mild *e6er. .t is
ussuall# 5it(in si; mont(s o* starting M-T. 1 *e5 patients get rea4tions later a*ter t(e
treatment (as "een su44ess*ull# 4ompleted. &n rare o44asions, a re6ersal rea4tion 4an o44ur
up to *i6e #ears a*ter treatment.
<
1nnual report o* -ermatolog#7Cenereolog# department o*
Ciptomangun+usumo Hospital, Ja+arta *rom :99<7:999 reported re6ersal rea4tion a"out
AA,@? *rom lepros# rea4tion.
9
Relapse is un4ommon, "ut it is a possi"ilit# t(at s(ould "e 4onsidered. T(e s#mptoms
o* rea4tions and o* relapse 4an "e 4on*used.
<
$H& suggested a trial 4ourse o* 4orti4osteroids
in distinguis( 4ase "et5een relapse and re6ersal rea4tion.
:
2
Case Report
1 :9 #ear7old girl 5as 4ome to -ermato7Cenereolog# outpatient -epartment o* -r.
M. -2amil Hospital ,adang on eptem"er =
t(
2008, 5it(:
Chief Co$plaint
T(ere 5ere 5(ite pat4( 5it( de4reased o* sensation on "ot( o* (er lo5er leg sin4e <,
mont(s ago.
Present illness history
T(ere 5ere 5(ite pat4( 5it( loss o* sensation on "ot( o* (er lo5er leg sin4e < mont(s ago.
.nitiall#, a"out < #ears ago t(ere 5ere 5(ite pat4(es 5it( de4reased o* sensation on t(e "a4+
side o* le*t lo5er leg. T(e pat4(es 5ere in4reased in si'e and spread to t(e *ront side le*t
lo5er leg and to t(e "a4+ side o* rig(t lo5er leg in last t(ree #ears. T(e pat4(es 5ere not
it4(#, dr# and 4o6ered "# *ine s4ales.
Her sister (ad disease li+e t(is a"out 8 #ears ago, t(e patient li*e in t(e same (ouse 5it( (er
sister.
T(ere 5as no (istor# o* pat4(es "e4ame reddis( and t(i4+ness during last t(ree #ears
*ollo5ed "# *e6er, 2oints pain and *atigue.
T(ere 5as (air loss on t(e 5(ite pat4(es.
T(ere 5as no (istor# o* (air loss on t(e e#e "ro5.
T(ere 5as no (istor# o* tenderness o* t(e *inger.
T(ere 5as no (istor# o* ul4er on t(e *oot.
T(ere 5as no (istor# o* 5ounds or ot(er s+in diseases on t(e a**e4ted area
Previous illness history
(e got 3CG 6a44ination 5(en (e 5as "a"#
(e (ad 5(ite pat4(es 5it( de4rease o* sensation in t(e "a4+ side o* le*t lo5er leg on
-e4em"er 200A and 5ent to dermatologist e;amined 14id /ast 3a4illi 81/39 5it( negati6e
result and t(en got green pa4+age o* medi4ines 8M-T7,39 *or si; mont( routinel#. T(e 5(ite
pat4(es and de4reased o* sensation "e4ame smaller t(en drug 5as stop.
T(ree mont( a*ter *inis(ed t(erap# 81ugust 200@9 5(ite pat4(es 5it( loss o* sensation on le*t
lo5er leg "e4ame larger and appeared ne5 smaller 5(ite pat4(es 5it( de4reased o* sensation
on *ront side o* le*t lo5er leg. T(e pat4( slo5l# in4reased in si'e. T(en patient got M-T7,3
again *or si; mont( routinel#. T(e 5(ite pat4(es and de4reased o* sensation "e4ame smaller
t(en drug 5as stop.
&n earl# 200B 5(ite pat4(es 5it( loss o* sensation on le*t lo5er leg "e4ame larger and
appeared ne5 5(ite pat4(es 5it( loss o* sensation on "a4+ side o* rig(t lo5er leg. T(e pat4(
slo5l# in4reased in si'e. T(ere 5ere no *e6er, pain on 2oints, *atigue a44ompanied. T(en
patient got M-T7,3 again *or si; mont( "ut no impro6ement.
%a$ily illness history
Her little sister su**ered t(e same disease a"out 8 #ears ago, and got "lue pa4+age o* medi4ine
8M-T7,3 *or 4(ildren9 regularl# *rom ,u"li4 Healt( Centre *or si; mont( and 4ure and ne6er
relapse.
&ocio-econo$ic history
(e li6ed in ,adang sin4e s(e 5as "orn.
3ot( o* (er parents 5ere *rom ,ariaman
<
(e (as middle e4onomi4 standard li6ing.
Physical e'a$ination
Cons4iousness : 4omposmentis 4ooperati6e General appearan4e : mild illness
,ulse rate : 80 ;/min 3reat( : :8 ;/min
3lood pressure : :20/90 mmHg Temperature : <B,2
0
C
3od# (eig(t : :A@ 4m 3od# 5eig(t : =2 +g
>#es : t(ere 5as no anemi4, i4teri4, lago*t(almus, or madarosis
!ose : t(ere 5as no sign o* de*ormit#
T(ora4i4 and a"domen : in normal limit
Regional l#mp( nodes : no enlargement
Der$atologic state
)o4ation : "a4+ side o* "ot( lo5er legs, *ront side o* rig(t lo5er leg
-istri"ution : lo4ali'ed
(ape/arrangement : unspe4i*i4
3order : 5ell de*ined 7 unde*ined
i'e : lenti4ular to plaDue
>**lores4ent : (#po pigmented ma4ula, 5it( *ine s4ales.

Teet( and oral mu4ous : t(ere 5ere no a"normalities
Genitalia : t(ere 5ere no a"normalities
!ail : t(ere 5ere no a"normalities
&ensibility e'a$ination
,inpri4+ : (#poest(esia on t(e lesions
)ig(t tou4( : (#poest(esia on t(e lesions
Temperature : (#poest(esia on t(e lesions
Motoric e'a$ination
m. or"i4ularis o44uli : A
m. a"du4tor digiti minimi : A
m. interoseous dorsalis : A
m. a"du4tor polli4is "re6is : A
m. ti"ialis anterior : A
Peripheral nerves e'a$ination
!. auri4ularis magnus : no enlargement
!. ulnaris : no enlargement
!. perenous lateral : no enlargement
!. dorsalis pedis : no enlargement
Autono$ic e'a$ination:
1n(idrosis : 4annot "e e;amined
1lope4ia : present on t(e lesion
(ther abnor$alities
Madarosis : none
/a4ies leonina : none
=
0l4er : none
1"sorption : none
Mutilation : none
Contra4ture : none
Eerosis 4utis : minimal on t(e lesion
1tro*i : none
&plit s)in s$ear
14id *ast "a4illi e;amination
)e*t earlo"e : 879
Rig(t earlo"e : 879
)esion on rig(t lo5er leg : 879
)esion on le*t lo5er leg : 879
*or)ing Diagnosis
3orderline tu"er4uloid t#pe lepros# relapses.
Differential Diagnosis
3orderline tu"er4uloid t#pe lepros# 5it( late re6ersal rea4tion
&uggestion
+in "iops#
Hematolog# and "lood 4(emistr#
.no4ulation M.leprae on mouse *ootpad
+eneral Treat$ent
>;plain a"out t(e disease F etiolog#, t(e 4ourse, 4ompli4ation, and transmission o* t(e
disease and possi"ilit# o* rea4tion on t(e 4ourse o* t(e disease
&"ser6ation o* t(e lesions
Prognosis
Guo ad 6itam : "onam
Guo ad sanam : "onam
Guo ad 4osmeti4um : "onam
Guo ad *un4tionam : "onam
%ollow ,p (ctober -
th
.//0
A1 : !o resolution
P21 : tatus Duo
3istopathology e'a$ination result
>pidermis : T(ere 5as a *o4al atrop(# and mild (#per+eratosis
-ermis : T(ere 5ere *ound tu"er4le 5it( epiteloid 4ell and -atia )ang(ans 4ell around
neural and in*iltration o* lim*osit 4ells peri6as4ular, periadne+sa, perineural
and upper dermis.
Result : Mor"us Hansen Tu"er4uloid
A
Laboratory result"
Routine "lood H" : :2,= g? 8:2 H :@ g?9
)eu4o4#te : BB00 / mm 8A0007:0.0009
-C : 0/</:/@B/28/@ 807:/:7</27@/A07B0/27=0/2789
)>- : 2= / *isrt (our
3lood 4(emistr# : 3lood glu4ose : 90 mg? 8I:20 mg?9
0reum : 2: mg? 820 7 =09
Creatinin : 0,8 mg? 80,@ H :,:9
!atrium : :<8 mg? 8:<A H :=89
Kalium : =,8 mg ? 8<,A H @9
G&T : :2 0/) 8A H :B9
G,T : :B 0/) 8A H 2<9
*or)ing Diagnosis
3orderline tu"er4uloid t#pe lepros# relapses.
Differential Diagnosis
3orderline tu"er4uloid t#pe lepros# 5it( late re6ersal rea4tion
+eneral Treat$ent
&"ser6ation o* t(e lesions
%ollow ,p
=7::72008 :97::72008 <7:272008 :B7:272008
1/ !o resolution
ome time
mild *e6er
and 2oint pain
Histor#
slig(tl#
redness and
5armt( on
t(e 5(ite
pat4(es
$(ite pat4(
"e4ame
smaller and
dar+er
$(ite pat4(
"e4ame
smaller and
dar+er
$(ite pat4(
"e4ame
smaller and
dar+er
,>/ tD -e4reased o*
(#po7
pigmented
ma4ule
-e4reased o*
(#po7
pigmented
ma4ule
-e4reased o*
(#po7
pigmented
ma4ule
-/ )ate re6ersal
rea4tion
)ate re6ersal
rea4tion
)ate re6ersal
rea4tion
)ate re6ersal
rea4tion
T(e/ Metil
prednisolon
:;2= mg/da#
Metil
prednisolon
:;20 mg/da#
Metil
prednisolon
:;:@ mg/da#
Metil
prednisolon
:;:2 mg/da#
@
Discussion
$e reported a dou"t 4ase "et5een relapse and re6ersal rea4tion a*ter 4ompleted M-T
,3 in :9 #ears old girl. .nitiall# patient diagnosed as relapse o* tu"er4uloid lepros# diagnosed
"ase on anamnesis and p(#si4al e;amination. T(e diagnosis o* Mor"us Hansen in t(is patient
"ase on 4ardinal sign o* lepros# 5(i4( are: :. Anesthesia. 2. T(i4+ened o* t(e ner6es on
predile4tion. <. +in lesion. =. 14id *ast "a4illi in slit s+in smear. .n t(is patient 5e *ind t5o
o* t(e 4ardinal signs 5(i4( anest(esia and s+in lesions to made diagnosis o* lepros#.
To 4lassi*# t(e patient in t(e spe4trum 5as "ased on 4lini4al *indings, la"orator# *inding
and (istopat(olog# *inding. 1/3 e;amination *rom slit s+in smear *ound negati6e result.
Histopat(olog# e;amination *ound tu"er4le 5it( epiteloid 4ell and -atia )ang(ans 4ell
around neural and in*iltration o* l#mp(o4#tes 4ells peri76as4ular, peri7apendagge, peri7neural
and upper dermis t(at usuall# *ound in tu"er4uloid t#pe. .n t(is 4ase t(ere 5ere no pre6ious
(istopat(olog# e;aminations. T(e patient 5as o"ser6ed *or *our 5ee+s and *ound no
resolution.
Clini4all# it 5as di**i4ult to distinguis( "et5een relapse and re6ersal rea4tion a*ter
4ompleted multi drugs t(erap#7pau4i"a4illar# 8M-T7,39 in tu"er4uloid lepros#.
:
.n t(is
patient t(ere 5ere no 4lassi4al sign o* re6ersal rea4tion. $e *ind ne5 lesion 5it(out s#stemi4
sign and t(e lesion slo5l# progress t(ere 5ere un+no5n signs o* in*lammation. .t 5as
pro"a"l# 4aused "# minimal sign o* in*lammation so t(e patient did not re4ogni'e t(at.
Histologi4al *indings s(o5 a s(i*t o* 4lassi*i4ation to5ard tu"er4uloid, edema is
present and in4reased num"ers o* de*ensi6e 4ells su4( as l#mp(o4#tes, epiteloid 4ells and
giant 4ells.
8
.n t(is 4ase t(ere 5ere no "iopsies *rom pre6ious spe4imen, "ut 5e *ind
in*iltration o* l#mp(o4#tes alt(oug( 4annot pro6ed in4reasing in num"er.
1 trial 4ourse o* 4orti4osteroids in t(e dou"t 4ases "ase on t(e assumption t(at
t(erapeuti4 4orti4osteroids 5ill suppress a re6ersal rea4tion and pre6ent ner6e damage, "ut
t(e treatment 5ould onl# partiall# and temporall# suppress a rea4tion. .n t(e ot(er (and
suppressed immune response "# 4orti4osteroid 4aused t(e rest o* 6ia"le "a4teria 5ould "e
multipl# during t(is period o* 4orti4osteroids imunosuppression. o i* t(at enoug( a4id *ast
"a4illus mig(t "e dete4ted "# smears.
:

Mouse pad ino4ulation *rom suspe4ted relapse patient 5ould raise 6ia"le lepros#
"a4illi and not present in re6ersal patient due to respond to antigens *rom dead "a4illi.
:
Relapse in lepros# 4an 4ause "# re7in*e4tion or persisten4e o* t(e 4ausati6e agent 8M leprae9
5(i4( t(ere 5as no total elimination o* t(e 4ausati6e agent "# M-T.
@,:0
T(e o44urren4e o*
B
drug7resistant "a4illi 4ould 4ause a relapse eit(er. ,ersistent "a4illi remain dormant in tissues
5(ere drugs do not penetrate. ,ro"a"l# t(e small num"er o* "a4illi remained 6ia"le a*ter
potent 4(emot(erap# is ta+en 4are o* "# t(e "od#Js general immune s#stem to pre6enting
relapse o* t(e disease.
Ho5e6er, in pra4ti4e relapse is not a signi*i4ant pro"lem. .t is Duoted t(at t(e relapse
rate is 5ell "elo5 :? 5it( $H&7multi drug t(erap# 8$H&7M-T9. .n a Duestion sur6e#
organi'ed "# $H&, data o"tained *rom <0 4enters *rom :B 4ountries s(o5ed an o6erall
relapse rate o* 0,A:? to 2,< ? patient #ears.
@
R2%2R24C2&
8
:. $aters M/R. -istinguis(ing "et5een relapse and late re6ersal rea4tion in multi drugs
treated 3T lepros#. )epros# Re6ie5. 200:F B2:2A07<.
2. 3rito M/M, Eimenes R11, Gallo M>!. Re7treatment o* lepros# relapses. 1nnual
3rasilia -ermatolog#. 200AF 80: <: 2AA7@0.
<. .)>,. Ho5 to Re4ogni'e and Manage )epros# Rea4tions. )ondon. 2002F 97:0.
=. $u GE, %in %,, Huo $, %u %H, K(ang )/, C(eng EH, et al. 1 stud# on a possi"ilit#
o* predi4ting earl# relapse in lepros# using a !-7&731 "ased >).1. .nternational
Journal o* )epros# and &t(er M#4o"a4terial -iseases . 2002F B0: <: 8079
A. Ge"re , aunderson ,, 3#ass ,. Relapse a*ter *i;ed duration multi drug t(erap#: t(e
1M/> 4o(ort. )epros# Re6ie5. 2000F B:: <2A7<:
@. Ge"re ., aunderson ,, 3#ass ,. T(e ris+ o* relapse a*ter multi drug t(erap# in
lepros#. .nternational Journal o* )epros# and &t(er M#4o"a4terial -iseases. 200<F B::
<: B27
B. C(opra !K, 1gara5al J, ,and#a ,G. 1 stud# o* relapse in pau4i"a4illar# lepros# in
a multidrug t(erap# pro2e4t, 3aroda -istri4t, .ndia. )epros# Re6ie5. :990F @:: 2::AB7
@2.
8. Jopling $H, M4-ougall 1C. Hand"oo+ o* )epros#. /i*t( edition. !e5 -el(i: C3
pu"lis(er and distri"utorsF :99@: 82790.
9. 1ndriani -, Triestiana5ati $. .munopatogenesis Rea+si Re6ersal ,ada ,en#a+it
)epra. M-C.. 200:F 28:2: 8:7B.
:0. Magan2et, 3(arti R. Relapse, re7in*e4tion or in adeDuate M-TL .ndian Journal
-ermatolog# Cenereolog# and )eprolog#. :99@F @2: =A7@.
9