ERYTHEMA NODOSUM LEPROSUM

Caroline Prisilia Marsella C111 08 268 Anton Suhuyanli C111 08 260 Yulianto Arifin Djie C111 08 351

CASE REPORT
Name

: Mr. R Age : 30 years old Address : jln. Asrama Haji Add. Date : 9 June 2012 No. Reg. : 527198

ANAMESIS
Chief

complain

: Bump at the all over

body. Brief anamnesis : At the first time (2 months ago), bump just at the hand then become all over body since 1 week ago. Sometimes patient felt pain & itchy on those bump. History of fever (+) 1 month ago. History of taking MDT since 4 months ago.

PRESENT STATUS
General status : Moderate illness Conciousness : Composmentis Nutritional status: Good nourished Vital sign :

BP HR RR Temp

: 100/60 mmHg : 90 x/minute : 24 x/minute : 37,2 0C

PHYSICAL EXAMINATION
Great

auricular nerve dextra enlargement Ulnar nerve dextra & sinistra neuritis.

DERMATOVENEROLOGY

FACE : Right : Plaque erythematous, well-defined.

Left : One nodule erythematous, well-defined.

Right arm : One plaque erythematous, well-defined, with lichenification

BODY : 3 nodules eritemaotus, well-defined.

Plaques & nodules erythematous, well-defined (right leg) and macules erythematous (left leg)

LABORATORY RESULT
RBC : 3,77 x 10 6 U/L WBC : 5,14 x 103 U/L PLT : 326.000 U/L HB : 12,1 g/dL HCT : 37,9% GDS : 147 mg/dL Ureum : 16 mg/dL Creatinine : 1,03 mg/dL SGOT : 31 mg/dL SGP T : 71 mg/dL

RESUME
A man, 30 years old, came to hospital with chief complain bump at the all over body since 1 week ago. At the first time (2 months ago), bump just at the hand then become all over body since 1 week ago. Sometimes patient felt pain & itchy on those bump. History of fever (+) 1 month ago. History of taking MDT since 4 months ago till now. In the physical examination, there are great auricular nerve dextra enlargement & ulnar nerve dextra et sinistra neuritis. In the dermatovenerology examination, there are nodules, plaques, & macules erythematous, well-defined at all over body.

TREATMENT
Prednison

40 mg/day Paracetamol 3 x 500 mg

ERYTHEMA NODOSUM LEPROSUM

DEFINITION
Erythema

nodosum leprosum is a type 2 leprosy reaction.

Reactions

can occur in patients with multy-bacillary disease, LL, and BL. They may occur spontaneously or whilst on treatment.

ETIOLOGY
Activation

humoral immune reaction at the leprosy patient (that infected Mycobacterium leprae before)

PATHOGENESIS
Excessive humoral immune reaction Formation of immune complexes

Small vessel vasculitis

Effect to cutaneus & systemic (e.g. joint, eye, scrotum, lymphatic system, hepatic, and spleen)

CLINICAL FINDING
Constitutional

symptom : Fever, myalgia,

malaise.
Can

many organs: cutaneous(nodule erythematous, painfull), neuritis, nerve dysfunction, and the other organ such as uveitis, orchitis, iridocyclitis, lymphadenitis) occur till 3 weeks or more.

Can

Symptom & sign

Cutaneus

Mild reaction
Nodul erythematous, painful, do not much, occur till2-3 days (-) (-)

Severe reaction
Nodul erythematous, painful, ulceration, much, occur more than 2-3 days (+) (+)

Neuritis & nerve dysfunction Other organ affected

DIAGNOSIS
Clinical

manifestation Diagnosis leprosy type MB Skin smear History of taking MDT

TREATMENT
Avoid ignite factors (e.g. stress, infection disease, etc) PREDNISON Adult :

40 mg/day 2 week (1st) 30 mg/day 2 week (2nd) 20 mg/day 2 week (3rd) 15 mg/day 2 week (4th) 10 mg/day 2 week (5th) 5 mg/day 2 week (6th)

For recurrent ENL we can add Clophazimine

3x100 mg/day 2 months (1st) 2x100 mg/day 2 months (2nd) 1x100 mg/day 2 months (3rd)

Children :

1 mg/kgBB max. 12 weeks.

DIFFERENTIAL DIAGNOSIS ERITHEMA NODOSUM

Nodule erythematous, symetric, warm, tender , No ulceration. Most common in lower extremity

SARCOIDOSIS

Plaque yellow red, apple jelly appereance Most common in head & neck

PROGNOSIS
If

untreated, the disease will be progresive, with morbidity occasioned by nerve injury and target organ damage. If with adequate treatment, can reduce target organ damage. The other hand, we have to follow-up dosage and side effect prednison to prevent side effect of therapy & monitor target of therapy.