Transcript File - thegreentraveler.net

Module 3a:
REACTIONS &
NEURITIS
REACTIONS:
The appearance of systemic or localized
signs of acute inflammation on patients with
leprosy or who have had leprosy.
Reactions can occur before diagnosis,
during treatment, and even after cure.
2 TYPES OF REACTIONS:
Type 1: Reversal Reaction
An effect of increased immune system
response to bacilli or fragments of bacilli.
This leads to an acute, localized, cell
mediated inflammatory response.
Affects both PB and MB patients.
2 TYPES OF REACTIONS:
Type 2: Erythema Nodosum Leprosum
Only affects MB patients.
Results when large numbers of
Mycobacterium leprae are killed and
decompose.
The proteins from
dead bacilli cause an
allergic reaction.
Most impairments occur
during reactions.
i
This is because of peripheral
nerve inflammation which manifests
in two (2) ways:
1. The nerve is
enlarged and/or
very painful.
This is because of peripheral
nerve inflammation which manifests
in two (2) ways:
2. “Silent neuritis” in which the patient
may not complain but there is
significant clinical evidence of nerve
function impairment by decrease of
sensation and/or decrease in muscle
strength.
The onset of any of the signs and
symptoms of a reaction warrants immediate
and appropriate action to prevent irreversible
damage.
These signs and symptoms are:
1. Red, swollen skin patches;
2. Fever, myalgia, body malaise;
3. Acute nerve pain or tenderness;
4. Severe joint swelling and pain;
5. Recent decrease in sensitivity;
These signs and symptoms are:
6. Recent decrease in muscle strength;
7. Lagophthalmos;
8. Redness, sensitivity to light and pain in
the eyes;
9. Swelling of the face, hands and feet;
10. Inflammation of the testicles.
Factors that may precipitate reactions:
1. MDT treatment;
2. Inter-current infections;
3. Anti-bacterial treatment;
4. Mental or physical stress;
5. Puberty;
6. Pregnancy and lactation;
7. Surgery.
MEDICAL MANAGEMENT:
When signs of reaction and/or neuritis
are found, ACT IMMEDIATELY!
Management of Mild Reversal or
ENL Reaction:
Features
• Mildly swollen
lesion.
• Mild fever.
Management
• Give only analgesics.
• Do Nerve Function
Assessment (NFA)
every two (2) weeks.
• Advise bed rest.
• Continue MDT.
Management of Severe Reversal Reaction:
Features
• Nerve damage of
less than 12 months
(muscle weakness, loss of
sensation, and/or nerve
pain)
• Nerve tenderness
• Swollen lesion(s) in
the face.
Management
• Give the prescribed
WHO Prednisone
treatment.
• Continue MDT
• Do NFA every two (2)
weeks.
• Refer patients with
persistent, recurrent &
non-responding
reactions.
Management of Severe ENL Reaction:
Features
•
•
•
•
•
•
High fever.
Reddish nodules
Painful neuritis.
Joint pain.
Skin ulceration
Orchitis, iritis,
ostitis, nephritis,
swollen hands, feet
& face.
Management
• Give the prescribed
WHO Prednisone
treatment.
• Continue MDT
• Do NFA every two (2)
weeks.
• Refer patients with
persistent, recurrent &
non-responding
reactions.
WHO Recommended Prednisone Regimen
(for adults)
• 1st & 2nd week: 40mg / day (or approx
•
•
•
•
•
1mg / kg body weight)
3rd & 4th week: 30mg / day
5th & 6th week: 20mg / day
7th & 8th week: 15mg / day
9th & 10th week: 10mg / day
11th & 12th week: 5mg / day
Prednisone should be
taken in the morning after
a full meal.
i
Duration of Prednisone treatment is 12
weeks but taper only until patient recovers
sensation and muscle force.
Reaction and neuritis may
occur for up to 3 years
after MDT treatment.
i
That is why it is often mistaken for cases
of relapse.
In such cases, MDT need not be restarted,
but the appropriate treatment of the reaction is
essential.
Contraindications to Prednisone Treatment:
Absolute:
• Peptic ulcer;
• Psychosis or depression;
• Acute or chronic bacterial infection.
Contraindications to Prednisone Treatment:
Relative:
• Diabetes mellitus;
• Lack of cooperation;
• Hypertension;
• Mature cataract;
• Glaucoma;
• Age below 15 years;
• Pregnancy;
• Age over 60.
• Ulceration;
If Prednisone is contraindicated or
insufficient to control recurrence, give:
Clofazimine:
• 300mg / day during the 1st month.
• 200mg / day during the 2nd month.
• 100mg / day during the 3rd month.
Distinguishing Features
Between Reaction and Relapse:
Feature
Onset
Reaction
Relapse
Sudden
Slow & insidious
(within a few hours)
(weeks or months)
Distinguishing Features
Between Reaction and Relapse:
Feature
Reaction
Time of Generally occurs
Onset
during
chemotherapy, but
may occur up to 3
years after
stopping
treatment.
Relapse
Generally occurs
long after
chemotherapy is
discontinued, after
an interval of at
least 6 months, but
usually after 2
years.
Distinguishing Features
Between Reaction and Relapse:
Feature
Old
Lesions
Reaction
Some or all the
existing lesions
become
erythematous,
shiny or swollen.
Relapse
The margins of
some may become
erythematous.
Distinguishing Features
Between Reaction and Relapse:
Feature
New
Lesions
Reaction
Previously
undetected lesions
may become
visible.
Relapse
Few, but always in
different sites than
previous lesions.
Distinguishing Features
Between Reaction and Relapse:
Ulceration
Feature
Reaction
Sometimes.
Relapse
Unusual.
Distinguishing Features
Between Reaction and Relapse:
Feature
Scaling
Reaction
Lesions
desquamate as
they subside.
Relapse
Absent.
Distinguishing Features
Between Reaction and Relapse:
Nerve
Involvement
Feature
Reaction
Common: many
nerves may
rapidly become
painful and tender;
disturbances
develop rapidly.
Relapse
A single nerve
becomes involved;
disturbances
develop slowly.
Distinguishing Features
Between Reaction and Relapse:
General
Condition
Feature
Reaction
Relapse
Fever and malaise Not affected.
are common
features of Type 2
reaction (Erythema
Nodosum
Leprosum).
Distinguishing Features
Between Reaction and Relapse:
Response to
Prednisone
Feature
Reaction
Excellent.
Relapse
Lesions do not
subside with
Prednisone.
Distinguishing Features
Between Reaction and Relapse:
Drug
Compliance
Feature
Reaction
May have been
good.
Relapse
Poor.
A relapse case should be started on the
standard MDT regimen.