Leprosy and its Inflammatory Response

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Leprosy is a disease caused by Mycobacterium leprae. The prevalence of new leprosy patients in Indonesia has decreased over time. However, leprosy patients usually experience an inflammation episode called leprosy reaction. There are two types of leprosy reactions, type 1 reaction, and type 2 reaction (Erythema nodosum leprosum). It is based on the type of immunity that plays a role. If it is not handled correctly, this reaction will lead to disability.

Type I leprosy reaction is caused by an increase in cellular immune response in the form of a slow type hypersensitivity reaction to Mycobacterium leprae antigens in the nerves and skin. This reaction is a result of the change in the balance of cell-mediated immunity (CMI) and bacilli. When a type 1 leprosy reaction occurs, there are two possible outcomes of this reaction: upgrading / reversal if there is an increase in the CMI response to the Mycobacterium leprae antigen that it leads to a tuberculoid or downgrading clinical form if there is a decrease in the CMI response to the antigen that leads to the clinical form of lepromatous.

Subpolar type of leprosy patients has unstable immunity, so they often experience repetitive type I reactions especially borderline borderline leprosy (BB) type because the number of bacilli and CMI levels are relatively balanced so it is very easy to experience changes in immune response. The prevalence of leprosy type 1 reactions reaches 8-33% of all leprosy patients. In multibacillary leprosy patients (MB), especially the BB type, the incidence reaches 70.9%. Type 1 leprosy reaction is experienced by many men and people aged 14 years and over.

Type 1 leprosy reaction will show inflammation symptom of the skin or nerves. There is redness, swelling, pain, and heat on the skin. In some instances, fever may be experienced by the patient. There are also pain and disruption in the nerves, and it may cause disability, such as paralysis and deformity.

A retrospective study conducted by the Leprosy Division of Dermatology and Venereology Outpatient Clinic RSUD Dr. Soetomo from January 2014 to December 2017 found that type 1 reactions occurred in 68 of 516 new leprosy patients (13.2%) where 60.3% were male, and 41.2% were aged between 15-34 years. Patients with type 1 reactions had some symptoms, thick red spots (80.9%) and without systemic symptoms (42.6%) and without peripheral nerve symptoms (70.6%). This reaction generally occurs during the first six months of multidrug treatment (MDT) administration. Patients who have been diagnosed with type 1 leprosy reaction were treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and sometimes combined with corticosteroids.

References showed that 6-67% of leprosy patients would experience type 1 leprosy reaction. Therefore, this reaction is a natural journey of leprosy, so the prevalence is not much different worldwide. The most type 1 reaction was found in MB type (97%) especially BB type (72.1%). The high proportion of new MB leprosy patients is caused by this type of symptom which is more visible than the papillary bacilli (PB) type or can be caused by late and irregular administration of MDT. The most common symptom that occurs most often in type 1 reactions are thickened long red blotches. Thickening long red spots is a sign of increased CMI which shows localized inflammation to the skin. Moreover, type 1 reactions may give symptoms of new spots, nodules, or a combination of the three. On the other hand, systemic or constitutional symptoms such as fever, malaise, and joint pain are rarely seen in patients with type 1 reactions because the increasing CMI makes the symptoms limited to nerves and skin. Patients with type 2 reactions often accompanied by systemic symptoms such as fever due to an increase in humoral immune response. Regarding the symptoms of peripheral nerves in type 1 reactions, there is only pain and disruption of nerve function due to increased CMI and sometimes even appear without symptoms.

Type 1 reactions frequently occur during the MDT treatment period due to excessive rise in CMI to eat fragments of germs that have died due to MDT administration. With a typical symptom of thick red spots long. If a type 1 reaction occurs, OAINS is given to mild degrees of corticosteroids to prevent further inflammation in the nerves that cause disability.

Author: Prof. Dr. dr. Cita Rosita Sigit Prakoeswa, SpKK (K), FINS-DV, FAADV

Details of the research available at:

https://e-journal.unair.ac.id/BIKK/article/view/12531

Article: Restrospective Study: Type 1 Leprosy Reaction

Ridha Ramadina Widiatma, Cita Rosita Sigit Prakoeswa

Department of Dermatology and Venereology, Faculty of Medicine, Universitas Airlangga / Dr. Soetomo General Hospital, Surabaya, Indonesiahttp://dx.doi.org/10.20473/bikk.V31.2.2019.144-149

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