Dr. Richard Wing

Communicable Disease Director, DSHS, Region 11

Harlingen, Texas

NHDP CPC 2Case 2 Jan 24 2005

•McAllen

China •

• Monterrey

• 9 ½ year old boy born in Monterrey, Mexico

• Lived with grandparents in China, Mexico until age 2

• Living in Mission, Texas for the last 7 ½ years

Mission •

• Grandfather with leg lesions for over 10 years• Mother with leg lesions 5 years ago (resolved)• Patient with leg lesions 3 years ago (resolved)• May 2005 nodular lesions to face progressing to target lesions over entire body• June 2005 biopsy done suggesting leprosy (tuberculoid)

• Multiple plaques with heavy scale; slight loss of sensation within some of the lesions

• Nasal septum with edema & mucosal erosions• Normal motor strength• Slit skin smears: knees 4+/globi; back 3+; elbows 3+; ears NF

• Enlarged right radial cutaneous & ulnar nerves

• Large plaque to palm of right hand

• Fissures at the base of the fingers

• 4th right finger swollen at proximal interphlangeal joint

• Painful with movement & tender to touch

• X-ray: bony erosion to distal end of 1st phalanx of the right 4th finger

• WHO classification: multibacillary; Ridley-Jopling classification: BT/BB

• Treatment: Dapsone 50 mg daily (1-2 mg/kg); Rifampin 300 mg daily (10 mg/kg)

• No Clofazamine given: none available to MD in south Texas & not FDA approved for use in children ( as per Dr. Pat Joyce )

• Paradoxical reaction: golf ball size lymph node swelling in right axilla 2 weeks after starting therapy

• After 3 weeks of therapy: development of bilateral hand edema, increased tenderness/induration of all lesions, & extensive desquamation of all lesions

• No new nerve findings

• Diagnosis: reversal reaction

• Treatment: Prednisone 20 mg daily; Rifampin 300 mg changed to once monthly dosing ( DOT); Dapsone remained at 50 mg daily

• Significant clinical improvement after 3 weeks of steroid therapy: flattening of lesions with fading erythema

• Same day: facial lesions show resolution of the desquamation

• Prednisone dose is decreased to 15 mg daily

• Prednisone dose subsequently decreased to 10 mg daily

• Within 2 weeks of decreasing Prednisone the patient experiences a flare-up of all lesions

• Prednisone dose now increased to 30 mg daily with a plan for a much slower taper than before

• Despite the breakthrough of the skin lesions on the lower dose of Prednisone, by this time in the therapy the swelling & pain to the right 4 th finger had completely resolved

• A little more than a month later the patient’s skin lesions have again faded

• He is tolerating the DDS/Rifampin & Prednisone without any difficulty

• No breakthrough reactions to this point with the slower steroid taper

• The patient comes to the clinic much happier than before because his skin lesions are no longer a topic of conversation among his classmates

• The grandfather comes from Mexico for an evaluation. History of ulcerations to hands/feet for more than 10 years, as well as nasal stuffiness for at least 4 years. Long history of shooting & skinning armadillos.

• Complete loss of sensation to upper & lower extremities in a stocking/glove distribution; note the amputation of the left 3rd toe due to previous gangrene

• Slit skin smears: knees/elbows 1+; ears NF• Receiving treatment in Mexico for “poor circulation”

• In a rather strange twist to the story: the patient is well-known to leprosy control in Mexico and was supposedly receiving standard multidrug therapy

• However, there is another man in his town with the same name and apparently the other man was receiving this gentleman’s leprosy medications