- Email: [email protected]
Reversal reaction in a patient with leprosy
Patients who continue having leprosy reactions after leprosy treatment
Reversal reaction in a patient with leprosy
Jackson Machado-Pinto, MD, PhD, Santa Casa de Belo Horizonte, Belo Horizonte, Brazil; Luiza Laborne Sousa Pinto, Santa Casa de Belo Horizonte, Belo Horizonte, Brazil; Marcos Salles Dias Pinto, Santa Casa de Belo Horizonte, Belo Horizonte, Brazil; Michelle dos Santos Diniz, MD, Santa Casa de Belo Horizonte, Belo Horizonte, Brazil
Vitor Perez, MD, Vitor Paulo de Freitas Perez, Rio de Janeiro, Brazil; Adriana Munoz, MD, Adriana Taquez Munoz, Rio de Janeiro, Brazil; Jose Nery, PhD, Jose Augusto da Costa Nery, Rio de Janeiro, Brazil; Lıvia Souza, MD, Lıvia Coelho de Souza, Rio de Janeiro, Brazil
(Poster reference number 5442)
Background: Leprosy is a curable disease, but it involves great morbidity. It causes physical incapacity and deformities besides the great damage to the quality of life. Objective: To evaluate the sociodemographic profile and the quality of life of the patients who continue, having reactions and undergoing pharmacologic treatment to suppress reactional episodes and/or neuropathic pain, after the end of leprosy treatment. Method: Transversal observational study of 20 adult patients at the dermatology clinic of Santa Casa of Belo Horizonte (Brazil). Results: Twenty percent of the patients did not have their quality of life compromised, 35% suffered little effect, 20% had a moderate compromise, and 25% had their quality of life greatly compromised. The mean DLQI score was 6.25 (moderate effect). Forty percent of the patients were female and the mean age 41.7 years. The mean education was 5.15 years of study. The mean time of treatment was 15 months, and 19 patients were multibacillary. According to multivariate analysis, the factors associated with the compromise in the quality of life were years of education and bacilloscopic index. The better the education and the lower the bacilloscopic index, the higher the compromise in the quality of life. Conclusion: Eighty percent of the patients had some compromise in their quality of life, which justifies not only proper pharmacologic treatment, but also a multidisciplinary approach for patients who continue having reactions after the end of leprosy treatment. Commercial support: None identified.
(Poster reference number 5661)
Leprosy is an infectious systemic disease that affects mainly the skin and peripheral nervous system. It presents with different clinical forms that depend on the individual immune response, with a low cell-mediated immunity in the lepromatous pole, while the opposite occurs in tuberculoid. The borderline form, considered intermediate is unstable and a continuous spectrum of disease. Reactions are changes in the immune system, manifesting as acute and subacute inflammatory manifestations that can occur before, during or after treatment with multidrug therapy. They can be divided into two types: type 1 reaction or reversal reaction and type 2 reaction, which may manifest as erythema nodosum leprosum or necrotizing (the Lucio phenomenon) or erythema multiforme. We present a 55-year-old patient, which featured a year ago, paraesthesia in lower limbs and the lateral left thigh that also showed xerosis. Tests done included Mitsuda test (negative), quantitatively scraped skin was 1.25 and cutaneous biopsy, which confirmed the diagnosis of leprosy. Based on the clinical, histopathologic, and positive skin scrapings, the patient was diagnosed with multibacillary leprosy, and started multidrug therapy with 12 doses. The patient did well; however, on the fourth dose, he returned with the appearance of infiltrated plaques, erythema, hyperesthesia, all over the skin. At this point, we had new histopathologic examination, which showed compatible findings with reverse reaction. At this time we remained multidrug therapy, and started 1 mg/kg/day of prednisone for 2 weeks. In return, the patient showed clinical improvement. The corticosteroid dose was being reduced gradually, and the patient is being followed in order to end up the leprosy treatment. Our purpose is show the importance of oral corticosteroid, which is the treatment of choice in literature and the rapid response of the patient, control and resolution of the syndrome. Commercial support: None identified.
Recurrent Campylobacter fetus infection presenting as lobular neutrophilic panniculitis
(Poster reference number 4882)
Vincent Richer, MD, Centre Hospitalier de l’Universite de Montreal, Montreal, Canada; Beno^ıt C^ ote, MD, Centre Hospitalier de l’Universite de Montreal, Montreal, Canada; Danielle Bouffard, MD, Centre Hospitalier de l’Universite de Montreal, Montreal, Canada Campylobacter fetus is a rare bacterial pathogen that causes infection mainly among immunosuppressed humans through hematogenous spread. It has been reported to cause cellulitis, meningitis, spondylodisciitis, peritonitis, mycotic aneurysms, and recurrent bacteremia. We present a case of a 70-year-old white female who presented to our dermatology clinic with a 4-month history of fluctuating subcutaneous nodules on her lowers legs, bilaterally. There was no history of diarrhea, travel, eating uncooked foods, or contact with animals. She had a history of lung transplant 9 years prior, breast cancer 12 years prior, long-standing diabetes with chronic kidney disease, treated Bowen disease of the right temple and Campylobacter fetus sepsis 6 months before presentation. She was treated with prednisone, cyclosporine, azathioprine, calcium, vitamin D, and bronchodilators. The first skin biopsy specimen revealed a rich neutrophilic infiltrate with areas of suppuration in the subcutis compatible with lobular neutrophilic panniculitis. PAS-D, Grocott, and Ziehl special stains were negative. Bacterial, fungal and mycobacterial biopsy specimen cultures were negative. A second skin biopsy showed identical histopathologic changes and tissue cultures remained negative. A third skin biopsy, nearly 6 months after presentation, demonstrated fibrosis in the reticular dermis, necrotic adipose tissue, and an inflammatory infiltrate composed primarily of neutrophils, compatible with late-stage lobular neutrophilic panniculitis. PAS-D, Grocott, and Ziehl special stains were negative, but bacterial culture yielded Campylobacter fetus 1+ growth. The patient was treated with intravenous meropenem for 8 weeks through a home IV program. Clinical resolution was evident during therapy. A high index of suspicion is required to diagnose Campylobacter fetus infection. Despite negative findings in the initial investigation, infection must be ruled out in patients presenting with neutrophilic panniculitis. Clinical, pathologic, and microbiologic correlation is required in order to diagnose and treat Campylobacter fetus infection. Commercial support: None identified.
AB112
J AM ACAD DERMATOL
Rhinoscleroma: Identification of a rare indolent infectious disease by histopathology, culture, and molecular techniques
(Poster reference number 4845)
Yung-YI Lee, MD, Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Taiwan; Ju-Hsin Chia, MD, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Jui-Hung Ko, MD, Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Taiwan; Shyue-Luen Chang, MD, Chang Gung Memorial Hospital, Taipei, Taiwan; Ya-Ching Chang, MD, Chang Gung Memorial Hospital, Taipei, Taiwan A 36-year-old man visited the dermatology clinic with a complaint of tumorous growth on bilateral nostrils and philtrum for 3 years. Tracing back his history, hoarseness and purulent rhinorrhea developed 15 years ago. He had received tracheostomy and endoscopic resection of laryngeal nodules due to sudden onset of dyspnea at another hospital 12 years ago. Hoarseness and rhinorrhea persisted during the past 12 years. Three years ago, pruritic erythematous papules developed on bilateral nostrils. He received multiple biopsies at the same hospital before and no definitive diagnosis was established. The pruritic papules progressed to crusted erythematous noduloplaques gradually during the past 6 months. On physical examination, there were multiple sharply demarcated, irregularly shaped, and infiltrated erythematous noduloplaques with overlying erosions and yellow crusts on the nostrils and philtrum. A skin biopsy was taken at our hospital which showed massive dermal infiltration of plasma cells with scattered foamy histiocytes. WarthineStarry and Giemsa stains both revealed many bacilli within foamy histiocytes. Gram stain showed the bacilli were Gram-negative. Bacterial culture grew Klebsiella species. Sequencing of 16S rDNA finally identified that the isolate was Klebsiella pneumoniae subspecies rhinoscleromatis strain ATCC 13884T (GenBank accession no. Y17657.1). After treatment with 10-week of ciprofloxacin, rhinorrhea and nasal stuffiness had improved and the skin lesions were dramatically fading with the residual thin plaques on bilateral nostrils. Commercial support: None identified.
APRIL 2012
Reversal reaction in a patient with leprosy
Jackson Machado-Pinto, MD, PhD, Santa Casa de Belo Horizonte, Belo Horizonte, Brazil; Luiza Laborne Sousa Pinto, Santa Casa de Belo Horizonte, Belo Horizonte, Brazil; Marcos Salles Dias Pinto, Santa Casa de Belo Horizonte, Belo Horizonte, Brazil; Michelle dos Santos Diniz, MD, Santa Casa de Belo Horizonte, Belo Horizonte, Brazil
Vitor Perez, MD, Vitor Paulo de Freitas Perez, Rio de Janeiro, Brazil; Adriana Munoz, MD, Adriana Taquez Munoz, Rio de Janeiro, Brazil; Jose Nery, PhD, Jose Augusto da Costa Nery, Rio de Janeiro, Brazil; Lıvia Souza, MD, Lıvia Coelho de Souza, Rio de Janeiro, Brazil
(Poster reference number 5442)
Background: Leprosy is a curable disease, but it involves great morbidity. It causes physical incapacity and deformities besides the great damage to the quality of life. Objective: To evaluate the sociodemographic profile and the quality of life of the patients who continue, having reactions and undergoing pharmacologic treatment to suppress reactional episodes and/or neuropathic pain, after the end of leprosy treatment. Method: Transversal observational study of 20 adult patients at the dermatology clinic of Santa Casa of Belo Horizonte (Brazil). Results: Twenty percent of the patients did not have their quality of life compromised, 35% suffered little effect, 20% had a moderate compromise, and 25% had their quality of life greatly compromised. The mean DLQI score was 6.25 (moderate effect). Forty percent of the patients were female and the mean age 41.7 years. The mean education was 5.15 years of study. The mean time of treatment was 15 months, and 19 patients were multibacillary. According to multivariate analysis, the factors associated with the compromise in the quality of life were years of education and bacilloscopic index. The better the education and the lower the bacilloscopic index, the higher the compromise in the quality of life. Conclusion: Eighty percent of the patients had some compromise in their quality of life, which justifies not only proper pharmacologic treatment, but also a multidisciplinary approach for patients who continue having reactions after the end of leprosy treatment. Commercial support: None identified.
(Poster reference number 5661)
Leprosy is an infectious systemic disease that affects mainly the skin and peripheral nervous system. It presents with different clinical forms that depend on the individual immune response, with a low cell-mediated immunity in the lepromatous pole, while the opposite occurs in tuberculoid. The borderline form, considered intermediate is unstable and a continuous spectrum of disease. Reactions are changes in the immune system, manifesting as acute and subacute inflammatory manifestations that can occur before, during or after treatment with multidrug therapy. They can be divided into two types: type 1 reaction or reversal reaction and type 2 reaction, which may manifest as erythema nodosum leprosum or necrotizing (the Lucio phenomenon) or erythema multiforme. We present a 55-year-old patient, which featured a year ago, paraesthesia in lower limbs and the lateral left thigh that also showed xerosis. Tests done included Mitsuda test (negative), quantitatively scraped skin was 1.25 and cutaneous biopsy, which confirmed the diagnosis of leprosy. Based on the clinical, histopathologic, and positive skin scrapings, the patient was diagnosed with multibacillary leprosy, and started multidrug therapy with 12 doses. The patient did well; however, on the fourth dose, he returned with the appearance of infiltrated plaques, erythema, hyperesthesia, all over the skin. At this point, we had new histopathologic examination, which showed compatible findings with reverse reaction. At this time we remained multidrug therapy, and started 1 mg/kg/day of prednisone for 2 weeks. In return, the patient showed clinical improvement. The corticosteroid dose was being reduced gradually, and the patient is being followed in order to end up the leprosy treatment. Our purpose is show the importance of oral corticosteroid, which is the treatment of choice in literature and the rapid response of the patient, control and resolution of the syndrome. Commercial support: None identified.
Recurrent Campylobacter fetus infection presenting as lobular neutrophilic panniculitis
(Poster reference number 4882)
Vincent Richer, MD, Centre Hospitalier de l’Universite de Montreal, Montreal, Canada; Beno^ıt C^ ote, MD, Centre Hospitalier de l’Universite de Montreal, Montreal, Canada; Danielle Bouffard, MD, Centre Hospitalier de l’Universite de Montreal, Montreal, Canada Campylobacter fetus is a rare bacterial pathogen that causes infection mainly among immunosuppressed humans through hematogenous spread. It has been reported to cause cellulitis, meningitis, spondylodisciitis, peritonitis, mycotic aneurysms, and recurrent bacteremia. We present a case of a 70-year-old white female who presented to our dermatology clinic with a 4-month history of fluctuating subcutaneous nodules on her lowers legs, bilaterally. There was no history of diarrhea, travel, eating uncooked foods, or contact with animals. She had a history of lung transplant 9 years prior, breast cancer 12 years prior, long-standing diabetes with chronic kidney disease, treated Bowen disease of the right temple and Campylobacter fetus sepsis 6 months before presentation. She was treated with prednisone, cyclosporine, azathioprine, calcium, vitamin D, and bronchodilators. The first skin biopsy specimen revealed a rich neutrophilic infiltrate with areas of suppuration in the subcutis compatible with lobular neutrophilic panniculitis. PAS-D, Grocott, and Ziehl special stains were negative. Bacterial, fungal and mycobacterial biopsy specimen cultures were negative. A second skin biopsy showed identical histopathologic changes and tissue cultures remained negative. A third skin biopsy, nearly 6 months after presentation, demonstrated fibrosis in the reticular dermis, necrotic adipose tissue, and an inflammatory infiltrate composed primarily of neutrophils, compatible with late-stage lobular neutrophilic panniculitis. PAS-D, Grocott, and Ziehl special stains were negative, but bacterial culture yielded Campylobacter fetus 1+ growth. The patient was treated with intravenous meropenem for 8 weeks through a home IV program. Clinical resolution was evident during therapy. A high index of suspicion is required to diagnose Campylobacter fetus infection. Despite negative findings in the initial investigation, infection must be ruled out in patients presenting with neutrophilic panniculitis. Clinical, pathologic, and microbiologic correlation is required in order to diagnose and treat Campylobacter fetus infection. Commercial support: None identified.
AB112
J AM ACAD DERMATOL
Rhinoscleroma: Identification of a rare indolent infectious disease by histopathology, culture, and molecular techniques
(Poster reference number 4845)
Yung-YI Lee, MD, Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Taiwan; Ju-Hsin Chia, MD, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Jui-Hung Ko, MD, Department of Dermatology, Chang Gung Memorial Hospital, Taipei, Taiwan; Shyue-Luen Chang, MD, Chang Gung Memorial Hospital, Taipei, Taiwan; Ya-Ching Chang, MD, Chang Gung Memorial Hospital, Taipei, Taiwan A 36-year-old man visited the dermatology clinic with a complaint of tumorous growth on bilateral nostrils and philtrum for 3 years. Tracing back his history, hoarseness and purulent rhinorrhea developed 15 years ago. He had received tracheostomy and endoscopic resection of laryngeal nodules due to sudden onset of dyspnea at another hospital 12 years ago. Hoarseness and rhinorrhea persisted during the past 12 years. Three years ago, pruritic erythematous papules developed on bilateral nostrils. He received multiple biopsies at the same hospital before and no definitive diagnosis was established. The pruritic papules progressed to crusted erythematous noduloplaques gradually during the past 6 months. On physical examination, there were multiple sharply demarcated, irregularly shaped, and infiltrated erythematous noduloplaques with overlying erosions and yellow crusts on the nostrils and philtrum. A skin biopsy was taken at our hospital which showed massive dermal infiltration of plasma cells with scattered foamy histiocytes. WarthineStarry and Giemsa stains both revealed many bacilli within foamy histiocytes. Gram stain showed the bacilli were Gram-negative. Bacterial culture grew Klebsiella species. Sequencing of 16S rDNA finally identified that the isolate was Klebsiella pneumoniae subspecies rhinoscleromatis strain ATCC 13884T (GenBank accession no. Y17657.1). After treatment with 10-week of ciprofloxacin, rhinorrhea and nasal stuffiness had improved and the skin lesions were dramatically fading with the residual thin plaques on bilateral nostrils. Commercial support: None identified.
APRIL 2012