CASE REPORT

ERYTHEMA NODOSUM LEPROSUM- A CASE REPORT.

Pra n"a Paramita Panda# P$ %$ &en'a# ($ Pani ra)i# D$ Pattnai'
1$ 2$ 0$ 1$ *ssistant Professor# De+artment of Microbiolo "# (IMS# ,)ubanes-ar# .dis)a$ /utor# De+artment of Microbiolo "# (IMS# ,)ubanes-ar# .dis)a$ *ssistant Professor# De+artment of Microbiolo "# (IMS# ,)ubanes-ar# .dis)a$ Professor# De+artment of Microbiolo "# (IMS# ,)ubanes-ar# .dis)a$

CORRESPONDING AUTHOR Dr$ Pra n"a Paramita Panda# *sst$ Professor# De+t$ of Microbiolo "# (IMS# ,)ubanes-ar# .dis)a$ E-mail2 b)avaar"a3"a)oo$com P)2 0041 5650562660$ ABSTRACT: &e+ros" is an ancient disease t)at )as survived into t)e modern a es des+ite an intense effort to eliminate it -orld-ide$718 9ere -e re+ort a case of recurrent# multi+le ulcerative lesions -it) +ittin edema of bot) lo-er e:tremities# in a 62 "ears old male$ 9e -as a dia nosed case of 9ansen;s disease -it) irre ular treatment since 2 "ears$ *ll bioc)emical +arameters -ere -it)in normal limits$ %)eumatoid factor# *<*# E&IS* for 9IV and VD%& -ere ne ative$ Modified =< stainin >usin !? sul+)uric acid@ s)o-s acid fast bacilli > radin AAA@# arran ed in lobi# 6!? -ere fra mented B 0!? -ere uniforml" stained$ .r anisms isolated in bacterial culture -ere Proteus mirabilis & Sta+)"lococcus aureus & Candida s++ isolated in fun al culture$ Patient -as admitted and -as started on MD/-M, alon -it) +rednisolone$ KEY-WORDS2 Er"t)ema nodosum le+rosum# M"cobacterium le+rae# Modified =< stain INTRODUCTION: &e+ros" is an ancient infectious disease caused b" M"cobacterium le+rae t)at affects t)e s'in and +eri+)eral nerves$ * -ide clinical s+ectrum of disease e:ists# from t)e tuberculoid +ole 7associated -it) a vi orous /)1 res+onse# relativel" fe- bacilli# and limited -ell-defined lesions8 to t)e le+romatous +ole 7associated -it) a ressive /)2 res+onse# man" bacilli# and diffuse s"mmetric lesions8$728 /)ou ) it is a c)ronic disease# it )as tendenc" for debilitatin acute e:acerbations termed reactionsD /"+e 1 %eaction [%eversal %eaction8 and /"+e 2 %eaction 7Er"t)ema <odosum &e+rosum >E<&@8$718 Er"t)ema nodosum le+rosum# is an acute inflammator" reaction seen in +atients -it) le+romatous le+ros" or occasionall" in borderline le+romatous le+ros"$708 /)ou ) it is usuall" seen durin t)e course of treatment it ma" occur in +reviousl" untreated +atients as -ell$718 /)e lesions are er"t)ematous +ainful tender +a+ules and nodules$ In mild reaction nodules are small in number and s+ontaneousl" resolve leavin be)ind )"+er+i mented macules$7!8 In severe reactions# nodules tend to increase in siEe and ulcerate$ Vesiculobullous# +ustular# ulcerated# and )emorr)a ic and er"t)ema multiforme-li'e lesions )ave been re+orted in E<&$768 In t)is article# -e )ave discussed a case -)ic) +resented to us -it) recurrent# multi+le ulcerative lesions -it) +ittin edema of bot) lo-er e:tremities$ /)e case -as admitted in our )os+ital# Pradumna ,al Memorial 9os+ital# (IMS# ,)ubanes-ar# -)ere )e -as investi ated# dia nosed and started on treatment$ CASE REPORT: * 62 "ear old male -as +resented -it) multi+le +ainful ulcerated s'in lesions over bot) t)e lo-er e:tremities and luteal areas of 0 mont)s duration$ 9e )ad )istor" of recurrent attac's of +a+ulo-+ustular lesions# and ulcerations since t-o "ears$ /)e s'in lesion

Journal of Evolution of Medical and Dental Sciences/Volume 1/Issue 6/December-2012

Pa e-101!

CASE REPORT
first started over t)e luteal re ion and slo-l" develo+ed over t)e ot)er sites$ Current e+isode -as most severe one and associated -it) lo- rade and intermittent fever$ .n e:amination# )e )ad multi+le subcutaneous# er"t)ematous blanc)in nodules on bot) t)e lo-er e:tremities and luteal areas$ * fe- nodules -ere crusted -it) serosan uinous disc)ar e 7Fi $18$ /)ere -ere no ot)er +atc)es# +laGues or nodules in ot)er +art of t)e bod"$ /)ere -as associated +ittin edema B loss of tem+erature sensation of lo-er e:tremities$ 9aematolo ical investi ations s)o-ed 9bH10 m?# /&CH12000/mm0 -it) 50? of neutro+)ils# ES% s)o-ed 00mm in t)e 1st )our# F,SH 40m ?$ Irine anal"sis and all ot)er bioc)emical +arameters -ere -it)in normal limits$ %)eumatoid factor# *<*# 9,s* # 9IV and VD%& -ere ne ative$ ,acterial culture of +us s)o-ed ro-t) of Sta+)"lococcus aureus and Proteus mirabilis and Candida s++ isolated in fun al culture$ Modified =< stainin >usin !? sul+)uric acid@ of +us s)o-s acid fast bacilli > radin AAA@# arran ed in lobi# 6!? -ere fra mented B 0!? -ere uniforml" stained$ S'in bio+s" s)o-ed atro+)ic e+idermis# fe- foam" macro+)a es -it) small a re ates of neutro+)ils in t)e dermis and oedematous dermal vessels$ /)e +atient -as dia nosed as a case of le+romatous le+ros" -it) t"+e 2 reaction 7E<&8$ Patient -as started on MD/ M, alon -it) +rednisolone 10 m /da" >-it) t)e +lan to be ta+ered and sto++ed over 0 mont)s +eriod@$ *t subseGuent follo--u+# +atient;s condition -as better -it) )ealin of all t)e lesions$ DISCUSSION: &e+ros" is a uniGue disease -it) a +eculiarl" lon incubation +eriod# a -ide s+ectrum of clinical +resentations related to )ost immunit" and acute e:acerbations termed reactions$718 /"+e 2 reaction or E<& occurs in +atients )avin )i ) load of le+ros" bacilli >!0? cases of le+romatous le+ros" and 2!? of borderline le+romatous le+ros"@$708 It can occur in t)e earl" sta es of treatment and even after com+letion of t)e treatment -it) MD/# commonl" -it)in first t)ree "ears after t)e start of treatment$ 9o-ever# 10? cases )ave been re+orted even before startin treatment or as t)e first clinical manifestation of le+ros"$718 It is a multis"stem disorder involvin s'in# +eri+)eral nerves# and sometimes# t)e internal or ans$ It +resents in t)e s'in as cro+s of +ainful or tender# er"t)ematous# cutaneous and subcutaneous nodules concentrated on t)e e:tremities$718 /)e" a++ear +referentiall" on cooler +arts of t)e s'in >face and outer surface of limbs and less freGuentl" on t)e trun'@ and usuall" s+are t)e -armer +arts$ %arel" t)e" can brea' do-n and su++urate / necrose +roducin Er"t)ema <odosum <ecroticans >ulcerative E<&@$ /)e condition is often accom+anied b" fever# neuritis# and inflammation of internal or ans in var"in de rees$ Individual +atients ma" )ave a sin le bout of E<& or c)ronic recurrent manifestations$ /)e +at)o enesis of E<& involves immune com+le: de+osition and d"sfunction of cell mediated immunit"$ *ctivation of com+lement and mi ration of neutro+)ils -it) release of tissue dama in enE"mes# includin I&-12 and /<F-J are im+ortant factors in t)e evolution of t)e disease$ Suc) +atients )ave +oor cellular immunit" to M$ le+rae# abundant bacilli in cutaneous and +eri+)eral nerves# and a stron +ol"clonal antibod" res+onse -it) )i ) levels of circulatin immuno lobulins$758 *s immune com+le: de+osition B defective CMI are t)e main cause in +at)o enesis of E<&# immunosu++ressants and /<F-J in)ibitors )ave a role in treatment$ /)alidomide and corticosteroids are t)e mainsta"s of treatment$ Various ot)er modalities of treatment are clofaEimine# aEat)io+rine# c"clos+orine# met)otre:ate# antimon" com+ound$758 <e-er modalities
Journal of Evolution of Medical and Dental Sciences/Volume 1/Issue 6/December-2012 Pa e-1016

CASE REPORT
of treatment are IV Immuno lobulins# and t)e ne- non-steroidal anti-inflammator" dru # /enida+$768 .ur case +resents -it) multi+le# +ainful ulcerated s'in lesions over bot) t)e lo-er e:tremities and luteal areas since 0 mont)s and -as on irre ular treatment M, le+ros" since 2 "ears$ /)e case ets com+licated b" secondar" bacterial and fun al infections due to dela" in dia nosis$ /)e case -as interestin because E<& occurrin after treatment -it) MD/-M, and +resentin -it) e:tensive cutaneous ulceration is a ver" rare entit"$ ,ut t)e dia nosis can be made on t)e basis of sim+le microsco+" B culture -)ic) )el+s in +atient;s recover" b" +ro+er treatment and follo- u+$ So occurrence of tender# red# ulcerative nodules in le+ros" +atients on treatment s)ould al-a"s +rom+t t)e treatin +)"sician to rule out E<& b" sim+le clinical and laborator" tests$ Earl" dia nosis B definitive treatment -it) lucocorticoid is essential to +revent secondar" com+lications

REFERENCES:

1$ Smit)a Prab)u# S D S)enoi# Sat)is) Pai ,# Sri+at)i 9$ Er"t)ema nodosum le+rosum as t)e +resentin feature in multibacillar" le+ros"2 Dermatolo " .nline Journal 1!>6@21!$ 2$ ,o ild *(# (e"stone JS# (ain (C$ &e+ros"2 a +rimer for Canadian +)"sicians$ CM*J 2001D150251H6$ 0$ 0$$ Pocaterra &# Jain S# %edd" %# MuEaffarulla) S et al$ Clinical course of Er"t)ema nodosum le+rosum2 an 11-"ear co)ort stud" in 9"derabad# India$ *m J /ro+ Med 9" 2006D512666-54$ 1$ %ea /9 and &evan <E$ Er"t)ema nodosum le+rosum in a eneral )os+ital$ *rc) Dermatol 145!D11121!5!-60$ !$ 9osa)alli %aKaia) Lo ees) 9%# SuKat)a C)an'ramat)# 9ari (is)an (umar Ladalla# S)ameem S)ariff et al$/"+e 2 le+ra reaction >enl@ +resentin -it) e:tensive cutaneous ulcerations2 .ur Dermatol .nline$ 2012D 0>1@2 15-20$ 6$ Me"erson MS2 Er"t)ema nodosum le+rosum$ Int J Dermatol 1446D 0!2 064-042$ 5$ Scollard DM# *dams &,# Millis /P# (ra)enbu)l J&# et al$ /)e continuin c)allen es of le+ros"$ Clin Microbiol %ev 2006D142006-61$ 6$ van Veen <9J# &oc'-ood D<J# van ,ra'el N9# %amireE Jr J# %ic)ardus J9$ Interventions for er"t)ema nodosum le+rosum$ >Protocol@ Coc)rane Database of S"stematic %evie-s 2006# Issue 1$ *rt$ <o$2 CD006414$ D.I2 10$1002/116!16!6$CD006414$

Journal of Evolution of Medical and Dental Sciences/Volume 1/Issue 6/December-2012

Pa e-1015

CASE REPORT

Fig.1: Mul i!l" #u$%u &'"(u#) "*+ ,"-& (u# $l&'%,i'g '(.ul"# (' $( , ," l(/"* "0 *"-i i"#.

Journal of Evolution of Medical and Dental Sciences/Volume 1/Issue 6/December-2012

Pa e-1016