- Volume 73 , Number 3
- Page: 225–7
Paucibacillary treatment for large tuberculoid lesions of leprosy?
To the Editor:
Under the title "Should large lesions of leprosy be considered as multibacillary for treatment purposes even if the total number of lesions is less than five?" [Int. J. Lepr. 72 (2004) 173-174], Kumarasinghe and Kumarasinghe called attention to an interesting aspect regarding the treatment of big size tuberculoid lesions or borderline-tuberculoid lesions according to Ridley & Jopling classification.
Their arguments for the treatment of patients with large plaques are valid but the recommendation since the beginning of Multi-drug Therapy - M.D.T./World Health Organization/82 (2) was to treat patients upon a positive or negative bacilloscopy. The size or the number of lesions were not to be taken into account. Millions of patients have been treated since, with a relapse rate of less than 1%. We present a patient classified and treated as PB leprosy with a large plaque and five smaller lesions.
Patient. N.R.L, 45 years old, registered at the Fundação de Medicina Tropical do Amazonas, Manaus, Brazil.
The patient presented a large plaque lesion on the chest (Fig. 1) and five smaller lesions on the face, arm and posterior part of the trunk. No enlargement of the ulnar nerve or of other peripheral nerves could be found. The patient was clinically classified as reactional borderline tuberculoid leprosy.
The histopathology (Hematoxylin-Eosin) showed a granulomatous lesion with lymphocytes, histiocytes and giant cells (Fig. 2). The Wade stain was negative for acid-fast bacilli. The patient was classified as borderline tuberculoid (BT) leprosy.
Paucibacillary M.D.T. according to the W.H.O. plus 60mg prednisone per day was started in March 2003. M.D.T. was stopped after 6 months of regular treatment and cortisone was slowly tapered off after 3 to 4 months.
All the lesions regressed leaving a hypopigmented area (Fig. 3). During the last clinical reexamination (10/11/04) no relapse was found. A new histopathology of the edge of the lesion showed a regressive infiltrate (Fig. 4).
COMMENTS
The W.H.O. recommendation to treat leprosy was based on bacilloscopy for many years on the bacilloscopy results, and the efficacy of M.D.T. has been the same worldwide: Less than 1% of relapses. The W.H.O. (3) recommendation to treat leprosy patients according to the number of lesions was mainly an operational decision to implement M.D.T. in the field. There was no recommendation related to the size of the lesion.
We think that a patient with a negative bacilloscopy and a histopathology consistent with a tuberculoid granuloma with scarce or no bacilli in the Wade or Fite-Faraco stain must be classified as paucibacillary leprosy. We agree with Kumarsinghe and Kumarsinghe (1) that ". . . the larger the lesions of leprosy, the higher the number of bacilli that cause the pathology. . . .," but in such a lesion the clinical aspect is roughly the same with defined edges and very well established borders between the lesion and the normal skin. Besides the relatively uniform clinical aspect as observed in our patient, the skin smears and the histopathology were the same in repeated biopsies with the number of bacilli scarce or negative. We could not find any information in the literature to substantiate the statement of the authors, that tuberculoid leprosy could evolve to the lepromatous pole over several years with the lowering of patient´s cellular immunity (1).
Figs. 1-4. 1. Borderline tuberculoid leprosy. Large infiltrated plaque with well defined edges. 2. Hematoxylin-Eosin-presence of granulomatous infiltrate with epithelioid cells, giant cells and lymphocytes. 3. After nearly two years. Regression of the plaque, leaving a residual hipochromic lesion. 4. Regression of the infiltrate.
We have been treating patients with multiple (more than 5) lesions as PB leprosy when the clinical aspect of the lesions and the histopathology showed a picture of tuberculoid leprosy.
We agree with Kumarasinghe and Kumarasinghe (1) that the W.H.O. recommendation is "particularly important in areas where treatment is initiated without any bacteriological and histopathological confirmation . . ." However, in referral centers and in universities with good laboratory support the present WHO guidelines to treat as PB leprosy or MB leprosy should not be followed. It seems there are no scientific data to justify a formal recommendation to treat leprosy according to the number or size of the lesions.
Acknowledgement. To Dr. Gotfried Schmer of the State University of Washington.
- Mônica Nunes Souza Santos
- Luis Carlos de Lima Ferreira
- Sinésio Talhari
Fundação de Medicina Tropical do Amazonas Departments of Pathology
REFERENCES
1. KUMARASINGHE, S. P. W., and KUMARASINGHE, M. P. Should large lesions of leprosy be considered as "multibacillary" for treatment purposes even if the total number of lesions is less than five? Int. J. Lepr. Other Mycobact. Dis. 72 (2004) 173-174.
2. Quimioterapia de la lepra para los programas de lucha. W.H.O./LEP 675 (1982).
3. W.H.O. The Final Push Strategy to Eliminate Leprosy as a Public Health Problem: Questions and Answers, 2nd edn. Geneva: World Health Organization.
Reprint requests to
Sinésio Talhari
Av. Pedro Teixeira, 25
Manaus, Am, Brazil
E-mail: sinesiotalhari@aol.com