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CMAJ
CMAJ
9711805
CMAJ : Canadian Medical Association Journal
0820-3946
1488-2329
CMA Impact Inc.

39284605
10.1503/cmaj.240040
196e1043
Practice
Clinical Images
A type 1 leprosy reaction in a 50-year-old man
Richard-Greenblatt Melissa PhD DTM&H
Stryjewska Barbara MD
Kalina Dale R. MD MBA
Public Health Ontario (Richard-Greenblatt), Toronto, Ont.; Department of Laboratory Medicine and Pathobiology (Richard-Greenblatt), University of Toronto, Toronto, Ont.; Hospital for Sick Children (Richard-Greenblatt), Toronto, Ont.; National Hansen’s Disease Program (Stryjewska), Health Systems Bureau, Health Resources and Services Administration, United States Department of Health and Human Services, Baton Rouge, La.; Department of Laboratory Medicine (Kalina), Brant Community Healthcare System, Brantford, Ont.; Division of Infectious Diseases, Department of Medicine (Kalina), McMaster University, Hamilton, Ont.
Correspondence to: Melissa Richard-Greenblatt, melissa.greenblatt@sickkids.ca
16 9 2024
16 9 2024
196 30 E1043E1044
© 2024 CMA Impact Inc. or its licensors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/
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pmcA 50-year-old man was diagnosed with leprosy on pre-immigration screening in the Philippines and was prescribed oral dapsone and rifampin. He immigrated to Canada 1 month later and discontinued therapy because of a lack of clinical improvement. During this time, new skin lesions developed and were accompanied by swelling and pain in his hands and feet. The patient was seen in our infectious diseases clinic 4 months later. He had erythematous plaque-like lesions on his head, trunk, and extremities (Figure 1) and normal sensation; the lesions were concerning for a type 1 leprosy reaction (T1R). Skin biopsy showed diffuse histiocytic aggregates, granulomas with sparse lymphocytic infiltrates, and acid-fast bacilli, suggestive of borderline lepromatous disease. We reinitiated antimicrobial therapy with 12 months of oral clofazimine 50 mg daily and 300 mg monthly, dapsone 100 mg daily, and rifampin 600 mg monthly. Given his extremity swelling, we also started prednisone 60 mg daily for the treatment of severe T1R.

Figure 1: A type 1 leprosy reaction in a 50-year-old man with borderline lepromatous leprosy showing numerous asymmetric macules, papules, and plaques with infiltrative borders and central healing. The patient’s skin lesions exhibit redness and edema due to the type 1 leprosy reaction.

Cutaneous manifestations of leprosy occur on a spectrum, depending on the patient’s immune response to the infection.1 Borderline categories of leprosy are immunologically unstable, and these patients are at increased risk of developing a T1R, an acute cell-mediated response to Mycobacterium leprae. Typically, T1Rs occur while a person is receiving multidrug therapy but can also be a presenting feature of leprosy or occur years after treatment completion.2 Three types of distinct leprosy reactions exist: T1R (reversal reactions), type 2 (erythema nodosum leprosum reactions), and, rarely, Lucio phenomenon (necrotizing vasculitis and dermal necrosis). These reactions occur in 30%–50% of patients and are clinically distinct from one another.2 With T1Rs, pre-existing skin lesions may become red and edematous, and new lesions can occasionally appear. In severe T1Rs, extremity and facial edema commonly occur, as do neuritis, paresthesia, and sudden loss of motor function. Mild T1Rs can be managed with analgesics; however, any signs of a severe reaction should lead to immediate treatment with corticosteroids (prednisone starting dose 0.5–1.0 mg/kg of body weight per day) to prevent nerve damage.3

Clinical images are chosen because they are particularly intriguing, classic, or dramatic. Submissions of clear, appropriately labelled high-resolution images must be accompanied by a figure caption. A brief explanation (300 words maximum) of the educational importance of the images with minimal references is required. The patient’s written consent for publication must be obtained before submission.

Competing interests: Dale Kalina reports consulting and speaking fees from Shaping Minds, infection prevention and control consulting fees from Appleby College, and consulting fees from FaceDrive. Dr. Kalina reports a faculty member teaching stipend from Woundpedia and Project ECHO Ontario Skin and Wound Care; media interviews (no honoraria received); speaking engagements and panel discussions for McMaster University Health Leadership Academy, Halton Public Health, Burlington Ontario Health Team, Canadian College of Health Leaders, Brazilian Canadian Chamber of Commerce, Ontario and New York: Covid Comparisons Webinar, and Masaryk University Faculty of Medicine; and participation in COVID-19 virtual town halls involving Joseph Brant Hospital, Burlington Dental Academy, Gerrie Electric, Head Injury Rehabilitation Ontario, White Rabbit Treatment Homes, Tansley Wood Retirement Home, and Tyndall Retirement and Nursing Home. Dr. Kalina reports advisory board membership with ViiV Healthcare and is chief medical information officer for the Brant Community Healthcare Centre. Dr. Kalina reports stock options with FaceDrive and receipt of medication samples from Gilead. No other competing interests were declared.

This article has been peer reviewed.

The authors have obtained patient consent.
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References

1 Ridley DS Jopling WH . Classification of leprosy according to immunity. A five-group system. Int J Lepr Other Mycobact Dis 1966;34 :255–73.5950347
2 Leprosy/Hansen disease: management of reactions and prevention of disabilities [technical guidance]. New Delhi: World Health Organization, Regional Office for South-East Asia; 2017. Available: https://www.who.int/publications/i/item/9789290227595 (accessed 2024 May 15).
3 Maymone MB Venkatesh S Laughter M . Leprosy: treatment and management of complications. J Am Acad Dermatol 2020;83 :17–30.32244016
