Dr. Richard Wing Communicable Disease Director, DSHS, Region 11 Harlingen, Texas

1. NHDP CPC 2 Case 2 Jan 24 2005 Dr. Richard Wing Communicable Disease Director, DSHS, Region 11 Harlingen, Texas

2. 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 • •McAllen China • • Monterrey

3. 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)

4. 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

5. Enlarged right radial cutaneous & ulnar nerves • Large plaque to palm of right hand • Fissures at the base of the fingers

6. 4th right finger swollen at proximal interphlangeal joint • Painful with movement & tender to touch

7. X-ray: bony erosion to distal end of 1st phalanx of the right 4th finger • WHO classification: multibacillary; Ridley-Jopling classification: BT/BB

11. 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

12. 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

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

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

15. Same day: facial lesions show resolution of the desquamation • Prednisone dose is decreased to 15 mg daily

16. Prednisone dose subsequently decreased to 10 mg daily • Within 2 weeks of decreasing Prednisone the patient experiences a flare-up of all lesions

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

18. 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 4th finger had completely resolved

19. 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

20. 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

21. 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.

22. 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”

23. 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