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
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