Clinical Course of Erythema Nodosum Leprosum: An 11-Year Cohort Study in Hyderabad, India

Abstract

Erythema nodosum leprosum (ENL) or type 2 lepra reactions complicate lepromatous leprosy and borderline lepromatous leprosy. We report an 11-year retrospective case record analysis of 481 outpatients with borderline lepromatous and lepromatous leprosy at the Dhoolpet Leprosy Research Center in Hyderabad, India.. The overall prevalence of ENL was 24%, 49.4% among cases of lepromatous leprosy (LL) and 9% among cases of borderline lepromatous (BL) leprosy. Logistic regression analysis identified LL (odds ratio [OR] = 8.4, 95% confidence interval [CI] = 4.6-15.4, P < 0.001) and BL with a bacterial index > or = 4+ (OR = 5.2, 95% CI = 2.1-12.9, P = 0.001) as major risk factors. The average patient with ENL was male, 34.7 years of age, and had multiple episodes of ENL (mean = 3.1) over an 18.5-month period. Three types of ENL were identified: single acute ENL, multiple acute ENL (repeated discrete episodes), and chronic ENL (continuous episodes). Acute single ENL is rare, accounting for only 8% of cases. Chronic ENL accounted for 62.5% of the cohort. Chronic ENL was of longer duration and more severe. An age > or = 35 years was a risk factor for developing chronic ENL. Patients with chronic ENL were more compliant with multi-drug therapy, especially during the first six doses of multi-drug therapy. Distinguishing these different types of ENL would be useful for patient management and developing improved treatment of these debilitating reactions. Improved strategies for treatment and management of these reactions need to be developed.

Leprosy type 1 reactions and erythema nodosum leprosum

“…32,33 Lepromatous leprosy (LL) and a bacillary index (BI) greater than 4+ have been shown to be risk factors for ENL. 31,32 Pregnancy, lactation, puberty, intercurrent infection, vaccination and psychological stress have been considered to precipitate ENL 3 but these associations have not been confirmed in prospective studies.…”

“…8 In Asia reported figures vary between 19-26% of BL and LL cases in Nepal, India and Thailand. 8,13,31,32 ENL reactions occur most commonly during the first year of MDT. [31][32][33] One third of patients with ENL have the diagnosis of leprosy made at the same time as their reaction.…”

“…8,13,31,32 ENL reactions occur most commonly during the first year of MDT. [31][32][33] One third of patients with ENL have the diagnosis of leprosy made at the same time as their reaction. 32,33 Lepromatous leprosy (LL) and a bacillary index (BI) greater than 4+ have been shown to be risk factors for ENL.…”

“…The majority of patients with ENL go on to develop several episodes over many years, as multiple acute episodes or chronic ENL. 11,31 Less than 10% of patients in a large cohort in India had only a single episode of ENL while 62.5% had chronic ENL. 31 The cutaneous manifestation of ENL is widespread crops of erythematous, inflamed nodules and papules, which may be superficial or deep.…”

A case of leprosy, erythema nodosum leprosum, and hemophagocytic syndrome: A continuum of manifestations of same agent-host interactions

“…The ENL, characterized by painful erythematous nodulations that grows in apparently normal skin, is seen mainly in the lepromatous type of leprosy patients (1). Although there is a consensus of decreasing cases of ENL after the inclusion of clofazimine containing multidrug therapy (MDT), however, the greatest concerns are associated with systemic manifestations, morbidity, and mortality (2).…”