Recidivas postratamiento de la lepra multibacilar.

Abstract

La persistencia de bacilos viables y la monoterapia con diamino-difenil-sulfona (DDS) son los principales factores que favorecen las recidivas de la lepra. Presentamos 33 pacientes con lepra lepromatosa (LL) diagnosticada 7 a 48 años antes de la recidiva, que recibieron monoterapia con DDS durante 4 a 38 años. Veintiocho fueron tratados, además, con poliquimioterapia (PQT) irregular, no supervisada, desde 1983. Cinco sólo recibieron DDS. Éstos presentaron la recidiva entre 13 y 20 años después de suspenderla. Las recidivas se diagnosticaron por reaparición de las lesiones clínicas o por la presencia de nuevas zonas anestésicas; todas se confirmaron con la baciloscopia y, en 20 casos, por la biopsia de piel. Cuatro pacientes presentaron en la biopsia de la recidiva, lepra indeterminada (LI) y uno lepra dimorfa tuberculoide (LDT), todos con presencia de bacilos intraneurales; los demás fueron LL. Dos pacientes recidivaron, aun con PQT razonablemente supervisada. Los demás curaron con PQT supervisada. Los factores predisponentes para la recidiva fueron: monoterapia con DDS por varios años; PQT irregular con dosis inadecuadas, sin supervisión del tratamiento; abandono de la PQT, y relación inadecuada entre el paciente y el personal de salud. Las recidivas de la lepra se deben buscar en todos los pacientes colombianos con lepra multibacilar que fueron tratados con DDS solo durante años. La clínica, la baciloscopia y la biopsia individualmente o en conjunto son métodos confiables para establecer las recidivas.Palabras clave: lepra multibacilar, recidivas de la lepra. Relapses after multibacillary leprosy treatmentLeprosy relapses are mainly due to bacillary persistence and diamino-diphenyl-sulphone (DDS) monotherapy. Case histories were examined for 33 patients with lepromatous leprosy (LL), diagnosed 7-48 years before the relapse and treated only with DDS during 4 to 38 years. Twenty-eight patients received irregular non-supervised polychemotherapy (PCT) since 1983. Five patients received only DDS, and presented relapses 13-20 years after the treatment was stopped. Relapses were diagnosed by clinical methods, including the reappearance of lesions or presence of new anesthetic areas. All cases were confirmed by bacilloscopy, and a subset of 20 cases by skin biopsy. Four patients presented indeterminate leprosy (IL) and one patient borderline tuberculoid leprosy (BT) in the biopsy. The latter 5 demonstrated presence of intraneural bacilli; the remainder were LL. Two patients relapsed even with PCT treatment. The others were cured with supervised PCT. Predisposing factors for relapses were as follows: DDS monotherapy, irregular PCT with inadequate dosage, unsupervised treatment, treatment uncompliance, and inadequate relationship between the patient and the health staff. Inspections for relapse in leprosy is recommended for in all multibacillary patients that were treated with DDS. The clinical appearance of new lesions or new anesthetic zones, the bacilloscopy and skin biopsy, used together, are effective in establishi...

Características clínico-laboratoriais no retratamento por recidiva em hanseníase

“…Serological tests could function as an alternative tool to classify paucibacillary and multibacillary leprosy in the first treatment and to confirm suspected cases of recurrence 34,35 . Histopathological tests are diagnostic criteria of recurrence in the majority of studies, similarly to the present study 15,17,18,24,28 . Although this procedure is important as diagnostic support for the confirmation of recurrence, bacilloscopy tests are also essential, especially in previous multibacillary cases 11 .…”

“…There is no consensus on the criteria established for the diagnostic confirmation of recurrence. The following variations are included: reappearance of new lesions and/or nerve injuries with clinical and histopathological signs consistent with active forms (borderline-borderline/BB, borderline-lepromatous/BL and lepromatous/LL), according to Ridley-Jopling's classification (1966) 14,15 ; new skin lesions; increase in the bacilloscopy index (BI) >2+ in one or more areas; and viability of M. leprae through inoculation in mice paw 16 ; reactivation after six months of regular treatment with multi-drug therapy; anesthetic lesions and/ or exacerbation of previous lesions; bacteriological evidence with or without clinical activity; nerve lesions with or without neuritis in cases of paucibacillary leprosy; and diagnostic confirmation with biopsy 17 ; reactivation and presence of new anesthetic lesions confirmed with bacilloscopy exam and skin biopsy 18 . Studies aimed at the technical-scientific support and infrastructure available for professionals to accurately diagnose recurrence in health services are essential.…”

Fatores associados à recidiva em hanseníase em Mato Grosso

“…Irregular treatment, which is seen as a form of noncompliance, may be related to the patient himself (not complying with prescribed treatment course, incorrect drug use and/or missing medical appointments) or to the organization of services (failure to schedule returns, lack of drugs at the facility, lack of direct supervision of drug treatment, and inadequate relationship between patients and providers). 11,19 The risk of relapse for the group of individuals who did not receive any guidance on the disease and treatment was nearly three times higher than that in those who reported receiving guidance. Sociocultural aspects such as knowledge, attitudes and practices about leprosy and access to information may affect treatment compliance.…”

“…Sociocultural aspects such as knowledge, attitudes and practices about leprosy and access to information may affect treatment compliance. 5,11,19 Ongoing patient education and community involvement including strategies to facilitate successful treatment can help the implementation of disease control actions. Successful relapse prevention requires taking responsibility, from political decision-making to health care quality.…”

Búsqueda Activa de Lepra y de Otras Enfermedades de la Piel en Escolares de Agua de Dios, Colombia

“…¿Qué factores propician esta alta incidencia? Losen Agua de Dios son comunes (1,17). La niña con LNP es vecina y amiga de un paciente con tres recidivas de la enfermedad.…”