Photo Rounds

Tender nodules after leprosy Tx

A 32-year-old man in Texas acquired leprosy while skinning, cooking, and eating an armadillo. (Armadillos are natural hosts for Mycobacterium leprae.) With the help of the Centers for Disease Control and Prevention (CDC) and an infectious disease doctor, the treating physicians started the patient on 3 antibiotics—clofazimine, rifampicin, and dapsone—to treat the leprosy. The next day, the patient broke out with red tender nodules on his extremities. On physical examination, his vital signs were normal.

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Tender nodules after leprosy Tx
Tender nodules after leprosy Tx

The treating physicians believed that the patient had developed erythema nodosum leprosum (ENL), based on the tender nodules that are characteristic of this treatment reaction. The CDC was again consulted and representatives there agreed.

ENL is a known as a Type 2 reaction to the treatment for leprosy. Management involves the use of oral prednisone, which may be needed for a prolonged time. The antibiotics used to treat leprosy should not be stopped, as ENL is not an allergic reaction. It is due to the destruction of bacilli and the immune response to the release of bacterial antigens.

The patient was transferred to a leprosy hospital in Baton Rouge, Louisiana for further management. The prednisone was not sufficient, and he required further treatment with thalidomide. After 2 years of treatment, he appeared to be free of leprosy and no longer had the ENL.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ, Diaz L, Paulis R. Erythema nodosum. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1169-1173.

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