Issue No. 12, November 1997

Advice from the Medico-Social Commission

1 INTRODUCTION

Leprosy reactions are the main cause of acutenerve damage and disability in leprosy. Reactionsare caused by changes in the immune response ofthe patient to the mycobacteria. There are twotypes of reaction, reversal reaction or type 1reaction and erythema nodosum leprosum (ENL)or type 2 reaction. (ILEP Technical Bulletin 9describes the management of ENL reaction).

Reversal reactions often occur in the first 6 monthsof multidrug therapy (MDT) and may occur inboth paucibacillary (PB) and multibacillary leprosy(MB), but more commonly in MB. Sometimespatients are found to have reversal reactions at thetime of diagnosis and it may be the symptoms ofthe reaction which makes the patient aware of thedisease. A reversal reaction may occur aftercompletion of MDT, particularly when shortduration regimens are used.

2 EARLY DETECTION

Early detection is very important to decrease theextent of nerve damage and the risk of furtherdisability. The outcome of treatment is much betterif reversal reaction is detected early and treatedpromptly. It is therefore important that detectionof reversal reaction is done as soon as possible. Thepatient may present with one or more of thefollowing features:

• Skin lesions become red and swollen.

• Painful, tender and swollen peripheral nerves.

• Signs of nerve damage - loss of sensation andmuscle weakness.

• Fever and malaise.

• Hands and feet may be swollen.

• New skin lesions may appear.

Note: Silent neuritis can occur, with gradual orsudden loss of nerve function, but with none of theother signs of acute reversal reaction.

There are four essential components to earlydetection:

• All health workers should be aware of thesigns and symptoms.

• Sensory and motor nerve function must beassessed and recorded in all patients at time ofdiagnosis. This is essential to detect any futurechanges.

• Sensory (ST) and motor nerve function (VMT)should be assessed monthly, and certainly notless than 3 monthly during MDT - the methodused will depend on local circumstances.

• All patients must be made aware of thepossibility of sudden nerve function loss andacute eye problems, and the need to reportthese promptly.

3 TREATMENT OF REACTION

A mild reaction is when there is no nerveinvolvement. This can be treated with rest andanti-inflammatory drugs (aspirin) at home. Thenerve function of the patient needs to be keptunder close surveillance because there is aconsiderable risk that function impairment maydevelop.

A severe reaction is when there is nerveinvolvement and to prevent disabilities, treatmentmust be started immediately. A red, raised,swollen patch overlying or around an eye issignificant. In addition to rest and analgesics, thepatient will need to be treated with cortico-steroidssuch as prednisolone, given as tablets, by mouth.The daily dose of prednisolone should not exceed1 mg per kg body weight. The course should last atleast 3 months and may be up to 6 months. The

EARLY DETECTION AND TREATMENT OF REVERSAL REACTION UNDERFIELD CONDITIONS

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daily dose should be reduced gradually and neverstopped suddenly.

Suggested dose of prednisolone for adults (WHOrecommended):

− 40 mg once a day for first 2 weeks, then− 30 mg once a day for weeks 3 & 4− 20 mg once a day for weeks 5 & 6− 15 mg once a day for weeks 7 & 8− 10 mg once a day for weeks 9 & 10 and− 5 mg once a day for weeks 11 & 12.

3.1 Availability of steroidsIt is important that steroids are available whenpatients are treated with MDT and that staff aretrained to give steroids when appropriate. Thesemay be distributed to patients in blister packswhere available.

3.2 Contra-Indications for the use ofsteroids

The use of steroids may be contra-indicated inpatients with the following problems: tuberculosis,peptic ulcer, serious infections and illnesses,diabetes, glaucoma and hypertension. In thesecircumstances, the patient should be referred tohospital.

Patients on MDT should continue the course ofMDT without interruption along with anti-reactiontreatment.

3.3 Patient informationThe patient should receive sufficient explanation tohelp him/her understand the following:

• That a reversal reaction is not a new leprosyinfection.

• That reaction can be treated with tablets.

• The treatment should not be stoppedsuddenly.

• Awareness of possible side-effects.

• Exercise is required to keep limbs mobile.

• Skin lesions will fade rapidly.

4 CARE OF INFLAMED NERVES

• While there are signs of neuritis, the nerveshould be rested to relieve any pain and toassist recovery.

• To rest a nerve in the arm, make a sling.

• To rest a nerve in the leg, the patient shouldnot walk.

• To keep the nerve warm by wrapping thetender area to relieve pain.

• Daily gentle massage and exercise of jointsshould be encouraged to avoid joint stiffness.

5 THE TREATMENT OF REVERSALREACTION UNDER FIELDCONDITIONS

Many patients are unable or unwilling to beadmitted to hospital for the treatment of reactions.The reasons for this are varied, but may be becausepatients for economic, or family reasons are notprepared to be hospitalised for the length of timerequired to complete treatment. In some areas,hospital in-patient and out-patient facilities maynot have the resources to cope with the numbersrequiring treatment and may be an inconvenientdistance away from the patient’s home.

Most patients with reversal reaction can bemanaged in the field provided that staff aresupervised and properly trained in the use ofsteroids. Patients must also be instructed not tostop the treatment suddenly and to report anychanges in sensation and muscle strength or anyadverse effects of steroid treatment.

If treated at home, the patient should be seen every2 weeks by the health worker and checked everymonth by the leprosy supervisor at their regularleprosy clinic. There must be careful monitoring:

• To ensure that the treatment is being taken.

• To assess response to treatment.

• To check for any adverse side-effects of thesteroid treatment. The important problemsinclude peptic ulcer, diabetes, menstrualirregularities, changes in mood and otheremotional problems.

Referral to hospital is recommended:

• If complications do occur.

• If the patient does not respond.

• If there is deterioration in the patient’scondition.

ReferencesPrevention of Disability in Leprosy , ILEP TechnicalBulletin No. 8, (December 1995) ILEP, London.

The Management of Erythema Nodosum Leprosum ,ILEP Technical Bulletin No. 9 (May 1996) ILEP,London.

Guidelines for Writing a Healthworkers Manual forLeprosy Control, (2nd Edition: April 1996, pp19-21)ILEP /TALMILEP London.

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Prevention of Disabilities in Patients with Leprosy, aPractical Guide, H Srinivasan, WHO, Geneva,(1993).

Preventing Disabilities in Leprosy , J Watson, TheLeprosy Mission International, London (1986).

Nerves in Leprosy , Nos. 26 & 27 Partners MagazineFor Paramedical Workers, The Leprosy MissionInternational (1994).

Guidelines for Multidrug Treatment in EndemicDistricts, NLEP in India. (1993)

Leprosy for Field Staff, A Summers, The LeprosyMission International, London (1st Edition 1993).

A Guide to Eliminating Leprosy as a Public HealthProblem, Action Programme for the Elimination ofLeprosy. WHO, Geneva (First Edition: 1995).

A Guide to Eliminating Leprosy as a Public HealthProblem, Pocket Edition, WHO, Geneva (1995).

A Guide to Leprosy Control, WHO, Geneva. (SecondEdition 1988).

ILEP is a Federation of autonomous anti-leprosyAssociations. The advice contained in this publication isnot binding on ILEP Members.

The text of this Techical Bulletin can be freely quotedsubject to acknowledgement of its source.