Pregnancy and the postpartum are periods where profound changes in immunity occur. More precisely hormonal and metabolic changes in pregnancy such as nutrient deficiencies and altered secretion of steroids account for depressed cellular immunity in pregnant women.
Leprosy relapses are immunologically mediated episodes of acute or subacute inflammation which occurring like a “bolt of thunder in a blue sky”, that is they interrupt the relatively uneventful usual chronic course of the disease.
During this process, the skin, nerves, mucous membranes and/or other sites are involved.
The authors report a 26-year old woman 16 weeks into her pregnancy who developed painless erythematous nodules 2 weeks after ending Leprosy treatment 3 months previously; the patient had then been Released From Treatment (RFT) after 12 months of treatment with MDT-MB regimen. The lesions were accompanied by fever. No neurological pain or signs were present.
Diagnosis was confirmed by Acid-Fast Bacill (AFB) positive staining and classified as borderline tuberculoid leprosy (BT Ridley-Jopling)
Treatment consisted of ibuprofen 200mg per mouth three times a day for 2weeks.
These Type I or reversal reactions are more frequent in patients with borderline and presented here with the clinical changes.
Reversal Reactions are as follows:
- Lepra type 1 reactions: these are caused by a reactivation of immunity towards the tuberculoid type and occur before or after treatment.
- Lepra type 2 reactions or Erythema Nodosum Leprosum (ENL).
In an Ethiopian study 40% of RR occur during pregnancy and 60% during lactation.
[To read more on the reactions (1 and 2), click here: LINK]
- Pregnancy and the postpartum period are periods of profound alteration of the immunological state and unsurprisingly are times of change in an otherwise adapted and stabilized immunological state, whilst the disease is present.
- The authors recommend regular follow up of the mother and child is necessary during the post-partum period.
Abstract (reproduced with permission):
Introduction: Leprosy relapse is a condition where the patients who have completed the treatment course of multi drug treatment (MDT) show new onset of clinical manifestation. There are many criteria to diagnose leprosy relapse which include clinical, bacteriological, histopathological, and serological criteria. Hormonal and metabolic changes in pregnancy such as nutritional changes and altered secretion of steroids account for depressed cellular immunity in pregnant women. Appearance of new lesions, reactivation of old disease or even relapse in treated patients can occur during pregnancy. Pregnancy-associated relapse is due to suppressed cell-mediated immunity (CMI). One study observed a relapse rate of 36% in pregnant women with PB leprosy, 3–36 months after release from treatment (RFT). Spectrum of symptoms observed in pregnant females are similar to those seen in general population. Owing to alterations in humoral and CMI, leprosy reactions may also be triggered off. Widespread implementation of multidrug therapy and it is safe use in pregnancy (with no teratogenicity) have aided in elimination of the disease and normal pregnancy outcomes.
Results: A 26-year-old woman in 16 week of pregnancy with chief complaint of having painless erythematous nodules and fever since 2 weeks prior. Previously, 3 months ago, the patient was released from treatment (RFT) after 12 months of treatment with MDT-MB regiment. Generally, the patient was moderately sickness and had a fever. Neurological examination showed neither nerve enlargement nor pain, but reduce sensory perception in palmar manus bilateral. Acid-fast bacilli staining revealed bacterial index (BI) +1 and negative morphology index (MI); histopathology investigation showed borderline tuberculoid (BT) leprosy. MDT-PB regiment was started daily for 12 months. Patient was also refered to Obstetrician and all general physical and obstetric examination showed normally.
Reference: Leprosy relapse in pregnancy after treatment. Riva AM et al. Department of Medicine Universitas Sriwijaya-Mohammad Hoesin General Hospital, Palembang, Indonesia. EADV annual meeting 2019 – Madrid, Spain