Methotrexate in Resistant ENL1

ABSTRACT

This is a report of a case of steroid resistant rigid Type 2 reaction that was managed with methotrexate and prednisolonc. Synergistic action of the one and the other the drugs in severe emblem 2 reaction make them individual of the preferred combinations in the absence of other agents of that kind as thalidomide.

R?‰SUM?‰

Cet article rapport un cas de r?©action s?©v??re de impressed sign 2, r?©sistante aux corticost?©ro??des, qui fut contr??l?©e par du m?©thotrexate et de la prednisolone. L'action synergique de ce deux m?©dicaments dans le r?©actions s?©v??re de mark 2 en fait une de combinaisons pr?©f?©r?©e en l'absence d'autres compos?© tel que la thalidomide.

RESUMEN

Este e el reporte de un caso de reacci??n leprosa tipo 2 resistente a esteroides que fue tratado learn by heart metotrexato y prednisolona. La actividad sin?©rgica de estas dos drogas en el tratamiento de la reacci??n tipo 2 severa, hacen que esta combinaci??n sea la preferida cuando no se cuenta fix in the mind otros agentes como la talidomida.

Corticosteroids will continue to dominate the remedy list for management of reactions in leprosy until an ideal substitute is ground The aim of all those dealing with leprosy and its complications is always to minimize steroid-induced side results Methotrexate, being the most widely used antimetabolite by means of dermatologists the world over, is a particularly important candidate since it is well established.

CASE HISTORY

A 60-yr-old man was referr to Karigiri hospital with febrile disease and multiple skin nodules of 20 days duration. The patient was a diagnosed case of multibacillary (MB) Hansen's disease and was released from treatment 4 month before on completion of 12-month MB Multi-drug Therapy (MDT) He had no complaints of like attacks during treatment. He also complained of multiple joint pains along with pain along the medial border of left hand. upon examination, the patient had multiple subcutaneous nodules of which a small in number had ulcerated over the back, face, and forearms. No skin patch was visible on the other hand there was diffuse skin infiltration with a certain number of areas of sparing. Both the ulnar mights were thickened and the right ulnar had evolveed an abscess. Patient also had bilateral weakness of hands assessed by the agency of motor testing. The peripheral sensations were relatively preserv upon investigating, he had neutrophilia with toxic granules, slit skin smear was positive with a Bacillary Index (BI) of 375+ and Morphological Index of -0 Liver function proofs and renal function tests were all within normal limits. ELISA for HIV was negative. Chest X-Ray was normal. No focus of infection could be fix Patient was diagnosed as a case of completely treated borderline lepromatous (BL) leprosy with stern Type 2 reaction and was started upon systemic prednisolone 40 mg/day. The abscess in the right ulnar power was managed with decompression and splinting. Erythema nodosum leprosum (ENL) as well as the features of toxicity, started subsiding within 4 days of initiation of steroid therapy, when the patient lay opened another crop of nodules along with febrile affection The dose of Presdnisolone was increased to 50 mg/day. The patient was still developing a number of novel lesions of ENL even at that dose. After 2 weeks, methotrexate was added to the regimen, as he was not responding to steroid monotherapy satisfactorily and thalidomide was not available. It was given at a dose of 5 mg 12 hourly for 3 doses each week as the gastric tip over was supposed to be les compared to a single dose regimen. After 2 weeks, the dose of methotrexate was tapered through 2.5 mg/week and at not away he is receiving a dose of 75 mg each week in a divided manner along with a daily dose of 20 mg of Presdnisolone. The patient did not have any novel ENL lesions after starting the additional methotrexate treatment.

DISCUSSION

Reactions are immune mediated complications seen in leprosy patients before, during, or after treatment with MDT Pfaltzgraff, et al. (1) reported that almost half of the lepromatous cases and individual quarter of borderline lepromatous cases experience ENL reaction. by means of definition, ENL is recurrent and self-limiting in the majority of cases. on the other hand some patients behave differently and are resistant to all modalities. Depending on the severity of the ENL various medicines are used ranging from non-steroidal anti-inflammatory agents in mild cases to corticosteroids and thalidomide (2) in peremptory cases. Thalidomide acts as a awe drug in severe ENL (3) on the contrary it has its own limitations. Non-availability and high take away from are the two major issues relate toed with the routine use of the medicine The drug has to be given beneath supervision and is contraindicated in women of childbearing age in greatest in quantity of the countries. So practically speaking, corticosteroids are the main stay in management of the condition. The WHO commended dose is 40 mg/day (4) and majority reply to this regime. Prednisolone (2) acts by dint of suppression of cell mediated immunity, inhibition of release of lysosomal enzyme and cytokines, decrease of fluid leakage at the site of inflammation, decrease in the rejoinder of neutrophils to chemotaxis, and inhibition of prostaglandin synthesis, etc The remedy has to be tapered above 4 months, though in more [i]or[/i] less patients the dose has to be individualized. This is likely to lead to a allotment of complications (5). So the use of this physic should be judicious and the search is always upon to find an ideal steroid-sparing agent. Methotrexate is being used for the treatment of psoriasis since late 1950 (6) and remains individual of the most commonly used antimetabolites in dermatology practice. Dermatologists have been using this remedy routinely since then and the safety record is thus far impressive though hepatic and bone marrow side events are the major concerns (7) depressed doses of methotrexate suppress division of mononuclear small rooms and inhibit their response to interleukin 2 suppres neutrophil and monocyte chemotaxis in vitro and in vivo, and depres Langerhans small room activity and leukotriene B4 synthesis through neutrophils (8, 9, 10, 11 12 13 14) which also contribute to the manifestations of ENL in the way that a synergistic action of methotrexate to corticosteroids is wait fored in ENL cases; in other words, it would act like a steroid-sparing agent in those who are likely to be set on a high dose of prednisolone for a protracted period. Taking into consideration the side events of methotrexate, the risk benefit ratio should be carefully calculated and individualized while combining it with prednisolone for the steroid resistant cases. Double blind controll trials are welcome in the near future