TYPE III & IV HYPERSENSITIVITY REACTION 1 Hypersensitivity reaction.
File Presentation Type i Leprosy Reaction Khunadi Hubaya
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Transcript of File Presentation Type i Leprosy Reaction Khunadi Hubaya
TYPE I LEPROSY REACTION
KHUNADI HUBAYADERMATOVENEREOLOGY DEPARTMENT OF
TUGUREJO GENERAL HOSPITAL, SEMARANG, CENTRAL JAVA, INDONESIA
PRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011
INTRODUCTION
• Leprosy Reaction
State of symptoms and signs of acute inflammation in the lesions
of leprosy
patients immunological disorder caused by hypersensitive reaction of M.leprae antigens.
Fifty percent (50%) of treated leprosy patients reactionsPRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011
Reaction occurs :• Leprosy occurs • Occur due to of immunological changes
as a result of anti–leprosy treatment • Occur spontaneously other infectious dis-
eases, anemia, mental and physical stress, puberty, pregnancy, childbirth, surgery.
Anti-leprosy treatment most frequent trig-ger factors
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TYPE I LEPROSY REACTION • T I LR = upgrading reaction, borderline reac-
tion, tuberculoid reaction, leprosy non-lepromatous reaction
• Occurs in 30% of patients with borderline lep-rosy (BT, BB, BL)
• Appears in: - First 6 months of treatment - Occur 2 years af-ter the first treatment - Not received therapy
• Jopling : delayed hypersensitivity reaction (type IV hypersensitivity reactions Coombs and Gell )PRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011
• Antigens from dead bacilli will react with T lymphocytes changes in cel-luler immune system.
• Result : upgrading/reversal to tubercu-loid form ( increase cellular immune system )
down grading to lepromatous form ( decrease cellular immune sys-tem)
• In fact, the type 1 reaction = reversal reaction most often encoun-tered, down grading reaction is rarer
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CINICAL FEATURES
• Prominent and shiny erythematous plaques, few days later, the color can change to purplish or brown-ish. The firm edge of the lesion, pressurized pain or feels hot when touched.
• In severe reactions desquamation or ulceration due to necrosis.
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• New lesions may show subclinical le-sions
Neuritis of the nerves are located super-ficially.
Mild neuritis, painless enlarged nerves, anesthesia , paralysis.
• In severe cases nerve enlargement, spontaneous or pressurized pain, anesthesia on the dermatomes.
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• The biggest cause nerve function damage (30% patients) claw hand, drop foot, facial palsy with or without lagoph-talmus , keratitis.
• Mild systemic symptoms : facial and leg edema.
• Severe symptoms: malaise, fever, face hands and leg edema
Histopathological: epitheloidcell granuloma edema, dermal edema, plasma cells and granuloma fraction PRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011
INFLUECE OF ANXIETY ON THE IMMUNE SYSTEM (WEBSTER, 1998)
Person experiences excessive anxiety symptoms CRH (Cortico Releas-ing Hormone) release catecholamin hormone more than the glucocorti-coid.
Catecholamin hormone stimulate macrophages stimulate IL – 1O
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increasing the formation of T-helper cell (Th-2) more humoral immu-nity will be formed Manifesta-tion type 2 leprosy reaction.
Minute glucocorticoid macrophage to slightly stimulate IL - 12 to secrete Th-1 cells the formed cellular immunity will be small Manifestation type 1 leprosy reaction
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MANAGEMENT
• Rest or immobilization• Elimination of triggering factor• Continuing treatment of anti-leprosy
drugs• Analgesic sedatives to cope with pain• Provision of anti reaction drugs
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Mild reaction •Nonmedicamentosa: rest, immobiliza-tion
•Medicamentosa: paracetamol, mefe-namic acid, aspirin, piroxicam, di-clofenac sodium,cyclooxygenase 2 (COX 2)
Severe reaction• Improvement of general condition by im-proving fluid/electrolyte balance
• Must be given corticosteroid PRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011
Provision of Corticosteroid
• Prednisone 40-60 mg/day single morning dose, tapering slowly until a few months/ years.
• Corticosteroid > one month, required minimum dose and alternate-day treat-ment
• Prednisone or prednisolone of 0.5 to 1.0 mg/BB kg/day single morning dose, tapering slowly and alternate-day treatment is more tolerated. PRESENTED IN THE INDONESIAN DUTCH TROPICAL DERMATOLOGY MEETING, YOGYAKARTA, APRIL 7TH - 9TH ,2011
• Hospital for Tropical Diseases in Lon-don: prednisolone 30-40 mg taper-ing to zero over a period of 5-6 months.
• Prednisolone 30 mg/day, slowly ta-pered to zero up to 20 weeks is better than 60mg/day tapered up to 12 weeks.
• Cyclosporin 5-10 mg/BB kg/day used if steroid fail,or as a steroid sparing agent.
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• Reported that a case of borderline lepromatous
leprosy with type 1 leprosy reaction
treated with prednisolone 1 mg/BB kg/
day for 4 weeks treatment condition
did not improve and the skin lesions re-
mained painful given topical therapy of
0.1% tacrolimus ointment twice daily
healing of all skin lesions after 2 weeks and
prednisolone dose become zero over a period
of 12 weeks of treatment
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• Tacrolimus: immunomodulatory and immuno suppressive agent
• Surgery
During the treatment failure in the repair of some nerve function ex-ploratory surgery to relieve me-chanical compression
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Tugurejo General Hospital Semarang
Uses corticosteroid treatment :methylprednisolone dose = prednisone/prednisolone dependence and the side effect is smaller.
Astaxanthin 4 mg, twice a day orally, astaxanthin a strong antioxidant po-tential against strong free radicals and having anti inflammatory effects by inhibiting cytokin and chemokin
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• Zinc 200 mg a day orally stabilizing the cell membrane, machrophage and mast cells that play a role in the immune system.
Changes in zinc metabolism function of immune cells to become abnormal.
Zinc supplementation improve of zinc metabolism increasing immune re-sponse against M.Leprae.
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Tgl 9 Oktober 2009 hari pertama
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Tgl 15 Oktober 2009 (hari ke 6)
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Tgl 22 oktober 2009( hari ke 13)
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Tgl tgl 26 Oktober 2009 (hari ke17)
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Tgl 24 November 2009 (hari ke 45)
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“leprosy work is not merely medical relief; it is transforming frustration of life into joy of dedication, personal ambition into selfless service”Mahatma Gandhi
Sandra Dewi, Duta Lepra Indonesia
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