Sie sind auf Seite 1von 11

R EVIEWS O F T HERAPEUTICS

Hansen’s Disease (Leprosy): Current and Future Pharmacotherapy and Treatment of Disease-Related Immunologic Reactions

Davey P. Legendre, Pharm.D., Christina A. Muzny, M.D., and Edwin Swiatlo, M.D., Ph.D.

Hansen’s disease, also known as leprosy, remains an important public health problem throughout the world, including North America. The causative microbe in Hansen’s disease is Mycobacterium leprae, an acid-fast organism that is difficult to grow in vitro. The nine-banded armadillo is the major animal reservoir in the United States. Manifestations of disease vary based on host immune response and can range from tuberculoid to lepromatous leprosy (paucibacillary to multibacillary disease). Hansen’s disease typically affects the skin, nerves, and eyes, and patients may present with skin lesions, weakness, numbness, eye pain, or loss of vision. Definitive diagnosis is based on a combi- nation of physical examination findings and skin biopsy and/or smear. Modern antibacterial therapy typically consists of combinations of dapsone and rifampin with or without clofazimine. Clofazimine is available only as an investigational drug through the National Hansen’s Disease Program. Other options include moxifloxacin, ofloxacin, minocycline, and clarithromycin. Hansen’s disease is associated with type 1 (reversal) and type 2 (erythema nodosum leprosum) immunologic reactions, during which the disease process appears to worsen dramatically. These reactions may occur at any time before, during, or after treatment. Antibacterial therapy should usually be continued during these reactions. Treatment options for these reactions differ based on clinical manifes- tations and include corticosteroids, thalidomide, pentoxiphylline, tumor necrosis factor inhibitors, and T cell inhibitors. Prompt diagnosis, antimicrobial ther- apy, and treatment of reactions dramatically reduce complications of the disease. Key Words: Hansen’s disease, leprosy, reversal reaction, erythema nodosum leprosum, ENL. (Pharmacotherapy 2012;32(1):2737)

OUTLINE Epidemiology Microbiology Pathogenesis Clinical Manifestations Diagnosis Immunologic Reactions Treatment of the Disease Dapsone Rifampin Clofazimine Fluoroquinolones Minocycline

Clarithromycin Future Therapy Prevention Treatment of Immunologic Reactions Corticosteroids Thalidomide Pentoxiphylline Tumor Necrosis Factor Inhibitors T-Cell Inhibitors Adjunctive Therapy Conclusion

28

Hansen’s disease, also known as leprosy, is an ancient infectious disease, with references dating back to Biblical times. 1 Recent research suggests that individuals have been afflicted with this disease dating back as early as 1550 B.C. 2 Throughout the course of history, Hansen’s dis- ease has played a significant role in the lives of mankind as a feared, misunderstood, and disfig- uring disease for which no treatment was avail- able. 2 Infected persons were forced to live in secluded “leper colonies,” until the 1940s when modern antibacterial therapy became available, due to concern for contagiousness and lack of effective treatment. 2 Mycobacterium leprae, the causative agent of this disease and the first human pathogen to be described, was identified in 1873 by Dr. Armauer Hansen of Norway. 2 Because of Hansen’s discovery, successful efforts to characterize the disease and find treatments that would slow or eliminate its progression were pursued.

PHARMACOTHERAPY Volume 32, Number 1, 2012

sen’s Disease Registry in 2008. 5 The annual number of endemic cases reported in the United States has remained relatively stable since 1988. The incidence of disease peaks in the age groups of 10 15 and 3060 years, and the male:female ratio of infection is ~2:1. No racial predilection for acquisition of this disease is known. Humans are the primary reservoir for M. leprae. Besides man, only wild nine-banded armadillos (Dasypus novemcintus) are known to be natural hosts of M. leprae. 6 Several cases of suspected zoonotic transmission from armadillos to humans have been reported. 7 10 Infected armadillos have been found in Alabama, Arkansas, Louisiana, Mis- sissippi, Texas, and Mexico. 11 Whole-genome sequencing of M. leprae from infected wild arma- dillos and patients with leprosy in the United States has revealed a unique M. leprae genotype (3I-2-v1) that has not been reported elsewhere in the world, lending further evidence to the hypoth- esis that M. leprae is a zoonosis in this region.

1

12

Epidemiology

Hansen’s disease occurs in both tropical and subtropical temperate climates. Worldwide, it remains an important public health problem, especially in Asia, Africa, and South America, including India, Brazil, Indonesia, Democratic Republic of the Congo, Bangladesh, Nepal, Angola, China, Madagascar, Mozambique, Nige- ria, the Philippines, and the United Republic of

Tanzania. Nevertheless, the annual case detec- tion rate of new infections with M. leprae has declined over the past decade as a result of more intensive infection control programs and the use of multidrug therapy. 3 In the United States, immigrants from endemic countries constitute the vast majority of cases diagnosed annually

Endemic foci do exist, however,

(8595%).

mainly in parts of Texas, Louisiana, Florida, and

3

4

5

California. A total of 150 endemic cases in the United States were reported to the National Han-

From the Pharmacy Division, Health Management Associates, Woodstock, Georgia (Dr. Legendre); the Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama (Dr. Muzny); and the Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi (Dr. Swiatlo). For reprints, visit https://caesar.sheridan.com/reprints/ redir.php?pub=10089&acro=PHAR. For questions or com- ments, contact Davey P. Legendre, Pharm. D., BCPS-AQID, Health Management Associates, Pharmacy Division, 5811 Pelican Bay Blvd., Suite 500, Naples, FL 34108.

Microbiology

Although M. leprae cannot be cultured in synthetic laboratory media, it does infect nine- banded armadillos and multiplies in mouse foot- pads. These animal hosts have provided sufficient quantities of bacteria for microbiologic investigations. The organism is an aerobic rod- shaped bacterium that is acid fast with carbol fuchsin and other commonly used bacterial stains. The cell wall of M. leprae is structurally simi- lar to that of most Mycobacterium species. The polymers that lie adjacent to the cytoplasmic membrane comprise a complex amalgam of polysaccharides and glycolipids. Mycolic acids constitute up to 60% of the cell wall by weight and are thought to be primarily responsible for the acid-fast staining characteristic of mycobac- teria. The outer surface of the cell wall contains surface-exposed proteins that are unique to each species. The complex mixture of polysaccharides and glycolipids renders mycobacterial cells impermeable to most solutes without specific transport mechanisms. Resistance to both cellu- lar and humoral immune responses is attributed, in large part, to the complex cell wall of patho- genic mycobacteria. 13 Little is known about the physiology of M. leprae, but its doubling time of nearly 14 days in vivo is the longest of any known pathogen. The complete genome of a strain of M. leprae isolated in the Indian state of Tamil

TREATMENT OF HANSEN’S DISEASE Legendre et al 29

Nadu has been published. 14 The genome is ~ 3.2 Mbp and has a G + C content of 57.8%,

compared with a G + C content of 65.6% in Myco- bacterium tuberculosis. Although M. leprae and M. tuberculosis appear to have originated from a common ancestor, the M. leprae genome is ~30% smaller and contains over 1000 pseudogenes that have functional full-length homologues in

M. tuberculosis. It appears that less than half the

genome of M. leprae is protein-coding sequence. Many metabolic pathways found in other Myco- bacterium species, including respiratory electron transport systems, are lacking in M. leprae, and its ability to generate energy in the form of adenosine triphosphate (ATP) is severely com- promised. 14

Pathogenesis

The mode of transmission of M. leprae has not been absolutely proven; however, the most com- mon mechanism is thought to occur through the respiratory route in a manner similar to that of tuberculosis. Inoculation of bacilli through bro- ken skin and other close physical contact has also been implicated. In the southeastern United States, armadillos carry M. leprae, and contact with these animals is presumed to cause some infections in this region. Most people are resis- tant to infection with M. leprae ; however, certain genotypes are increasingly recognized as risk fac- tors for leprosy. Both human leukocyte antigen (HLA) and non-HLA alleles have been linked to susceptibility to infection. 15 A recent genome- wide association study in eastern China associ- ated variant genes in the NOD2 signaling pathway with susceptibility to infection with

M. leprae . 16

The pathogenesis of infection with M. leprae is poorly understood, but most evidence suggests that clinical manifestations of infection result

primarily from host immune responses to the leprosy bacillus. Classified on the basis of the Ridley-Jopling scale or by the World Health Organization (WHO), the immune response to

M. leprae varies over a large continuum and is

thought to be responsible for the heterogeneous clinical appearance of leprosy. 17 19 The Ridley-

Jopling scale combines clinical, immunologic, and histopathologic evidence and recognizes five forms of leprosy: tuberculoid, borderline tuber- culoid, midborderline, borderline lepromatous, and lepromatous leprosy. The WHO classifica- tion scheme is superimposed on the Ridley- Jopling scale to fit two distinct multidrug

therapy regimens and consists of two broad cate- gories: paucibacillary disease, which includes the tuberculoid and borderline tuberculoid forms, and multibacillary disease, which includes the midborderline, borderline lepromatous, and lepromatous forms (Figure 1). At the paucibacillary tuberculoid end of the spectrum, skin and nerve lesions have character- istics of well-developed T helper cell type 1 (Th1) mediated immune responses and possess few acid-fast bacilli that signify presence of the organ- ism. This form of leprosy typically is associated with a low burden of organisms and few skin lesions. In contrast, at the multibacillary leproma- tous end of the spectrum, Th2-type cellular immune responses predominate, with numerous skin lesions containing many acid-fast bacilli. This form of infection results in multiple progres- sive skin lesions and may extensively involve peripheral nerves. Between these two phenotypic extremes is a highly variable continuum of clini- cal disease that is marked by dynamic immuno- logic responses to M . leprae. The clinical manifestations of infection in an individual may evolve in a waxing and waning manner dependent on the predominant immuno- logic response at any time. These clinical forms of infection have been studied in the context of gene expression profiling, 20 and this approach has uncovered new insights into the mechanisms underlying the regulation of disparate immune responses to M. leprae.

Clinical Manifestations

Because of the large variability in host immune response to M. leprae, patients present

TT

Borderline disease

to M. leprae , patients present TT Borderline disease BT B B BL LL Unstable clinical
to M. leprae , patients present TT Borderline disease BT B B BL LL Unstable clinical

BT

BB

BL

LL

Unstable clinical presentation CMI AFB
Unstable clinical presentation
CMI
AFB

Paucibacillary

Multibacillary

Figure 1. Relationships of bacterial burden, immune response, and clinical classification schemes. The five forms of leprosy based on the Ridley-Jopling Scale are tuberculoid (TT), borderline tuberculoid (BT), midborderline (BB), borderline lepromatous (BL), and lepromatous (LL). CMI = cell-mediated immunity; AFB = acid-fast bacilli.

30

with heterogeneous clinical manifestations of disease. The period between infection and overt disease varies widely from several months to 30 40 years. 1 The disease typically affects the skin, nerves, and eyes, and patients may present with skin lesions, weakness or numbness, eye pain, or loss of vision. The clinical diagnosis of lep- rosy should always be suspected in someone with skin lesions and/or enlarged nerves accom- panied by sensory loss. 17 19 At the paucibacillary tuberculoid end of the spectrum of disease, patients can have one to sev- eral large asymmetric skin lesions, typically ma- cules or plaques, with sharply defined borders and hypopigmented, anesthetic centers. In bor- derline tuberculoid, the most common form of leprosy, skin lesions resemble those of tubercu- loid leprosy but are more frequent and variable in appearance with less well-demarcated borders. Asymmetric enlargement of peripheral nerves and progressive nerve damage are common, and patients may present with muscle weakness or trauma secondary to sensory impairment. Pro- gressing toward the multibacillary lepromatous end of the spectrum, patients with the midbor- derline form are immunologically unstable and may shift rapidly toward the borderline tubercu- loid end of the spectrum during a reversal reac- tion (Figure 1). Skin lesions are numerous; vary in size, shape, and distribution; and may be hyp- opigmented or erythematous. A characteristic “target lesion,” typically pres- ent in patients with the midborderline form of leprosy, has a broad, erythematous border with a vague outer edge and a punched-out pale center with sensory impairment. Patients with the bor- derline lepromatous form also have numerous skin lesions, generally with intact sensation, although occasionally lesions may exhibit hypoesthesia. Patients at the lepromatous end of the disease spectrum have extensive disease and widespread involvement of the skin and other organs. Generalized infiltration of the dermis may cause the skin to have a smooth, shiny appearance. Numerous skin lesions (macules, papules, or nodules) are symmetri- cally distributed, but with retained sensation. Progressive thickening of the skin causes coarse facial features and thickening of the ear lobes. Eyebrows and eyelashes are thinned out, and infiltration of the nasal mucosa may occur, resulting in discharge and obstruction. Erosion of the cartilage and nasomaxillary bones can result in perforation of the nasal septum, collapse of the nose, and saddle-nose

PHARMACOTHERAPY Volume 32, Number 1, 2012

deformity. Extension into the eye can cause keratitis and iritis. Infiltration of dermal nerves can cause peripheral sensory loss. 17, 18

Diagnosis

More than 125 years after the discovery of M. leprae, the bacillus is yet to be cultivated in vitro. The diagnosis of leprosy is based on a combina- tion of physical examination findings and skin biopsy and/or smear. 17, 18 Slit-skin smears can be performed by making a shallow incision in the skin at standard sites (bilateral earlobes, elbows, and knees), as well as from several typi- cal skin lesions. After the incision is made, the inner surface of the wound is scraped with a blade held at a right angle to the incision. Upon scraping, tissue fluid and dermal tissue are obtained and transferred to a clean microscopic slide where a circular smear is made. After the slide is stained with ZiehlNeelsen carbol-fuch- sin and counterstained with methylene blue, the number of acid-fast bacilli viewed under the microscope per oil immersion field is deter- mined and expressed as a “bacteriologic index.” This technique may be used to guide multidrug therapy by assessing the bacterial load before and during therapy. In addition, a full-thickness skin biopsy specimen from the margin of an active lesion can be obtained and the Fite stain used to visu- alize acid-fast bacilli in the tissue. If another mycobacterial infection is suspected, culture of tissue biopsy material can be performed; growth will exclude M. leprae . Also, a rapid molecular assay using real-time polymerase chain reaction to identify and quantify M. leprae DNA in tissue samples can be performed at laboratory facilities equipped to perform this test, such as the National Hansen’s Disease Program (NHDP) Laboratory in Baton Rouge, Louisiana. 21, 22

Immunologic Reactions

Immunologic reactions to M. leprae antigens are generally classified as either type 1 (reversal) or type 2 (erythema nodosum leprosum [ENL]) and reflect the predominant immuno- logic response locally in either nerves or skin. An example of a type 1 (reversal) reaction is shown in Figure 2. Approximately one third of patients with borderline leprosy are at risk for type 1 reactions, whereas type 2 reactions affect 50% of patients with the lepromatous form and 10% of those with the borderline leproma-

TREATMENT OF HANSEN’S DISEASE Legendre et al 31

TREATMENT OF HANSEN’S DISEASE Legendre et al 31 Figure 2. Example of a type 1 (reversal)

Figure 2. Example of a type 1 (reversal) reaction to therapy for Hansen’s disease (leprosy) appearing as skin lesions on the patient’s back.

tous form of leprosy. These reactions may be a presenting feature of the disease or occur during or after multidrug therapy. 23 These reactions have also been described in patients with human immunodeficiency virus as part of the immune reconstitution inflammatory syndrome. 24 Prompt recognition and treatment of inflammatory reac- tions are necessary to minimize progressive nerve damage that can occur with sustained inflammatory responses. Type 1 reactions are characterized by a shift to Th1-type immune responses in the host and are associated with locally elevated levels of interferon- c, tumor necrosis factor-a (TNF- a ), interleukin-12, and inducible nitric oxide syn- thase. 25 This type of reaction can be seen in any type of leprosy but is uncommon in the tuberculoid form of the disease as an appropri- ate Th1-type immune response already exists. The diagnosis of type 1 reactions is generally made clinically; however, skin biopsy is often useful. Histologic criteria for type 1 reactions are not standardized, but common findings include dermal edema, large epithelioid granu-

Skin lesions may

lomas, and plasma cells.

become larger and more erythematous and may ulcerate. New or worsening symptoms of neuri- tis may appear and can include both motor and sensory nerve dysfunction. 23 Generalized edema may occur, but systemic symptoms are not common. Type 2 reactions, also known as ENL, are dis- tinguished clinically by fever, malaise, and the rapid appearance of new subcutaneous nodules that are erythematous and quite painful. 17 These lesions are typically found on the face and exten-

26

sor surfaces of the limbs, but any site of the body can be affected. 23 Painful neuritis is a common complication. Erythema nodosum leprosum is thought to be an immune complex disease with consequent activation of complement. Circulat- ing levels of TNF- a and interferon-c are ele- vated. 27 Widespread immune complex deposition can occur and cause polyarthritis, iridocyclitis, orchitis, lymphadenitis, and glumerulonephritis. Peripheral leukocytosis with neutrophils is a com- mon laboratory finding. Patients with borderline or the lepromatous form of leprosy are at highest risk for ENL because they have a higher bacterio- logic index. 23 A rare but potentially life-threatening reaction to M. leprae is erythema necroticans or Lucio’s phenomenon. 28 This reaction is distinct from type 1 and 2 reactions and is characterized by necrotizing vasculitis that has been ascribed to invasion of vascular endothelium with M. leprae. Clinical manifestations include bluish or violace- ous and hemorrhagic plaques, followed by necrotic ulcerations. These symptoms typically occur in the absence of systemic complaints or leukocytosis. The precise role of dysregulated immune responses in this reaction has not been fully studied.

17

Treatment of the Disease

Before the advent of sulfone treatment, therapy for Hansen’s disease consisted of potassium iodide, arsenic, antimony, copper, sera, vaccines, aniline dyes, thymol, strychnine, baths, X-rays, radium, and electrical current. 29 Chaulmoogra oil, a product of the seeds of several species of the Hydnocarpus tree, was a hallmark of therapy in the late 19th and early 20th centuries, with varying reports of documented success and indifferent results. The oil was mixed with lard and applied locally as well as taken orally sev-

eral times/day.

chaulmoogric acid became available in 1909 by

Bayer and Company under the name Antileprol and later Chaulmestrol (Winthrop Chemical Company). 31 Oral therapy appeared to be the most effective, but the dosage had to be titrated over time primarily because of nausea. The drug was also prepared as an injection, but the adverse effects of fever, local reactions, and abscess made therapy difficult to tolerate. In his book Alone No Longer, Stanley Stein, a pharmacist who contracted Hansen’s disease, filled capsules of “foul smelling oily liquid” that left him “so nauseated that [he] quickly recorked

Commercial preparations of

30

32

PHARMACOTHERAPY Volume 32, Number 1, 2012

Table 1. Recommended Therapy According to the World Health Organization 33 and the National Hansen’s Disease Pro- gram 34

WHO

Classification of

Disease

NHDP Recommendation

WHO Recommendation

Single-lesion

Dapsone 100 mg/day + rifampin 600 mg/ day for 12 mo Dapsone 100 mg/day + rifampin 600 mg/ day for 12 mo Dapsone 100 mg/day + rifampin 600 mg/ day + clofazimine 50 mg/day for 24 mo

Rifampin 600 mg once + ofloxacin 400 mg once + minocycline 100 mg once a Dapsone 100 mg/day (unsupervised) + rifampin 600 mg/mo (supervised) for 6 mo Dapsone 100 mg/day (unsupervised) + rifampin 600 mg/mo (supervised) + clofazimine 300 mg/mo (supervised) for 24 mo

paucibacillary

Paucibacillary

Multibacillary

WHO = World Health Organization; NHDP = National Hansen’s Disease Program. a This regimen is not recommended in the United States and is associated with clinical failure.

Table 2. Pharmacokinetic Properties of Antibacterials 36 38

Antibacterial

Bioavailability (%)

Half-Life (hrs)

Metabolism

Route of Elimination

Dapsone

80

99

30

Acetylation Deacetylation Not available Hepatic Glucoronidation, sulfation Hepatic Hepatic

20% urine 60% feces, 30% urine Feces 95% urine, 5% feces 20% urine, 25% feces 20% urine 30% urine

Rifampin

60

99

a

35

Clofazimine

20

70

b

70 days

Ofloxacin

98

48

Moxifloxacin

86

15

Minocycline

100

14 18

Clarithromycin

55

3

a Food decreases absorption. b Food increases absorption.

the bottle.” 32 Ironically, he distributed pills in the cafeteria at the leprosarium in Carville, Loui- siana. He also described a chaulmoogra oil injec- tion combined with olive oil and benzocaine that left “painful suppurating abscesses” and resulted in several hospitalizations. 32 Although modern recommendations for ther- apy differ between the U.S. Public Health Service NHDP and the WHO, antibacterials targeting M. leprae are the mainstay of therapy. Table 1 shows recommendations for therapy, noting WHO suggestions for directly observed ther-

apy. 33 35 Pharmacokinetic properties of the

antibacterials are listed in Table 2.

36

38

Dapsone

Sulfones have long been the cornerstone for treatment of Hansen’s disease. Dapsone exerts weakly bactericidal activity against M. leprae by inhibiting dihydropteroate synthase, ultimately preventing folic acid synthesis. In a mouse foot- pad model, oral dapsone therapy killed 99.4% of viable organisms as evidenced by a lag of an average of 78 days for M. leprae growth curves in dapsone-treated versus control animals. 39 It is taken orally once/day with or without meals, with nearly complete absorption and peak serum concentrations of 28 hours. There is no dosage

adjustment needed for patients with renal

dysfunction, but patients with hepatic impair- ment should be monitored closely. Dapsone may cause hepatitis and cholestatic jaundice, but no dosage adjustment guidelines are available for those with liver disease. Dapsone was initially used as monotherapy, but resistance, estimated at 210%, has become problematic. 40 One proposed mechanism of resistance is a mutant folP1 gene, which encodes a resistant dihydropteroate synthase capable of folic acid synthesis under a variety of extreme

conditions. 41

gence of resistance expected with monotherapy, multidrug therapy is the standard of care. The adverse effects of dapsone can be quite limiting with the most profound being methemo- globinemia and hemolysis related to glucose- 6-phosphate dehydrogenase (G6PD) deficiency. All patients should be screened for G6PD defi- ciency before starting dapsone, and those with mild G6PD deficiency may be started at 25 mg/ day with close monitoring. 35 Dapsone is used in pregnant patients, although it is a category C drug. It is excreted substantially in breast milk and is potentially harmful to nursing infants with G6PD deficiency. Cutaneous manifestations that may be confused with worsening disease are also possible, sometimes accompanied with lymphade-

42

In an effort to prevent the emer-

TREATMENT OF HANSEN’S DISEASE Legendre et al 33

result from induction of the following cyto- chrome P450 isoforms: 3A4, 1A2, 2C8, 2C9, 2C19, and 2D6. Pharmacists should check for drug interactions before starting therapy. Rifam- pin increases the metabolism of dapsone, but this interaction is not significant for the treat- ment of Hansen’s disease. In contrast, the drug interaction between rifampin and prednisone is quite significant, and the rifampin dosage should be reduced from 600 mg/day to 600 mg/month with the addition of corticosteroid therapy.

nopathy, fever, hepatitis, leukopenia, anemia, and

acute psychosis.

There are also reports of

43

peripheral neuropathy, although this adverse

effect is rare.

44

Rifampin

Although not U.S. Food and Drug Administra- tion (FDA) approved for Hansen’s disease, rifam- pin is recommended for every manifestation of the disease. It is rapidly bactericidal against M. le- prae with bacteriologic success within 3 weeks of starting therapy. Even a single high dose was effi- cacious in a mouse footpad model. 45 The rifamyc- ins bind to the b -subunit of RNA polymerase in prokaryotic cells and block RNA transcription. Bactericidal activity is observed even in slowly dividing cells, such as Mycobacterium species . Patients may take rifampin once/day unsupervised or once/month supervised, depending on the treat- ment algorithm. It is readily absorbed with an elim- ination half-life of ~3 hours. It is available as an intravenous infusion but is rarely used in this fash- ion for Hansen’s disease. There is no dosage adjustment necessary for patients with hepatic dysfunction, but the dose should be reduced by 50% when a patient’s creatinine clearance is less than 10 ml/minute as calculated by the Cock- croft-Gault equation. 36 Rifampin is a pregnancy category C drug although not considered a terato- gen, and the American Academy of Pediatrics con- siders rifampin compatible with breastfeeding although it is excreted in breast milk. Rifampin should never be used as monothera- py because of rapid development of resistance. Point mutations in rpoB, which encodes the b -subunit of RNA polymerase, are the likely

mechanism of resistance.

Therefore, rifampin

is a component of multidrug therapy most com- monly paired with dapsone, which reduces the rate of clinical failure resulting from resistance to either component. Adverse effects of rifampin therapy include rash, hepatotoxicity, and malaise. Patients should be warned of orange discoloration of tears, urine, and sweat, which can stain contact lenses and be disconcerting to the patient. Mild thrombocyto-

penia is also possible, but this adverse effect rarely requires discontinuation of the drug. Rifampin’s rapidly bactericidal activity leads to a proinflammatory state induced by subcellular components of dead bacteria. Therefore, it is contraindicated during the active phase of a

reversal reaction.

The major issue with rifam-

pin therapy is multiple drug interactions that

Clofazimine

Clofazimine is a phenazine dye with antibacterial activity similar to that of dapsone. Its mechanism is poorly understood, but its ability to bind to DNA of M. leprae may contribute to its antibacte- rial activity. There is also some suggestion that the immunomodulatory activity of clofazimine may be useful during reversal reaction. It retains activity in the presence of dapsone resistance. 47 Clofazimine is taken orally once/day, but it is incompletely absorbed in the gastrointestinal tract. Food may increase absorption. The adverse effects are relatively mild, with gastrointestinal symptoms and skin discoloration as the most common. The skin discoloration manifests as increased melanin pigmentation that persists after therapy discontinuation, and there are reports of suicide due to depression from this change. This hyperpigmentation is also associated with sun- light sensitivity, so avoidance of prolonged sun exposure is encouraged. As a dye, the drug can be excreted in urine, sweat, and tears, so those wear- ing contact lenses should be cautioned. 37 Clofazimine is no longer commercially avail- able in the United States, but it can be obtained as an investigational new drug through the NHDP. The prescriber is considered to be an investigator and must submit an FDA form 1572 and curricu- lum vitae to the NHDP. The institutional review board is provided by the Centers for Disease Con- trol and Prevention. Consent forms and other documents will be provided to the prescriber upon request. For more information, visit www. hrsa.gov/hansens/clinical/regimens.htm or call

46

1-800-642-2477.

Fluoroquinolones

Although not considered primary therapy in most instances, fluoroquinolones, such as moxi- floxacin and ofloxacin, remain an important option for treating Hansen’s disease, especially in

35

34

patients with intolerance, resistance, or clinical failure to primary therapy. Fluoroquinolones are active against M. leprae by inhibiting DNA gyrase and inhibiting DNA replication and transcrip- tion. 48 Agents, such as moxifloxacin, exhibit pow- erful bactericidal activity similar to that of rifampin, with one dose producing substantial kill. In one study, no viable organisms remained after 3 weeks of daily therapy. 49 Ofloxacin has substantial activity and is recommended as a single dose with other drugs for single-lesion disease, but due to a slightly increased failure rate compared with stan- dard therapy, this regimen should be limited to countries with limited resources or operational difficulties. 50, 51 Other agents in this class, such as ciprofloxacin, show little to no activity. 52 Fluoroqu- inolone resistance occurs primarily through muta- tions in gyrA but is not associated with mutations in gyrB. 53

PHARMACOTHERAPY Volume 32, Number 1, 2012

Future Therapy

There is little in terms of novel therapy being explored for future treatment of Hansen’s disease, and the same is true for many diseases caused by Mycobacterium species. The diarylquinolone, R207910, is a promising new drug with bacterici- dal activity comparable to that of moxifloxacin

and rifapentine.

Its novel mechanism is believed

to be inhibition of ATP synthase. 60 In a murine model, R207910 retained bactericidal capabilities even when dosed once/month. 61 Although it must be studied in humans, this drug remains an excit- ing option for the future.

59

Prevention

Vaccines are effective at preventing infectious diseases and epidemics. There is no vaccine for M. leprae, but bacillus Calmette-Gue´ rin (BCG), often used as a tuberculosis vaccine, also offers some protection against M. leprae, with a single dose providing 50% protection. Some have advo- cated adding killed M. leprae to the BCG vaccine for increased immunologic response, but trials of this strategy conducted in Malawi have not proved effective. 62 Using BCG for prevention of Hansen’s disease alone is not recommended at this time, and BCG is generally not recom- mended for any indication in the United States.

Minocycline

Minocycline is the only tetracycline with intrinsic activity against M. leprae. Minocycline is a lipo- philic molecule that passively enters the bacterial cells and exerts its action on the 30S ribosomal subunit. Although not as active as rifampin, mino- cycline remains an effective and useful alternative in the treatment of Hansen’s disease. 54, 55 It is part of single-lesion therapy recommended by the WHO, and it has been used to successfully treat patients with lepromatous leprosy at a dose of 100 mg/day. 56 Adverse effects, even with long- term treatment, are usually very mild, although skin pigmentation, gastrointestinal symptoms, and central nervous system symptoms have been reported. Minocycline should not be used in chil- dren or during pregnancy because it may deposit in tooth enamel and discolor teeth.

Treatment of Immunologic Reactions

Immunologic reactions are medical emergen- cies that must be evaluated and treated immediately to prevent long-term sequelae. Anti- microbial therapy should continue throughout the type 1 (reversal) reaction, although many cli- nicians will stop rifampin, especially in the pres- ence of active neuritis. Cutaneous manifestations of a type 1 reaction generally do not require addi- tional therapy. However, if the patient experi- ences loss of sensation or other peripheral nerve symptoms, corticosteroids should be started immediately to prevent permanent damage. Type 2 reactions may not respond to corticosteroids

alone, and the addition of drugs such as thalido- mide may be useful in these cases. Patients not responding to any therapy may benefit from clof- azimine if not already taking this drug.

Clarithromycin

Clarithromycin is a semisynthetic macrolide antibiotic with bactericidal activity against M. leprae greater than other macrolides although less bacteri-

cidal than minocycline.

Its mechanism may be

due to reduction of ATP in the bacteria. 57 It is use-

ful as an alternative to primary therapy due to either resistance or intolerance and has been used to treat lepromatous leprosy as monotherapy with success, although higher doses lead to some gastrointestinal distress. 58 Clarithromycin 500 mg/ day has been paired successfully with minocy- cline. 56

54

Corticosteroids

Corticosteroids provide symptomatic relief from a reversal (type 1) reaction frequently within

TREATMENT OF HANSEN’S DISEASE Legendre et al 35

1 week. Prednisone 1 mg/kg up to 80 mg/day tapered over several months can be used. The dose may be increased by 20 mg/day if symptoms persist after initiation of therapy. Prednisolone is available as an oral solution that may be used in place of prednisone. Long-term use of high-dose corticosteroids certainly has complications associ- ated with adrenocortical atrophy and hypoalbu- minemia. Myopathy, osteoporosis, ocular effects, hyperglycemia, and skin reactions are just a few of the major adverse effects that must be moni- tored and addressed throughout the treatment. Some practitioners will also prescribe a bis- phosphonate, such as alendronate, to prevent osteoporosis.

Thalidomide

The mechanism of action of thalidomide in patients with Hansen’s disease is not fully under- stood, but it does reduce systemic concentrations of TNF- a, a cytokine involved in systemic inflammation. Thalidomide is useful for treat- ment for ENL when corticosteroids are not effec- tive or are contraindicated. The initial dose is 100 300 mg/day. Once symptoms subside, ther- apy can be tapered by 50 mg every 2 4 weeks. Thalidomide is known to cause birth defects and is a pregnancy category X drug. In this case, cor- ticosteroids are the hallmark of therapy. Breast- feeding is also contraindicated while taking thalidomide. Those who wish to prescribe ther- apy must be licensed through the System for Thalidomide Education and Prescribing Safety (STEPS) program, and pharmacists are also responsible for complying with these regulations.

Pentoxiphylline

This methylxanthine’s mechanism of action is unknown, but oral pentoxiphylline 400800 mg 3 times/day appears to decrease levels of TNF-a. 63 The major adverse effects are related to the gastrointestinal tract and central nervous sys- tem, but these effects are reduced by using a controlled-release formulation. Thalidomide outperformed pentoxiphylline in a randomized clinical trial in patients with type 2 reactions, in terms of limb edema and systemic symp- toms, but 62.5% of patients in the pentoxiph- ylline group had symptom relief. Although this drug is not first line, it is a useful option when other therapies are ineffective or contrain- dicated. 64

Tumor Necrosis Factor Inhibitors

Since the mechanism of action of several drugs is proposed to inhibit TNF- a concentrations, biologic TNF inhibitors are a promising option for treatment of refractory type 2 reactions. Various case reports show successful treatment of difficult reactions with etanercept and inflix- imab. 65, 66 However, these drugs are known to exacerbate infectious complications, and several case reports show development or worsening of disease with agents such as infliximab and ada- limumab. 67, 68 It is interesting to note that two patients who developed disease when starting inf- liximab also developed a type 1 reaction after its discontinuation. The true efficacy and safety of these drugs in type 2 reactions are still unknown, but these drugs may be useful in situations when all other therapies are ineffective and the patient desperately needs relief of symptoms.

T

Cell Inhibitors

There is some evidence that drugs that disrupt

T

cell activation and function can provide relief

during a reaction. Oral cyclosporine resulted in complete response in 3 of 4 patients, with the remaining patient achieving a partial response. 69,

However, M. leprae grew more readily in BALB/c mice infected with M. leprae who were treated with extended courses of cyclosporine. 71 Sixty-seven patients, with 20 experiencing chronic neuritis while receiving prednisone, were treated with cyclosporine 5 mg/kg reduced over 12 months. 72 Therapy resulted in reduc- tions of antibodies to nerve growth factor to normal levels and improvement of sensory impairment. One published case reported dramatic improvement of skin lesions after daily topical administration with tacrolimus 0.1%. 73 Cyclosporine and other drugs that inhi- bit T cells are another option for patients not responding to standard treatment of a reaction.

70

Adjunctive Therapy

There is little evidence that directly supports the use of nonsteroidal antiinflammatory drugs, but they are commonly used in very high doses to treat reactions, because of their antiinflammatory effects. Amitriptyline and gabapentin have also been used to mitigate neuropathy despite little evidence to demonstrate effect. Some evidence points to the utility of leukotriene inhibitors, such as zafirlukast, in the treatment of ENL. 74

36

The Leprosy Mission in Bangladesh proposed a clinical study in 2006 to test montelukast. In Ban- gladesh, thalidomide is unavailable and clofazi- mine is difficult to obtain. However, no patients have been enrolled in this trial to date.

PHARMACOTHERAPY Volume 32, Number 1, 2012

9. West BC, Todd JR, Lary CH, Blake LA, Fowler ME, King JW. Leprosy in six isolated residents of northern Louisiana: time- clustered cases in an essentially nonendemic area. Arch Intern Med 1988;148:198792.

10. Freiberger HF, Fudenberg HH. An appetite for armadillo. Hosp Pract (Off Ed) 1981;16:13744.

11. Truman R. Armadillos as a source of infection for leprosy. South Med J 2008;101:581 2.

12. Truman RW, Singh P, Sharma R, et al. Probable zoonotic lep- rosy in the southern United States. N Engl J Med 2011;364:

162633.

13. Colston MJ. The microbiology of Mycobacterium leprae: pro- gress in the last 30 years. Trans R Soc Trop Med Hyg

1993;87:5047.

14. Cole ST, Eiglmeier K, Parkhill J, et al. Massive gene decay in the leprosy bacillus. Nature 2001;409:100711.

15. Moraes MO, Cardoso CC, Vanderborght PR, Pacheco AG. Genetics of host response in leprosy. Lepr Rev 2006;77:189

202.

16. Zhang FR, Huang W, Chen SM, et al. Genomewide associa- tion study of leprosy. N Engl J Med 2009;361:260918.

17. Britton W. Leprosy. In: Cohen J, Powerly W, Opal S, ed.

Infectious diseases, 3rd ed. London: Mosby; 2010:1099105.

18. Britton WJ, Lockwood DN. Leprosy. Lancet 2004;363:1209

19.

19. Ridley DS, Jopling WH. Classification of leprosy according to immunity: a five-group system. Int J Lepr Other Mycobact Dis

1966;34:25573.

20. Bleharski JR, Li H, Meinken C, et al. Use of genetic profiling in leprosy to discriminate clinical forms of the disease. Science

2003;301:152730.

21. Truman RW, Andrews PK, Robbins NY, Adams LB, Krahenbuhl JL, Gillis TP. Enumeration of Mycobacterium leprae using real- time PCR. PLoS Negl Trop Dis 2008;2:e328.

22. Lini N, Shankernarayan NP, Dharmalingam K. Quantitative real-time PCR analysis of Mycobacterium leprae DNA and mRNA in human biopsy material from leprosy and reactional cases. J Med Microbiol 2009;58:7539.

23. Walker SL, Lockwood DN. The clinical and immunological features of leprosy. Br Med Bull 2006;8:10321.

24. Batista MD, Porro AM, Maeda SM, et al. Leprosy reversal reaction as immune reconstitution inflammatory syndrome in

Conclusion

Hansen’s disease (leprosy) remains problem- atic in the United States and throughout the world. Transmission of bacteria from person to person is uncommon, and armadillos remain the major reservoir in the United States. There is no efficient way to grow the organism in culture, which makes research efforts difficult. Prompt recognition of disease and treatment reduces disease signs and symptoms, such as anesthetic lesions, loss of vision, and amputation. The discovery of antibacterial therapy targeting M. leprae has dramatically improved those infected with Hansen’s bacillus. Patients benefit from comprehensive care involving numerous health care professionals. Astute pharmacists who effectively manage antibacterial and reac- tion therapy will notice improved patient out- comes and quality of life. Major complications today involve immunologic reactions and drug resistance due to lack of compliance. Clinicians can recognize these issues early and adjust treat- ment appropriately to limit long-term complica- tions from this disease.

Acknowledgments

The authors would like to thank Barbara Stry- jewska, M.D., and Jackie Lea, R.Ph., from the NHDP for helpful discussions regarding the manuscript.

patients with AIDS. Clin Infect Dis 2008;46:e5660.

25. Little D, Khanolkar-Young S, Coulthart A, Suneetha S, Lock- wood DN. Immunohistochemical analysis of cellular infiltrate and gamma interferon, interleukin-12, and inducible nitric oxide synthase expression in leprosy type 1 (reversal) reac- tions before and during prednisolone treatment. Infect Immun

2001;69:34137.

References

1. Hastings RC. Leprosy, 2nd ed. Edinburgh and New York:

Churchill Livingstone; 1994.

2. Stanford University. History of leprosy. Available from http://

www.stanford.edu/group/parasites/ParaSites2005/Leprosy/history.

htm. Accessed March 1, 2011.

3. World Health Organization. Global leprosy situation, 2007. Wkly Epidemiol Rec 2007;82:22532.

4. Joyce M a S Leprosy (Hansen’s disease). In: Rakel R, Bope ET, eds. Conn’s current therapy. Philadelphia: Saunders; 2003:

1005.

5. U.S. Department of Health and Human Services, Health Resources and Services Administration. Registry report: a summary of Hansen’s disease in the United States, 2008. Avail- able from http://www.hrsa.gov/hansens/dataandstatistics.html. Accessed March 1, 2011.

6. Monot M, Honore N, Garnier T, et al. On the origin of lep- rosy. Science 2005;308:1040 2.

7. Lumpkin LR III, Cox GF, Wolf JE Jr. Leprosy in five arma- dillo handlers. J Am Acad Dermatol 1983;9:899903.

8. Lumpkin LR III, Cox GF, Wolf JE Jr. Leprosy in armadillo handlers [letter]. J Am Acad Dermatol 1984;10:1073.

26. Lockwood DN, Lucas SB, Desikan KV, Ebenezer G, Suneetha S, Nicholls P. The histological diagnosis of leprosy type 1 reactions: identification of key variables and an analysis of the process of histological diagnosis. J Clin Pathol 2008;61:595

600.

27. Iyer A, Hatta M, Usman R, et al. Serum levels of interferon- gamma, tumour necrosis factor-alpha, soluble interleukin-6R and soluble cell activation markers for monitoring response to treatment of leprosy reactions. Clin Exp Immunol

2007;150:2106.

28. Ang P, Tay YK, Ng SK, Seow CS. Fatal Lucio’s phenomenon in 2 patients with previously undiagnosed leprosy. J Am Acad

Dermatol 2003;48:95861.

29. Parascandola J. Chaulmoogra oil and the treatment of leprosy. Pharm Hist 2003;45:4757.

30. Cottle W. Chaulmoogra oil in leprosy. Br Med J 1879;1:968

9.

31. Annonymous. Chaulmoogra oil therapy in leprosy. Cal State J

Med 1922;22:64 5.

32. Stein S. Alone no longer. Carville, LA: The Star; 1974.

33. World Health Organization. WHO Expert Committee on Leprosy. Seventh report. World Health Organ Tech Rep Ser

1998;874:143.

TREATMENT OF HANSEN’S DISEASE Legendre et al

37

34. U.S. Department of Health and Human Services, Health Resources and Services Administration. Recommended treatment regimens, National Hansen’s Disease Center, 2011. Available from http://www.hrsa.gov/hansensdisease/diagnosis/recommended treatment.html. Accessed June 22, 2011.

35. Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases, 7th ed. Philadelphia: Churchill Livingstone/Elsevier; 2010.

36. sanofi-aventis. Rifadin (rifampin) product monograph. Bridge- water, NJ; 2010. Available from http://www.sanofiaventis.ca/ products/en/rifadin.pdf. Accessed June 20, 2011.

37. Novartis Pharma AG. Lamprene (clofazimine) international package leaflet. Basel, Switzerland; 2005. Available from http:// www.lamprene.com/fileadmin/pharmaworld/lamprene/lamprene_ packing_insert.pdf.Accessed June 21, 2011.

38. Goodman LS, Brunton LL, Chabner B, Knollmann BC, eds. Goodman & Gilman’s pharmacological basis of therapeutics, 12th ed. New York: McGraw-Hill; 2011.

39. Levy L. Bactericidal action of dapsone against Mycobacterium leprae in mice. Antimicrob Agents Chemother 1976;9:6147.

40. Jacobson RR, Hastings RC. Primary sulfone resistant leprosy. Int J Lepr Other Mycobact Dis 1978;46:116.

41. Williams DL, Spring L, Harris E, Roche P, Gillis TP. Dihy- dropteroate synthase of Mycobacterium leprae and dapsone resistance. Antimicrob Agents Chemother 2000;44:15307.

42. Pengelly CD. Dapsone-induced haemolysis. Br Med J

1963;2:6624.

43. Browne SG. Desensitization for dapsone dermatitis. Br Med J

1963;2:6646.

44. Rapoport AM, Guss SB. Dapsone-induced peripheral neuropa- thy. Arch Neurol 1972;27:1845.

45. Bullock WE. Rifampin in the treatment of leprosy. Rev Infect Dis 1983;5(suppl 3):S60613.

46. Honore N, Cole ST. Molecular basis of rifampin resistance in Mycobacterium leprae. Antimicrob Agents Chemother 1993;

37:4148.

47. Levy L, Shepard CC, Fasal P. Clofazimine therapy of leproma- tous leprosy caused by dapsone-resistant mycobacterium le- prae. Am J Trop Med Hyg 1972;21:31521.

48. Matrat S, Petrella S, Cambau E, Sougakoff W, Jarlier V, Aubry A. Expression and purification of an active form of the Mycobacterium leprae DNA gyrase and its inhibition by quinol- ones. Antimicrob Agents Chemother 2007;51:16438.

49. Pardillo FE, Burgos J, Fajardo TT, et al. Powerful bactericidal activity of moxifloxacin in human leprosy. Antimicrob Agents Chemother 2008;52:31137.

50. Single-Lesion Multicentre Trial Group. Efficacy of single dose multidrug therapy for the treatment of single-lesion paucibacil- lary leprosy. Indian J Lepr 1997;69:1219.

51. Lockwood DN. Rifampicin/minocycline and ofloxacin (ROM) for single lesions: what is the evidence? Lepr Rev 1997;68:299300.

52. Franzblau SG, White KE. Comparative in vitro activities of 20 fluoroquinolones against Mycobacterium leprae. Antimicrob Agents Chemother 1990;34:22931.

53. Matrat S, Cambau E, Jarlier V, Aubry A. Are all the DNA gyr- ase mutations found in Mycobacterium leprae clinical strains involved in resistance to fluoroquinolones? Antimicrob Agents Chemother 2008;52:7457.

54. Ji B, Perani EG, Grosset JH. Effectiveness of clarithromycin and minocycline alone and in combination against experimen- tal Mycobacterium leprae infection in mice. Antimicrob Agents Chemother 1991;35:57981.

55. Gelber RH, Siu P, Tsang M, Alley P, Murray LP. Effect of low-level and intermittent minocycline therapy on the growth of Mycobacterium leprae in mice. Antimicrob Agents Chemo- ther 1991;35:9924.

56. Ji B, Jamet P, Perani EG, Bobin P, Grosset JH. Powerful bac- tericidal activities of clarithromycin and minocycline against

Mycobacterium leprae in lepromatous leprosy. J Infect Dis 1993;168:188 90.

57. Franzblau SG, Hastings RC. In vitro and in vivo activities of macrolides against Mycobacterium leprae. Antimicrob Agents Chemother 1988;32:175862.

58. Chan GP, Garcia-Ignacio BY, Chavez VE, et al. Clinical trial of clarithromycin for lepromatous leprosy. Antimicrob Agents Chemother 1994;38:5157.

59. Ji B, Chauffour A, Andries K, Jarlier V. Bactericidal activities of R207910 and other newer antimicrobial agents against Mycobacterium leprae in mice. Antimicrob Agents Chemother

2006;50:155860.

60. Andries K, Verhasselt P, Guillemont J, et al. A diarylquino- line drug active on the ATP synthase of Mycobacterium tuber- culosis. Science 2005;307:2237.

61. Gelber R, Andries K, Paredes RM, Andaya CE, Burgos J. The diarylquinoline R207910 is bactericidal against Mycobacterium leprae in mice at low dose and administered intermittently. Antimicrob Agents Chemother 2009;53:398991.

62. Karonga Prevention Trial Group. Randomised controlled trial of single BCG, repeated BCG, or combined BCG and killed Mycobacterium leprae vaccine for prevention of leprosy and tuberculosis in Malawi. Lancet 1996;348:17 24.

63. Sampaio EP, Moraes MO, Nery JA, Santos AR, Matos HC, Sarno EN. Pentoxifylline decreases in vivo and in vitro tumour necrosis factor-alpha (TNF-alpha) production in lepromatous leprosy patients with erythema nodosum leprosum (ENL). Clin Exp Immunol 1998;111:300 8.

64. Sales AM, de Matos HJ, Nery JA, Duppre NC, Sampaio EP, Sarno EN. Double-blind trial of the efficacy of pentoxifylline vs thalidomide for the treatment of type II reaction in leprosy. Braz J Med Biol Res 2007;40:2438.

65. Faber WR, Jensema AJ, Goldschmidt WF. Treatment of recur- rent erythema nodosum leprosum with infliximab. N Engl J Med 2006;355:739.

66. Ramien ML, Wong A, Keystone JS. Severe refractory erythema nodosum leprosum successfully treated with the tumor necrosis factor inhibitor etanercept. Clin Infect Dis 2011;52:

e1335.

67. Scollard DM, Joyce MP, Gillis TP. Development of leprosy and type 1 leprosy reactions after treatment with infliximab: a report of 2 cases. Clin Infect Dis 2006;43:e1922.

68. Oberstein EM, Kromo O, Tozman EC. Type I reaction of Han- sen’s disease with exposure to adalimumab: a case report. Arthritis Rheum 2008;59:10403.

69. Miller RA, Shen JY, Rea TH, Harnisch JP. Treatment of chronic erythema nodosum leprosum with cyclosporin A pro- duces clinical and immunohistologic remission. Int J Lepr Other Mycobact Dis 1987;55:4419.

70. Frankel RI, Mita RT, Kim R, Dann FJ. Resolution of type 1 reaction in multibacillary Hansen’s disease as a result of treat- ment with cyclosporine. Int J Lepr Other Mycobact Dis

1992;60:812.

71. Tanaka M, Tanaka Y, Kohsaka K. Effects of cyclosporin A on bacterial growth and immunological responsiveness in BALB/c mice infected with Mycobacterium leprae. Int J Lepr Other My- cobact Dis 1991;59:598604.

72. Sena CB, Salgado CG, Tavares CM, Da Cruz CA, Xavier MB, Do Nascimento JL. Cyclosporin A treatment of leprosy patients with chronic neuritis is associated with pain control and reduction in antibodies against nerve growth factor. Lepr Rev 2006;77:1219.

73. Safa G, Darrieux L, Coic A, Tisseau L. Type 1 leprosy reversal reaction treated with topical tacrolimus along with systemic cor- ticosteroids. Indian J Med Sci 2009;63:35962.

74. Vides EA, Cabrera A, Ahern KP, Levis WR. Effect of zafirluk- ast on leprosy reactions. Int J Lepr Other Mycobact Dis

1999;67:715.