Recidivas postratamiento de la lepra multibacilar / Relapses after multibacillary leprosy treatment

RESUMEN

La persistencia de bacilos viables y la monoterapia con diamino-difenil-sulfona (DDS) son los principales factores que favorecen las recidivas de la lepra. Presentamos 33 pacientes con lepra lepromatosa (LL) diagnosticada 7 a 48 años antes de la recidiva, que recibieron monoterapia con DDS durante 4 a 38 años. Veintiocho fueron tratados, además, con poliquimioterapia (PQT) irregular, no supervisada, desde 1983. Cinco sólo recibieron DDS. Éstos presentaron la recidiva entre 13 y 20 años después de suspenderla. Las recidivas se diagnosticaron por reaparición de las lesiones clínicas o por la presencia de nuevas zonas anestésicas; todas se confirmaron con la baciloscopia y, en 20 casos, por la biopsia de piel. Cuatro pacientes presentaron en la biopsia de la recidiva, lepra indeterminada (LI) y uno lepra dimorfa tuberculoide (LDT), todos con presencia de bacilos intraneurales; los demás fueron LL. Dos pacientes recidivaron, aun con PQT razonablemente supervisada. Los demás curaron con PQT supervisada. Los factores predisponentes para la recidiva fueron monoterapia con DDS por varios años; PQT irregular con dosis inadecuadas, sin supervisión del tratamiento; abandono de la PQT, y relación inadecuada entre el paciente y el personal de salud. Las recidivas de la lepra se deben buscar en todos los pacientes colombianos con lepra multibacilar que fueron tratados con DDS solo durante años. La clínica, la baciloscopia y la biopsia individualmente o en conjunto son métodos confiables para establecer las recidivas.

ABSTRACT

Leprosy relapses are mainly due to bacillary persistence and diamino-diphenyl-sulphone (DDS) monotherapy. Case histories were examined for 33 patients with lepromatous leprosy (LL), diagnosed 7-48 years before the relapse and treated only with DDS during 4 to 38 years. Twenty-eight patients received irregular non-supervised polychemotherapy (PCT) since 1983. Five patients received only DDS, and presented relapses 13-20 years after the treatment was stopped. Relapses were diagnosed by clinical methods, including the reappearance of lesions or presence of new anesthetic areas. All cases were confirmed by bacilloscopy, and a subset of 20 cases by skin biopsy. Four patients presented indeterminate leprosy (IL) and one patient borderline tuberculoid leprosy (BT) in the biopsy. The latter 5 demonstrated presence of intraneural bacilli; the remainder were LL. Two patients relapsed even with PCT treatment. The others were cured with supervised PCT. Predisposing factors for relapses were as follows DDS monotherapy, irregular PCT with inadequate dosage, unsupervised treatment, treatment uncompliance, and inadequate relationship between the patient and the health staff. Inspections for relapse in leprosy is recommended for in all multibacillary patients that were treated with DDS. The clinical appearance of new lesions or new anesthetic zones, the bacilloscopy and skin biopsy, used together, are effective in establishing the presence of relapses.