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Review
. 2011 Jun;84(6):973-7.
doi: 10.4269/ajtmh.2011.10-0547.

A patient with erythema nodosus leprosum and Chagas cardiopathy: challenges in patient management and review of the literature

Maria Ângela B Trindade  1 , Noemia B Carvalho, Elaini C Belfort, Carla Pagliari, Erika Gakiya, Neusa Y Sakai-Valente, Gil Benard, Maria A Shikanai-Yasuda
Affiliations
Review

A patient with erythema nodosus leprosum and Chagas cardiopathy: challenges in patient management and review of the literature

Maria Ângela B Trindade et al. Am J Trop Med Hyg. 2011 Jun.

Abstract

We report a patient with severe multi-bacillary leprosy complicated by recurrent episodes of erythema nodosum necrotisans that required thalidomide and/or corticosteroids during follow-up. Although the patient was from an area to which Chagas disease is endemic, this diagnosis was initially missed and was only investigated when heart failure developed in the patient. The difficulties of managing erythema nodosum necrotisans and heart failure concomitantly and those involved in excluding the diagnosis of acute myocarditis caused by reactivation of Chagas disease secondary to the immunosuppressive regimen are discussed. Other potential causes for the heart failure and possible interactions between the two diseases and their treatments are discussed. We also reviewed the literature for the association between leprosy and Chagas disease, both of which are highly endemic in Brazil. This case emphasizes the importance of searching for subclinical co-infections in leprosy patients because reactions frequently develop during specific treatment in these patients, and these reactions require prolonged therapy with immunosuppressive drugs.

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Figures

Figure 1.
Figure 1.
Increased heart-thorax index on a chest radiograph of the patient caused by a global cardiomegaly with predominance of left ventricle dilatation.
Figure 2.
Figure 2.
Electrocardiogram for the patient showing an anterosuperior divisional block, a disturbance of right bundle branch conduction, nonspecific alterations of ventricular repolarization of the anterior and septal wall and periods of ectopic atrial rhythm.
Figure 3.
Figure 3.
Immunophenotypical analysis of infiltrating cells of an erythema nodosum necrotisans lesion in the patient. A large number of T cells was present and TCD4+ cells (A) predominated over TCD8+ cells (B). Cells expressing tumor necrosis factor-α (TNF-α) (C) and transforming growth factor-β (TGF-β) (F) were present in high numbers, but only a few cells expressed interferon-γ (IFN-γ) (D) or interleukin-4 (IL-4) (E). Reactions were performed with streptavidin-biotin peroxidase (LSAB K690; Dako, Glostrup, Denmark) and primary antibodies mouse anti-CD4 (M834; Dako), mouse anti-CD8 (M 7103; Dako), goat anti-TNF-α (AF-210-NA; R&D Systems, Inc., Minneapolis, MN), mouse anti-IFN-γ (MAB 285; R&D Systems, Inc.), goat anti-IL4 (AF-204-NA; R&D Systems, Inc.), and rabbit anti-TGF-β (SC82; Santa Cruz Biotechnology, Inc., Santa Cruz, CA) and streptavidin-biotin peroxidase (magnifications ×400.)
Figure 4.
Figure 4.
Frequency of cells expressing the subpopulations markers (CD4 and CD8 cells) and cytokines (tumor necrosis factor-α, interferon-γ, interleukin-4 and transforming growth factor-β) in the patient detected by immunochemical analysis.
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References

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