CASE REPORT

I. Patient identity
Name : Mr. Umar
Age : 64 Years
Gender : Man
Address :Ds. Rindau city
Work : Private
Religion : Islam
Status : Married
Date Sign RS : 12 June 2017

II. Anamnesis: Alloanamnesis

1. Main complaint :
Reddish bumps appear on the body
2. History of present illness :
A man came in with the complaint appears bumps redness spread
across the upper body as well as the second limb in naturally more or less
since one week ago, initially appear reddish on both legs, a complaint with
pain like being stabbed, especially in the area of the lesion , Scattered patches
on the face, neck, chest, abdomen, back, arms and legs. The size varies from
lentikuler to nummular. Fever (-), liver uluh pain (-), nausea (-), vomiting (-).
Complaints have never experienced before. Patient 1 year ago in the diagnosis
of leprosy, and regular medical treatment and complete treatment ± 2 mnggu
ago before these complaints arise.

3. Previous medical history:

1
 Patients previously never suffered like this
History of diabetes and hypertension denied
A history of food allergies and medications denied

4. Treatment history:
MH treatment history and has been completed teratus ± 2 weeks ago.

5. Riwayatpenyakitkeluarga:
No family members and close relatives who have the same complaint with the
patient.

III. Physical examination

Generalists Status:
1. KeadaanUmum : Sick moderate
2. Awareness : Komposmentis
3. Nutritional status : Baik
4. Vital Signs
a. Blood pressure : 110/70 mmHg
b. Heart Rate : 81 x / minute
c. Temperature : 36.8 ºC
d. Respiratory : 20 x / min
5. Head
a. sclera : Ikterik (-)
b. conjunctiva : Anemis (-)
c. Lip : Sianosis (-)
6. thorax : Within normal limits
7. abdomen : Within normal limits
8. Lymph nodes : No No enlarged lymph nodes
IV. Status of Dermatology

2
 locations : Regio dextra et sinistra superior extremities, lower
extremities dextra et sinistra, thorakal region, and the
region vertebra
Size : lentikuler until numular
Efloresensi : Looks skin disorders berupanodul ertitematous
multiple

V. resume
A man came in with the complaint appears bumps redness spread across
the upper body as well as the second limb in naturally more or less since one
week ago, initially appear reddish on both legs, a complaint with pain like
being stabbed, especially in the area of the lesion , Scattered patches on the
face, neck, chest, abdomen, back, arms and kaki.Ukuran ranging from
lentikuler to nummular.Demam (-), liver uluh pain (-), nausea (-), vomiting
(-). The complaint has not been sebelumnya.Pasien experienced one year ago
in the diagnosis of leprosy, and regular medical treatment and complete
treatment ± 2 mnggu ago before these complaints arise.
New patient first felt such complaints, history of diabetes and
hypertension is undeniable, a history of food allergies and medications denied,
no family history of MH treatment ada.Riwayat regular and thorough ± 2
weeks ago.
On physical examination for generalist status compos mentis patient
awareness, blood pressure (110/70), pulse (81 x / min), temperature (36,8oC),
respiratory (22x / min).
At dermatological examination, skin disorders Looks form multiple
erythematous nodules on ekstemitas superior et inferior, as well as vertebral
region, thorakal, abdomen.
In laboratory tests obtained WBC (6.7 / UL), RBC (3.45 / UL), HGB
(10.8 g / dl), HCT (31.7%), GDS (91mg / dl), NEU (66%).

3
VI. Prompts Investigation
1. Bacteriology
2. Serology
3. Histopathology
VII. Working diagnosis
Erythema Nodosum Leprosum
VIII. prognosis
Qua add vitam: bonam
Qua add sanationam: ad dubia bonam
Qua add fungtionam: bonam
Qua add cosmetic: ad dubia bonam

IX. follow-up
dat June 13, 2017 (DAY ONE)
e
S Itching and pain in the foot and hand
O vital signs
BP 110/80 mmHg

4
 Nadi 80x / minute
temperature 37,8oC
Breathing 20x / minute
Status of Dermatology
Location: Regio dextra et sinistra superior extremity, the region of the
extremities
dextra and regio inferior vertebra, thorakal and abdomen.
Size: Numular
Efloresensi: Looks equivalent berupanodul ertitematous multiple skin
disorders

A Erythema Nodosum Leprosum

P medikamentosa
Non-Medical
 Fix patient's general condition
 medikamentosa
 Prednisone 5 mg (4 - 4- 0)
 Lampren 3 x 100 mg
 Vit. C 1 x 1
 PCT 3 x 1
 Neurodex 2 x 1

documentation:

5
Laboratory results:
No
Checking type result Information
.
1 Reitz Serum + 2 / Positive Location: right
lobe,

6
Neurological examination results:
1. ulnar nerve
- Anesthesia in the anterior finger tip little and ring
2. the median nerve
- Anesthesia in the anterior part of the mother fingertip forefinger, and
middle finger
3. radial nerve
- No abnormalities
4. Lateral popliteal nerve
- Anesthesia of the lower limbs. The lateral section and the dorsum of the
foot
5. The posterior tibial nerve
- Anesthetics on the soles
6. facial nerve
- No abnormalities
7. trigeminal nerve
- No abnormalities

dat June 14, 2017 (DAY TWO)

e
S Patients still feel itching and pain in the feet and hands
O vital signs

7
 BP 120/80 mmHg
Nadi 82x / minute
temperature 36,7oC
Breathing 20x / minute
Status of Dermatology
Location: Regio dextra et sinistra superior extremity, the region of the
extremities
dextra and regio inferior vertebra, thorakal and abdomen.
Size: Numular
Efloresensi: Looks intentions skin disorders multiple nodules ertitematous

A Erythema Nodosum Leprosum

P Medikamentosa
 Fix patient's general condition
 medikamentosa
 Prednisone 5 mg (4 - 4- 0)
 Lampren 3 x 100 mg
 Vit. C 1 x 1
 Neurodex 2 x 1

8
 Documentation:

Neurological examination results:

1. ulnar nerve
- Anesthesia in the anterior finger tip little and ring
2. the median nerve
- Anesthesia in the anterior part of the mother fingertip forefinger, and
middle finger
3. radial nerve
- No abnormalities
4. Lateral popliteal nerve
- Anesthesia of the lower limbs. The lateral section and the dorsum of the
foot

9
5. The posterior tibial nerve
- Anesthetics on the soles
6. facial nerve
- No abnormalities
7. trigeminal nerve
- No abnormalities

10
dat June 15, 2017 (DAY THREE)
e
S Complaints of patients is reduced
O vital signs
BP 120/80 mmHg
Nadi 82x / minute
temperature 36,7oC
Breathing 20x / minute
Status of Dermatology
Location: Regio dextra et sinistra superior extremity, the region of the
extremities
dextra et sinistra inferior region.
Size: Numular
Efloresensi: Looks intentions skin disorders multiple nodules ertitematous

A Erythema Nodosum Leprosum

P medikamentosa
 Fix patient's general condition
 medikamentosa
 Prednisone 5 mg (4 - 4- 0)
 Lampren 3 x 100 mg
 Vit. C 1 x 1
 Neurodex 2 x 1

11
Documentation.

12
dat June 16, 2017 (FOUR DAYS)
e
S SDH reduced patient complaints
O vital signs
BP 120/80 mmHg
Nadi 82x / minute
temperature 36,7oC
Breathing 20x / minute
Status of Dermatology
Location: Regio dextra et sinistra superior extremity, the region of the
extremities
inferior dextra et sinistra
Size: Numular
Efloresensi: Looks intentions skin disorders multiple nodules ertitematous

A Erythema Nodosum Leprosum

P medikamentosa
 Fix patient's general condition
 medikamentosa
 Prednisone 5 mg (4 - 4- 0)
 Lampren 3 x 100 mg
 Vit. C 1 x 1
 Neurodex 2 x 1

13
documentation:

14
 DISCUSSION

A man came in with the complaint appears bumps redness spread across the
upper body as well as the second limb in naturally more or less since one week ago,
initially appear reddish on both legs, a complaint with pain like being stabbed,
especially in the area of the lesion , Scattered patches on the face, neck, chest,
abdomen, back, arms and kaki.Ukuran ranging from lentikuler to nummular.Demam
(-), liver uluh pain (-), nausea (-), vomiting (-). The complaint has not been
sebelumnya.Pasien experienced one year ago in the diagnosis of leprosy, and regular
medical treatment and complete treatment ± 2 mnggu ago before these complaints
arise.
This is consistent with the theory that nodusum erythema
leprosum is type 2 leprosy reactions with manifestations of skin
lesions Painful red nodules then undergo necrosis and ulceration
and issued a yellow pus that kental.Predileksi lesions found on the
face and extremities ekstendor surface, but also can appear The
areas of the body lainnya.1
In case Tn.U, 64-year note started to experience pain in a lump in the body
before patients taking the medicine MDT.
This is consistent with the theory that generally ENL may occur in patients who
have not received treatment leprosy Multi Drug Therapy (MDT) is thought to be a
manifestation .ENL antigen-antibody complex deposition in vessel darah.Termasuk
hypersensitivity reactions type III according to Coombs & Gel.2,3
Namely ENL Patomekanismeantigen-antibody complex occurs which then settles
along the blood vessels which ultimately lead to vasculitis. TNF-α levels were

15
excessive and IL-6 increased in the serum of patients with ENL indicate that the
cellular immune response was instrumental to the mechanism of the ENL. TNF-
αcells derived from a variety of mainly mononuclear phagocytes and T cells are
activated by antigens, natural killer cells (NK cells) and mast cells. Biological effects
may affect both locally and systemically, and can be protective or pathological
depending on concentration, duration of exposure, and the availability of other
mediators in mobile environments.2.3
Local production can increase the body's defense against pathogens by providing
the inflammatory response which led to the arrival of neutrophils and monocytes to
the site of infection and activate these cells to kill microbes, stimulate the expression
of vascular cell adhesion molecule (VCAM), stimulate macrophages to secrete
chemokines and induce chemotaxis, stimulates mononuclear phagocytes to secrete
IL-1 with the same effect as TNF-αetc. 2.3
As it is known that neutrophils are useful for cell movement, including E-selectin
were upregulated by IL-1β, Activation of Toll-Like Receptor 2 (TLR2) in vitro
induces IL-1β which along with Interferon Gamma (IFNγ) Would stimulate E-
selectin expression and neutrophil adhesion to endothelial cells. Meanwhile, when the
widely produced, the levels of TNF-αmay harm the host because it can lead to a
thrombus endothelial cells, furthermore can occur very fatal clinical syndrome called
septic shock. secretion of TNFαexcessive in ENL thought to have come from the
inner wall Mycooacterium leprae which can stimulate natural immunity in the human
body, namely Triacetylated Lipoprotein (TLP) and the Pathogen Associated
Molecular Pattern (PAMPs).2.3
TLP is a lipoprotein membrane components on all of the genus mycobacteria and
thought to be the main indicator of the secretion of TNFαby makrofag.IFN-γ
produced by T cells and NK cells also stimulate macrophages to increase the
synthesis of TNFα, Pro-inflammatory cytokines, including TNF-α, IFNγAnd IL-1 has
been reported to play a role in the mechanism of occurrence of leprosy reactions both

16
type I reaction (reversal reaction) and reaction type 2 (excluding ENL). In ENL,
levels of TNF-αyang released by peripheral blood mononuclear cells more than any
other illness. In one of the TNF-αdapat work synergistically with IFNγ as protective
immunity to mediate granuloma formation and inhibit the growth of in-
vitro.Sedangkan M.Leprae on the other hand, TNF-αdapat cause nerve damage and
tissue necrosis.2,3,4
In the case found symptoms in patients with multiple nodules are reddish, found
in second-hand and right leg. Patients also said that when these lumps appear, usually
accompanied by fever patients nyeri.Selain it up and down from one week ago.
This is consistent with the theory that type II leprosy reactions common in
patients with leprosy MB type and the humoral immune response due to high
penderita.Kompleks immune humoral immune response to circulating blood and
organ settles on the skin, nerves, lymph nodes and ENL testis.Diagnosis obtained
with clinical and histological examination. Microscopic specimens ENL classified
into 3 main sections follow the location of inflammation are: classical
(subcutaneous), skin and surfaces.2.3
Symptoms ENL in theory can be seen in changes in the skin lesions in the form
of nodules reddish multiple, glossy, appear in the form of nodules or plaques, size is
generally small, distributed bilateral and symmetrical, especially in the lower limbs,
face, arms and thighs, and can also emerge in almost all parts of the body except the
head area of the hair, axilla, groin and perineum. Additionally obtained pain, and
ulceration accompanied pustulasi systemic symptoms such as fever, malaise, joint
pain, muscle pain and eye, neuritis, nerve dysfunction, disorders of the constitution
and complications in other organs. When the other organs can cause symptoms such
as iridocyclitis, acute neuritis, lymphadenitis, arthritis, orchitis, and acute nephritis
with proteinuria. It can also be accompanied by constitutional symptoms from mild to
severe. ENL long journey can last three weeks or more.3,4,5

17
Here below is a description of erythema nodosum leprosum:

a) b)
Figure 2.EritemaNodus Leprosum a) Overview diwajah papular contained in
ENL patients, b) Reaction type 2 before and after pengobatan.1,5

18
 By weight, reaction type II can be divided into mild and severe reactions. The
difference between type II leprosy reactions of light and heavy can be seen in the
following table:5.6
Table 1 Overview of type 2 leprosy reactions
Organs are
mild reaction severe reactions
attacked
Skin Nodes bit, can ulcerate -Nodus many, painful,
- Low-grade fever and malaise ulcerated
- High fever and malaise
peripheral - distention - Very enlarged
nerve - There is no tenderness nerve - Tenderness
- Function no interference - Malfunctioning
Organs - No disruption of the body's - There was an
organs inflammation:
eyes: pain, decreased visual
acuity, red around the
limbus
-Testis: soft, painful and
enlarged

In this case seem erythematous nodules that occur with pain. Where in theory
neuritic pain and rapid changes of peripheral nerve damage that results in claw hand
or foot drop.
Journey eye disorder in leprosy is divided into two forms, namely: tuberculoid
and lepromatous. In tuberculoid form there is little lesions on the skin and nerves, and
not the organ dalam.Bentuk more rarely bermanifesitasi to intraocular, but more
common in the eyes of the outside like lagophtlamus, exposure keratitis and turbidity
kornea.Bentuk skin lesions were found in palpebra demarcated, hypopigmentation,
and lepromatous hipoanestesi.Bentuk often manifest into intraocular such as uveitis,
iritis, atrophic skin iris.Lesi not demarcated, thickening, hyperpigmentation and

19
anestesi.Kerusakan nerve caused by leprosy germ invasion and infiltration of the
nerve fibers that cause swelling or thickening peripheral nerves.
Damage to the zygomatic and temporal branch of the facial nerve causing parese
orbicularis oculi muscle, resulting in lagoftalmus.Kelainan been exacerbated by the
rigidity of the eyelid, skin and muscle atrophy orbikularis.Kerusakan the ophthalmic
branch of the trigeminal nerve causing conjunctival and corneal anesthesia resulting
in loss of sensation, dryness, inflammation and infection on kornea.Kombinasi
damage to the trigeminal nerve and facial nerve can occur early in the disease so
frequent exposure keratitis that cause turbidity and damage to the cornea
kornea.Ulserasi can occur in a more lanjut.Lesi corneal damage the cornea can be
attributed to two factors, the first directly through inflammation of the iris and ciliary
body are repeated and long, which causes corneal endothelial function disorder
causing corneal edema.Both corneal lesions occur in the form of erosion, keratitis and
corneal ulcers caused by lagoftalmus and decreased corneal sensation because of
damage to the trigeminal nerve and facial nerve, causing keratitisexposure on the
surface kornea.4,7
Physical examination status of dermatology location: regionekstremitas superior
and inferior, and vertebral region, size numular, efloresensi: etitematous nodules are
multiple.In laboratory tests obtained anti-dengue Ig G and Ig M negative, WBC
(23.0 / UL), RBC (4.65 U / L), HGB (12.1 g / dl), HCT (35.6%), GDS (113 mg / dl),
NEU (82.6%). ExaminationReitz Serum: + 3 / Positive.
Diagnosis is made berdasarkan clinical picture, and examinationsupporting, for
the investigation of this case are generally less meaningful. Signs of reaction is
generally sufficient in diagnosing leprosy reactions are found in the skin of
inflammatory skin patches, the nerves of pain or tenderness in the nerves, arising loss
of sense of touch new, raised muscle weakness new, and in the eyes of pain or redness
at eyes, raised a new decline in the power of vision, and the resulting weakness of the
muscles blindfold baru.7

20
 Prompts investigation needs to be done is a bacteriological examination and
inspection histopalogi:

Figure 4.Gambaran Histopathology Erythema Nodosum Leprosum (ENL). Foamy macrophage

infiltrates are many small arteries and visible swelling at the tengahnya.7

In reaction leprosum erythematosa nodosum (ENL) addressing any number of

reactions, infiltrate from granuloma, inflammation of the blood vessels and is
characterized by a degeneration of macrophages in cell formation busa.3,7
In the case of patients with Tn. Y is given prednisone 3-2 - 0, Lampren twice a
day, three times a day paracetamol, neurodex twice daily.
In mild ENL reaction can be administered analgesic / antipyretic such as aspirin
or asetaminofen.Berikut is WHO guidelines for the management of erythema
nodosum leprosum reactions (ENL) severe, severe ENL reaction is often recurrent
and chronic and can vary in its manifestation, the management of severe ENL is best
done by a doctor the referral center, and the dose and duration of anti-reaction drugs
used can be adjusted by the physician according to the individual patient's needs. 5
This is consistent with the theory of anti-leprosy reactions
consisted of:

21
- Prednisone (for reaction types 1 and 2)
Corticosteroids are an option ENL therapy, including
corticosteroids prednison.Prednison is a medium potential with a
half-life 12-36 jam.Dosisnya depending on the degree of ENL. At
the beginning of treatment used a dose of 40 mg daily for 2
weeks and can be reduced if the complaints or clinical
symptoms berkurang.Pemakaian corticosteroids should pay
attention to contraindications, such as tuberculosis, severe
stomach ulcers and severe infections at the extremities
worsened. Patients should be educated properly to prevent long-
term side effects or drug discontinuation mendadak.2,5
- Clofazimine (for reaction type 2)
This drug is used for handling / treatment of recurrent ENL
reactions (steroid dependent) is a derivative of this .Obat
fenazin which have a bactericidal effect after 50 days of
treatment in patients kusta.Selain it, clofazimine has a mild anti-
inflammatory effect to treat ENL. Its onset is slow, which
emerged only after 2-3 minggu.Dosis for ENL higher than
leprosy patients without reaction, ie 200-300 mg /
hari.Klofazimin is the treatment of choice for severe ENL with
recurrent episodes (≥2 times) to kortikosteroid.Klofazimin same
cause dependence as sepertikortikosteroid administered once a
day, only in urgent situations, can be administered in divided
doses. The use of high doses of no more than 12 months. Side
effects include skin pigmentation and gastrointestinal disorders.
Skin discoloration will disappear after 3 months of medication is
discontinued. Clofazimine reversal of the reaction is less

22
 effective, so it is rarely or never used. Clofazimine is available in
capsules of 100 MG.2
- Thalidomide (for reaction type 2)
thalidomide is the drug of choice in the management of ENL.
Thalidomide works as an anti-inflammatory kuat.Thalidomide is
analogracemic glutamic acid which consists of two enantiomers
R- and S-enantiomer thalidomide.Dua have different properties,
one of which has a more potent suppressive effect against TNF-α
release from blood cells edge, while others have a sedative
effect. Thalidomide mechanism is still unclear, but TNF-α, IFN-γ,
IL-10, IL-12, cyclooxygenase-2 and possibly pro-inflammatory
transcription factors (NF-γB) becomes the target of thalidomide
work. One mechanism of action is believed to occur
padathalidomide suppressive effect against TNF-α potent. This
mechanism is very important to control the ENL. In in-vitro
studies indicate that M. leprae can induce the activation of NF-
γB in Schwann cells, resulting in suppression of transcription
factor by TNF-α. This condition can be inhibited by the latest
thalidomide.Studi said that thalidomide can inhibit the response
Immunoglobulin G (IgG) and causes apoptosis of neutrophils was
also involved in the pathophysiology of ENL. Thalidomide dose
may be administered from 400 mg at bedtime or 4 × 100 mg a
day. This dose can control ENL reactions occur within 48 jam.Bila
clinical improvement, thalidomide dose was lowered to 300 mg /
hari.Setelah that thalidomide dose can be lowered slowly into
100 mg every month. Giving thalidomide is not indicated in
women of reproductive age. Side effects have ever been
reported is a teratogenic effect, neuropathy, thromboembolism,

23
somnolence and others. This condition can be inhibited by the
latest thalidomide.Studi said that thalidomide can inhibit the
response Immunoglobulin G (IgG) and causes apoptosis of
neutrophils was also involved in the pathophysiology of ENL.
Thalidomide dose may be administered from 400 mg at bedtime
or 4 × 100 mg a day. This dose can control ENL reactions occur
within 48 jam.Bila clinical improvement, thalidomide dose was
lowered to 300 mg / hari.Setelah that thalidomide dose can be
lowered slowly into 100 mg every month. Giving thalidomide is
not indicated in women of reproductive age. Side effects have
ever been reported is a teratogenic effect, neuropathy,
thromboembolism, somnolence and others. This condition can
be inhibited by the latest thalidomide.Studi said that
thalidomide can inhibit the response Immunoglobulin G (IgG)
and causes apoptosis of neutrophils was also involved in the
pathophysiology of ENL. Thalidomide dose may be administered
from 400 mg at bedtime or 4 × 100 mg a day. This dose can
control ENL reactions occur within 48 jam.Bila clinical
improvement, thalidomide dose was lowered to 300 mg /
hari.Setelah that thalidomide dose can be lowered slowly into
100 mg every month. Giving thalidomide is not indicated in
women of reproductive age. Side effects have ever been
reported is a teratogenic effect, neuropathy, thromboembolism,
somnolence and others. Recent studies say that thalidomide can
inhibit the response Immunoglobulin G (IgG) and causes
apoptosis of neutrophils was also involved in the
pathophysiology of ENL. Thalidomide dose may be administered
from 400 mg at bedtime or 4 × 100 mg a day. This dose can

24
control ENL reactions occur within 48 jam.Bila clinical
improvement, thalidomide dose was lowered to 300 mg /
hari.Setelah that thalidomide dose can be lowered slowly into
100 mg every month. Giving thalidomide is not indicated in
women of reproductive age. Side effects have ever been
reported is a teratogenic effect, neuropathy, thromboembolism,
somnolence and others. Recent studies say that thalidomide can
inhibit the response Immunoglobulin G (IgG) and causes
apoptosis of neutrophils was also involved in the
pathophysiology of ENL. Thalidomide dose may be administered
from 400 mg at bedtime or 4 × 100 mg a day. This dose can
control ENL reactions occur within 48 jam.Bila clinical
improvement, thalidomide dose was lowered to 300 mg /
hari.Setelah that thalidomide dose can be lowered slowly into
100 mg every month. Giving thalidomide is not indicated in
women of reproductive age. Side effects have ever been
reported is a teratogenic effect, neuropathy, thromboembolism,
somnolence and others. This dose can control ENL reactions
occur within 48 jam.Bila clinical improvement, thalidomide dose
was lowered to 300 mg / hari.Setelah that thalidomide dose can
be lowered slowly into 100 mg every month. Giving thalidomide
is not indicated in women of reproductive age. Side effects have
ever been reported is a teratogenic effect, neuropathy,
thromboembolism, somnolence and others. This dose can
control ENL reactions occur within 48 jam.Bila clinical
improvement, thalidomide dose was lowered to 300 mg /
hari.Setelah that thalidomide dose can be lowered slowly into
100 mg every month. Giving thalidomide is not indicated in

25
 women of reproductive age. Side effects have ever been
reported is a teratogenic effect, neuropathy, thromboembolism,
somnolence and others.2
Management with corticosteroids: If you're still in the anti-leprosy treatment,
continue the provision of MDT, use of analgesic doses adequate to cope with fever
and pain, and the use of prednisolone at a dose per day does not exceed 1mg / KgBW
with a total duration of 12 weeks.2
Management with clofazimine and corticosteroids: The administration is for the
indication in severe ENL cases that do not respond to corticosteroid treatment or
where the risk of toxicity with corticosteroids is high. First, if it is still in the
treatment of anti-leprosy, continue the provision of MDT, use of analgesic doses
adequate to cope with fever and pain, use of prednisolone at a dose per day does not
exceed 1mg / KgBW, began giving clofazimine 100mg 3xsehari for a maximum of 12
weeks, and continue standard treatment prednisolon.4,5
Management with clofazimine alone: The indication in severe ENL cases where
there are contraindications to the use of corticosteroids. If still in the anti-leprosy
treatment, continue the provision of MDT, use of analgesic doses adequate to cope
with fever and pain, began giving 100mg clofazimine 3xsehari for a maximum of 12
weeks, reduce dosage to 100mg clofazimine 2xsehari for 12 weeks and then 100 mg 1
x daily for 12- 24 minggu.4,7
The prognosis in these patients was quite bad due to leprosy reactions suffered
already for many years and has been accompanied by damage to the nerves and
mata.Pada theory leprosum prognosispada mild erythema nodosum reactions may
disappear soon, however, and in severe ENL can persist for many patients can
tahun.Terkadang suffered permanent nerve damage even kematian.4,8

26
 BIBLIOGRAPHY

1. Lee DJ, TH Rea, Modlin RL. Leprosy. In: Wolff K, Goldsmith LA, Katz SI,
Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick's Dermatology In
General Medicine. 8th ed. New York: McGraw-Hill Companies; 2012. p. 2253-
62.
2. Renata Prameswari. The Role of TNF-α in Immunopathogenesis of ENL and the
Contribution in Management of ENL) .2012. Vol. 24 No. 1.
3. VK Mahajan, [Et al],Erythema nodosum leprosum mimicking 2014. Sweet's
syndrome: an uncommon presentation.Available at:
https://www.ncbi.nlm.nih.gov/pubmed/25675656, Accessed June 1, 2017:
4. James D, [et al], Hansen's Diseases. Andrews' Diseases of the Skin - Clinical
Dermatology, Edition 10, Medical. 2005, page 343
5. NLEP. Leprosy Reaction and its management. Available
at:http://nlep.nic.in/pdf/Ch%208%20-%20Lepra%20reaction.pdf.Diakses June 1,
2017:
6. National Guidelines Leprosy Control Program. Ministry of Health Directorate
General of Disease Control and Environmental Health. 2012. Page: 111-120
7. Lockwood DNJ. Leprosy. In: Burns T, Breathnach S, Cox N, Griffiths C, editors.
Rook's Textbook of Dermatology. 8th ed. UK: Wiley-Blackwell; 2010. p. 32.1 -
32. 20.
8. Nascimento O, de Freitas MRG, Escada T. Leprosy Late-onset neuropathy: an
Uncommon Presentation of leprosy. Brazil: Department on Neurology. Published
January 1st, 2012.

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