Novel approaches in the treatment of Hansen’s disease (Leprosy): a case series of multidrug therapy of monthly rifampin, moxifloxacin, and minocycline (RMM) in the United States

Abstract

The World Health Organization (WHO) recommends multidrug therapy (MDT) for the treatment of paucibacillary and multibacillary forms of leprosy, also known as Hansen’s disease (HD). MDT combinations of dapsone, rifampin, and clofazimine have reduced the prevalence of the disease but are not without adverse effects impacting regimen adherence. Hence, an urgent need exists to consider alternative MDT regimens with an improved safety profile that promotes treatment adherence. Herein, we described a case series of 10 patients with HD (nine patients with multibacillary leprosy and one with pure neural leprosy) treated with monthly rifampin, moxifloxacin, and minocycline (RMM). The United States National Hansen’s Disease Program (NHDP) diagnosed and treated patients across US institutions. All patients received a regimen of 12–24 months of RMM. We reviewed the clinical outcomes, adherence, rate of completion, and adverse events of patients treated with monthly RMM from January 2019 to August 2022. Nine patients had multibacillary leprosy, with some having type-2 reactions. One patient had pure neural leprosy with a reversal reaction. In this case series, we identified that all patients completed the RMM regimen without treatment interruptions. None of the patients experienced any skin hyperpigmentation or any significant side effects. All patients tolerated the monthly RMM regimen with rapid improvement of skin lesions and without logistic hurdles. Based on previous clinical evidence and the results of this case series, the NHDP and other programs should consider the RMM regimen as first-line therapy.

Skin Lesions, Foot Drop, and Hand Contractures

“…Humans are the primary carriers of infection, and in the US, the 9-banded armadillo is a zoonotic reservoir . Approximately 200 000 individuals worldwide and 200 to 300 people in the US are diagnosed with leprosy annually . The most common route of transmission is through respiratory secretions, but skin contamination with tattooing and vertical transmission have been reported .…”

“…Some patients may develop an immune response to M leprae , called a leprosy reaction, which presents as urticarial swelling of skin lesions, fever, neuritis, erythema nodosum, and permanent loss of motor and sensory nerve function . Leprosy reactions can occur before, during, or after treatment for leprosy …”

“…The WHO recommends a 6-month course of dapsone, rifampin, and clofazimine for paucibacillary leprosy and a 12-month course for multibacillary leprosy . Treatment with rifampin, moxifloxacin, and minocycline taken monthly for 12 to 24 months has similar efficacy, fewer adverse effects, and improved adherence compared with the WHO regimen but is 4 times more expensive …”

“…Leprosy relapse rates after completion of WHO multidrug therapy are 0.77% for multibacillary leprosy and 1.07% for paucibacillary leprosy . Relapse rates appear similar after completing the regimen of rifampin, moxifloxacin, and minocycline . Risk factors for relapse include high mycobacterial load, increased number of skin lesions, insufficient treatment duration or regimen, and poor treatment adherence …”

Leprosy on the horizon: an upward trend in Central Florida

“…Some of the main challenges include the stigma associated with leprosy is a significant challenge, as it can lead to affected individuals avoiding health care facilities and late diagnosis. Health care professionals may not be familiar with its symptoms, leading to diagnostic delays or misdiagnosis [7] . Ensuring that health care providers have the knowledge and tools to identify leprosy cases promptly is critical.…”