The Mortality Associated with Erythema Nodosum Leprosum in Ethiopia: A Retrospective Hospital-Based Study

Background: Erythema nodosum leprosum (ENL) is a debilitating multisystem disorder which complicates leprosy. It is characterised by fever, malaise and painful erythematous cutaneous nodules. ENL is often recurrent or chronic in nature and frequently severe. Patients often require prolonged treatment with high doses of oral corticosteroids. There are no data on the mortality associated with treated ENL. Methodology: The notes of patients who were admitted, discharged, transferred to another facility or died with a diagnosis of leprosy or a leprosy-related complication for a five year period were reviewed. Result/Discussion: 414 individuals were identified from the ward database. 312 (75.4%) patient records were located and reviewed. Ninety-nine individuals had ENL and 145 had a Type 1 reaction. The median age of individuals with ENLwas 25 years. Eight patients with erythema nodosum leprosum died compared with two diagnosed with Type 1 reaction. This difference is statistically significant (p = 0.0168, Fisher's Exact Test). There is a significant mortality and morbidity associated with ENL in this Ethiopian cohort. The adverse outcomes seen are largely attributable to the chronic administration of oral corticosteroids used to control the inflammatory and debilitating symptoms of the condition. Author Summary: Erythema nodosum leprosum (ENL) is an immunologically mediated complication of leprosy. It is a painful debilitating multi-system condition which can occur before, during or after completion of treatment of the multi-drug therapy for leprosy. ENL is often a chronic condition requiring long-term treatment often with oral corticosteroids or thalidomide. This study shows that in Ethiopia (where thalidomide is not available) there is a significant mortality associated with ENL. It appears that much of the mortality is attributable to adverse effects of corticosteroids. This study provides additional evidence of the need for alternative agents to manage ENL particularly when thalidomide is not available, contraindicated or unaffordable.