University of Wisconsin–Madison Medical College of Wisconsin

Leprosy in the Upper Midwest: Vigilance Needed for Contacts

Pugazhenthan Thangaraju, MD, Sajitha Venkatesan, MD

WMJ. 2024;123(1):4.

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Dear Editor:

A case report by Bach et al has brought attention to a case of leprosy in the upper Midwest.1 Several critical points need emphasis for the management of the patient’s contacts and to prevent future complications for the patient. Specifically, the possibility of administering a single dose of rifampicin2 or rifapentine3 to the patient’s contacts should be explored, as the patient is classified with borderline lepromatous leprosy, which carries a higher risk of transmission due to high bacillary loads.

It is imperative to conduct physical examinations of all the patient’s contacts and provide them with a single dose of rifampicin or rifapentine as a preventive measure. A contact is defined as an individual who has had significant, prolonged exposure to a leprosy patient, such as living in close proximity for at least 20 hours per week over a 3-month period annually. This would typically include family members, neighbors, friends, classmates, and coworkers.

The World Health Organization’s single-dose rifampicin recommendations are based on age and weight. For individuals 15 years and older weighing around 60 kg, the prescribed dose is 600 mg; for those aged 10-14 years, it is 450 mg; for those aged 6 to 9 years weighing 20 kg or more, it is 300 mg; and for children aged 2 years or older weighing less than 20 kg, the dose is calculated at 10-15 mg/kg.

It should be further emphasized that this patient is at a significant risk of developing erythema nodosum leprosum, which is a type 2 reaction, due to the abundant presence of bacilli. It is recommended to manage such cases with steroids, especially considering the neural involvement, but it should be done cautiously due to the associated decreased visual acuity and the increased risk that steroids present. If severe reactions with systemic involvement are not controlled by steroids and methotrexate, thalidomide may be considered as an alternative treatment.4 The initial dose of thalidomide is 100 mg 3 times daily, with subsequent dose reduction as appropriate.

  1. Bach K, Hinshaw MA, Shields BE. Leprosy in the upper Midwest. WMJ. 2023;122(3):205-207. PMID:37494653.
  2. Wang L, Wang H, Yan L, et al. Single-dose rifapentine in household contacts of patients with leprosy. N Engl J Med. 2023;388(20):1843-1852. doi:10.1056/NEJMoa2205487.
  3. Scollard DM. A new step in postexposure prophylaxis for leprosy. N Engl J Med. 2023;388(20):1904-1905. doi:10.1056/NEJMe2302667.
  4. Thangaraju P, Venkatesan S, Gurunthalingam M, Babu S, T T. Rationale use of Thalidomide in erythema nodosum leprosum – a non-systematic critical analysis of published case reports. Rev Soc Bras Med Trop. 2020;53:e20190454. doi:10.1590/0037-8682-0454-2019

Author Affiliations: All India Institute of Medical Sciences, Raipur, Chhattisgarh, India (Thangaraju, Venkatesan).
Corresponding Author: Pugazhenthan Thangaraju, MD, Assistant Professor, Department of Pharmacology, All India Institutes of Medical Sciences, Raipur, Chhattisgarh India; email
Funding/Support: None declared.
Financial Disclosures: None declared.
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