Written by Mary Marschner
Spoon Feed
This is a tiny proof-of-concept study that showed patients with multibacillary leprosy treated with monotherapy bedaquiline cleared M. leprae in 4 weeks and improved skin lesions in 7 weeks.
Looking at leprosy
Let’s have fun and review an old illness that is rare in the US, but not in the world, and appreciate the development of new regimens as resistance patterns continue to evolve. Leprosy/Hanson’s disease is caused by Mycobacterium leprae or Mycobacterium lepromatosis, which are acid fast bacilli and grow best in the cooler areas of the body. They attack the peripheral nerves and the skin (think nose, ears, cheeks) and are classified as paucibacillary (5 or fewer skin lesions without bacilli on skin smears) or multibacillary (6 or more lesions and may be skin smear positive). Current guidelines for treatment are multidrug therapy (dapsone/rifampin/clofazimine) for 12 to 24 months. Length of treatment, dapsone toxicity, and drug resistance make developing alternative regimens extremely important. If you find yourself concerned about leprosy, the WHO has a great guideline for the diagnosis and treatment of the disease. This study evaluated bedaquiline monotherapy for multibacillary leprosy in an open-label proof-of-concept trial in Brazil. Nine patients received bedaquiline for 8 weeks, followed by standard multidrug therapy. Results showed a significant reduction in Mycobacterium leprae growth in mouse footpads and improvement in skin lesions, with no growth after 4 weeks of bedaquiline therapy. The limitations of this study are the tiny sample size (9 patients!), and length of duration (8 weeks).
How will this change my practice?
I have only seen one case of leprosy in my career practicing in the US. Not surprisingly, the physician who recognized it was one who trained in an endemic country. I’ll think about leprosy if I come across a patient, likely from a different country, with slowly developing peripheral skin lesions and neuropathy. So I won’t say this study is going to change my practice, but hopefully bedaquiline will be a monotherapy option in the future.
Source
Bedaquiline Monotherapy for Multibacillary Leprosy. N Engl J Med. 2024 Dec 12;391(23):2212-2218. doi: 10.1056/NEJMoa2312928. PMID: 39665652
