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Hansen's disease in the era of COVID‐19: An observation on a series of six patients with co‐infection

Abstract Since the onset of the present pandemic, effect of the novel corona virus on other infectious conditions continues to be investigated. Although the immunological responses to SARS‐Cov‐2 infection have been elaborated extensively, they fail to explain, variations in its clinical manifestations and its interaction with other diseases. Hansen's disease is known to present as a complex immunological response to the lepra bacilli, resulting in its varied spectral manifestations. An interaction between these two infectious agents, hence, may affect Hansen's disease. We came across six cases of Hansen's disease who developed COVID19 co‐infection. This series presents their clinical course and outcome, during the period of co‐infection. All cases were followed up for a minimum eight‐week period thereafter. In all these cases the active phase of coronavirus infection had no effect on Hansen's disease and those on prednisolone for their lepra reaction had a more favorable outcome, with two cases manifesting exacerbation of their lepra reactions in the follow period.


| INTRODUCTION
The effect of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection on preexisting diseases is yet to be fully explored. The immune response to SARS-CoV-2 continues to be a riddle with variable clinical outcomes. This variability is bound to affect other immune responsive diseases such as Hansen's disease. We came across six such cases of Hansen's disease who developed SARS-CoV-2 co-infection. Their course during the period of this co-infection and follow up is elaborated and reported after institutional ethical committee review.

| OBSERVATIONS
Six cases of Hansen's disease with coexistent COVID19 infection were managed at the skin centre of a tertiary care hospital between April 2020 to October 2020. The 04 cases reported with upper respiratory symptoms while 02 were screened following a recent exposure to a positive COVID19 case. Their COVID19 diagnosis was on the basis of a positive reverse transcriptase polymerase chain reaction test (RTPCR) for SARS-Cov-2 (E and RdRp gene) sampled by a nasopharyngeal swab. The four cases were already on Multidrug Therapy (MDT) as per the standard WHO regimen for Hansen's disease 1 while two were diagnosed afresh and placed on treatment. The 02 cases, intolerant to dapsone were placed on modified MDT (rifampicin 600 mg once a month and clofazimine 50 mg daily), four were on prednisolone for lepra reactions, of which one was placed on thalidomide later.
They were managed at our institution's dedicated Coronavirus Disease (COVID19) facility, and declared free from infection once their SARS-CoV-2 RTPCR tested negative (tested 10th day after initial detection or every 7 days thereafter in case of persistent positivity).

| Case 3
A 32-year-old male symptomatic for 4 months with Hansen's disease borderline-lepromatous on MDT and type-I-lepra-reaction of 6 weeks duration on prednisolone tapered from 60 mg daily to 40 mg daily was detected positive upon screening post COVID19 high risk exposure. COVID illness and recovery except for a prolonged 24-day period of infectivity was uneventful. His lepra reaction exacerbated 2 weeks later, for which he was reinstituted on 60 mg prednisolone daily and is now asymptomatic.

| Case 4
The 20 year old male with Hansen's disease pure-neuritic on MDT

| Case 5
A case of Hansen's lepromatous-lepromatous on MDT for 7 months, manifested Type 2 reaction at 5 months of MDT, was on tapering doses of prednisolone at 30 mg when he became symptomatic with cough and nasal stuffiness.
He had a prolonged COVID19 illness along with microcytic hypochromic anemia (6.4 g%) and LDH 189 U/L but no lung involvement.
He was managed symptomatically along with a single unit of packed red blood cells.
After a prolonged COVID 19 illness of 35 days, he continued to have persistent malaise and tiredness. In the immediate follow up period he had exacerbation of his lepra reaction and multiple furunculosis. He was managed with thalidomide 100 mg four times a day and withdrawal of prednisolone for his Type 2 lepra reaction; amoxycillin 625 mg with clavulanic acid 125 mg thrice daily for 5 days for furunculosis. He is now asymptomatic after 10 weeks on MDT and thalidomide.

| Case 6
A young 20-year-old male, pure-neuritic Hansen's disease case, symptomatic for past 2 years with mild bilateral ulnar clawing presented in the recovery period of his COVID19 illness. He had remained asymptomatic and recovered in 10 days.

| DISCUSSION
Mycobacterium leprae elicits a varied immune response; a specific Th1 and Th17 response preventing its multiplication (tuberculoid spectrum) and a specific Th2 response that allows its dissemination (lepromatous spectrum