Dexamethasone/prednisolone/thalidomide

Abstract

Deep vein thrombosis: 2 case reports In a report, a 35-year-old man and a 42-year-old man was described who developed deep vein thrombosis (DVT) during treatment with dexamethasone, prednisolone and thalidomide for lepromatous leprosy with erythema nodosum leprosum (ENL) and neuritis [not all routes, time to reactions onset and outcomes stated]. Case 1: A 35-year-old man presented with a history of recurrent episodes of joint pain, fever and erythematous nodules since one year. He had been receiving prednisolone 40 mg/day and unspecified multibacillary multidrug therapy (MBMDT). The dose of prednisolone had to be repeatedly altered due to frequent remissions and exacerbations. On detailed investigations, he was diagnosed with lepromatous leprosy (LL) chronic ENL and neuritis. He started receiving treatment with injectable dexamethasone 8mg with gradually tapering after clinical improvement. After 10 days, he was discharged on tablet prednisolone 60mg/day (week 0) tapered by 5mg every week. After 6 weeks, new ENL lesions cropped up when he reached a dose of prednisolone 30 mg/day. Hence, thalidomide tablet at a dose of 100mg thrice daily was added to the treatment regimen. He responded dramatically by day 4 and the dose of prednisolone was further reduced by 5mg every week and maintained at 10 mg from week 10 onwards. However, two months later, he developed asymptomatic swelling of the left leg. Doppler ultrasonography showed left DVT of the superficial femoral vein, common femoral vein and popliteal vein. Blood investigations revealed neutrophilic leukocytosis and INR 4.13. Therefore, the prednisolone treatment was discontinued, and thalidomide was decreased to 100mg twice daily. He was treated with unspecified low molecular weight heparin and maintained on warfarin with INR a target range of 2–3. He was free of ENL lesions. However, two months later, asymptomatic swelling with DVT was detected in the right leg, for which dose of anticoagulant therapy was adjusted. He was continued on thalidomide tablet at a dose of 100mg twice daily. Case 2: A 42-year-old man presented with tender skin lesions, fever and joint pain for 10 months. He had been receiving unspecified MBMDT for leprosy for 10 months and prednisolone tablet 40 mg/day with inadequate control. On detailed investigations, he was diagnosed with lepromatous leprosy (LL) with chronic ENL and neuritis. He started receiving treatment with injectable dexamethasone 8mg and later switched to prednisolone tablet at a dose of 60 mg/day (week 0) with gradual tapering by 5mg every week with control of symptoms. He had severe exacerbation of the symptoms after reducing the prednisolone dose to 40 mg/day at week 4. Hence, thalidomide tablet at a dose of 100mg thrice daily was added. Gradual improvement was observed during follow-up visits. However, at prednisolone dose of 20mg started at week 8, he developed swelling and severe pain in his left leg. Doppler ultrasonography of the affected limb revealed diffuse hypoechoic thrombus distension up to inferior vena cava bifurcation of the common femoral vein and superficial femoral vein contiguous into popliteal vein also involving the short saphenous vein and its tributaries with diffuse subcutaneous oedema of the left lower limb suggestive of DVT. Thalidomide was immediately discontinued. He was treated with unspecified LMWH and warfarin for 7 days. Thereafter, he was maintained on warfarin with a target INR of 2–3. Limb elevation with crepe bandage application was performed. His swelling and leg pain improved significantly, and he was restarted on thalidomide 100mg. Prednisolone dosage was tapered and maintained at 10mg from week 10 onwards. After 24 MBMDT, he was asymptomatic. Currently, he had been receiving warfarin on alternate days with monitoring of INR.