Successful treatment of severe recalcitrant erythema nodosum leprosum with infliximab

29 year old female presented with lepromatous leprosy with erythema nodosum leprosum (ENL) in January 2017 (bacillary index-5+, morphological index-20%) to National Hospital of Sri Lanka. Multidrug treatment (rifampicin, clofazimine and dapsone) was started but dapsone was replaced by ofloxacin due to anaemia. She developed seven episodes of severe recalcitrant ENL with five hospital admissions within one year despite high dose prednisolone, clofazimine, azathioprine and pentoxifylline.

Weekly rifampicin, minocycline and moxifloxacin were added in September 2017 to reduce the burden of high antigenaemia. She underwent one cycle of plasmapheresis and intravenous dexamethasone pulse. Despite all, her ENL reactions got worse while having overwhelming drug side effects.

Infliximab was started in March 2018 and five doses were given with successful outcome. Prednisolone, clofazimine and azathioprine were tailed off and discontinued. Most importantly she did not experience any ENL reactions for last 2 years after starting infliximab highlighting its success.