03260nas a2200277   4500000000100000008004100001653002100042653002600063653002200089653001200111653002200123653003500145100001400180700002800194700001300222700002100235700001500256700001400271700001300285245017300298856008900471300000800560490000700568520239300575022001402968       2017                            d10aType 1 reactions10aRenal transplantation10aRegulatory T cell10aleprosy10aImmunosuppressors10aImmune reconstitution syndrome1 aVieira AP1 aBianconcini Trindade MA1 aPaula FJ1 aSakai-Valente NY1 aDuarte AJS1 aLemos FBC1 aBenard G00aSevere type 1 upgrading leprosy reaction in a renal transplant recipient: a paradoxical manifestation associated with deficiency of antigen-specific regulatory T-cells?  uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5404339/pdf/12879_2017_Article_2406.pdf  a3050 v173 a<p><strong>BACKGROUND: </strong>Due to its chronic subclinical course and large spectrum of manifestations, leprosy often represents a diagnostic challenge. Even with proper anti-mycobacteria treatment, leprosy follow up remains challenging: almost half of leprosy patients may develop reaction episodes. Leprosy is an infrequent complication of solid organ transplant recipients. This case report illustrates the challenges in diagnosing and managing leprosy and its reactional states in a transplant recipient.</p>

<p><strong>CASE PRESENTATION: </strong>A 53-year-old man presented 34&nbsp;months after a successful renal transplantation a borderline-tuberculoid leprosy with signs of mild type 1 upgrading reaction (T1R). Cutaneous manifestations were atypical, and diagnosis was only made when granulomatous neuritis was found in a cutaneous biopsy. He was successfully treated with the WHO recommended multidrug therapy (MDT: rifampicin, dapsone and clofazimine). However he developed a severe T1R immediately after completion of the MDT but no signs of allograft rejection. T1R results from flare-ups of the host T-helper-1 cell-mediated immune response against Mycobacterium leprae antigens in patients with immunologically unstable, borderline forms of leprosy and has been considered an inflammatory syndrome in many aspects similar to the immune reconstitution inflammatory syndromes (IRS). The T1R was successfully treated by increasing the prednisone dose without modifying the other immunosuppressive drugs used for preventing allograft rejection. Immunological study revealed that the patient had a profound depletion of both in situ and circulating regulatory T-cells and lack of expansion of the Tregs upon M. leprae stimulation compared to T1R leprosy patients without iatrogenic immunosuppression.</p>

<p><strong>CONCLUSIONS: </strong>Our case report highlights that leprosy, especially in the transplant setting, requires a high degree of clinical suspicion and the contribution of histopathology. It also suggests that the development of upgrading inflammatory syndromes such as T1R can occur despite the sustained immunosuppressors regimen for preventing graft rejection. Our hypothesis is that the well-known deleterious effects of these immunosuppressors on pathogen-induced regulatory T-cells contributed to the immunedysregulation and development T1R.</p>
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