Correspondence

10. Moilanen E, Vuorinen P, Kankaanranta H, et al. Inhibi-tion by nitric oxide-donors of human polymorphonuclearleukocyte functions. BrJ Pharmacol 1993; 109:852-858.

Chemoimmunotherapy :Its Relevance in Contemporary Context

To the Editor:The article, "Localized lepromatous leprosy and its responseto chemoimmunotherapy," by Beena et al.' was rather in-triguing. They have once again endeavored to project chemo-immunotherapy in the treatment of leprosy, albeit, with usualhaste. The fallout from a study of this nature is quite clear.At the outset, it must be pointed out that Ridley and Jopling^classified leprosy into five groups, not types, which were laterextended to include indeterminate (i) and polyneuritic (p),thus forming a seven-group classification.' Accordingly, LLdenotes "lepromatous lepromatous" and not "lepromatousleprosy" in the standard nomenclature.

The report tends to point out the role of histopathologyand slit-skin smear in the diagnosis of leprosy; however, con-trary to expressed opinion, it has been highlighted time andagain that the diagnosis of leprosy is primarily clinical.Histopathology can only supplement and not supplant theclinical diagnosis.** The role of the slit-skin' smear cannot beoveremphasized, for its help in the delineation of patientsinto pauci- (abacillary) and multibacillary leprosy, which isconsidered important only for administering multi-drug ther-apy (Mm). The endeavor to exemplify the superiority ofchemoimmunotherapy over existing MDT, and that in an un-usual case of lepromatous leprosy, is indeed amusing.

The upgrading from lepromatous lepromatous (l,L) to bor-derline tuberculoid has been supported by apparent docu-mentation of clinical bacteriologic and histopathologic para-meters and in vivo and in vito immunologic assays. It wouldbe interesting to reiterate that such immunologic change maybe evoked by MDT per se,^ repeated lepromin testing, sponta-neous upgrading, and other antigenic challenges that inducelymphocytic activation with release of cytokines.^"' More-over, it is a well-known fact that delayed hypersensitivity(DH) may not parallel specific cellular immunity in mycobacte-rial infection.'" It is apparent that these facts have not foundfavor in the report, despite earlier suggestions."

It is thus reiterated that to date, the WHO recommendedMDT as the standard mainstay treatment for leprosy. It is ableto stop the proliferation and kill Mycobacterium leprae. It isalso reputed to stall the emergence of drug-resistant mutantand persisting strains.'^ The clearence of dead bacilli fromthe skin by macrophages continues even after cessation ofMDT. That chemoimmunotherapy may accelerate this bacteri-al clearance is still debatable. Although it may evoke ecstasy,the superiority of chemoimmunotherapy over MDT cannot beaccepted on the basis of scattered case reports. The claims re-quire to be authenticated by meticulously planned vaccine tri-als. It is imperative to segregate patients into three groups,namely those administered MDT alone, vaccine alone, andMDT and vaccine together.

Chemoimmunotherapy, therefore, remains an intriguingapproach to the correction of immune deficits in leprosy. Novaccine preparation with documented efficacy is as yet avail-

able. It probably awaits a better insight into the immuno-pathogenesis of leprosy. Furthermore, undertaking such trialsseems unethical.

Virendra N. Sehgal, M.D.Sanjiv Jain, M.D.New Delhi, India

References1. Beena KR, Zaheer SA, Guleria I, et al. P, localized lep-

romatous leprosy and its response to chemoimmuno-therapy. Int J Dermatol 1994; 33:64-67.

2. Ridley DS, Jopling WH. Classification of leprosy ac-cording to immunity. Int J Leprol Other Mycobact Dis1966; 24:255-273.

3. Sehgal VN. A seven group classification of leprosy forinstitutional and field work. Lepr Rev 1989; 60:75.

4. Sehgal VN. Histopathology only supplements not sup-plants the clinical diagnosis of Hansens' disease. TheStar 1990; 49:15-16.

5. Sehgal VN, Joginder. Slit-skin smear in leprosy. Int JDermatol 1990; 29:9-16

6. Esquenazi Da, Sampaio EP, Morevia AL, et al. Effect oftreatment of immune responsiveness in lepromatousleprosy patients. Lepr Rev 1990; 61:251-257.

7. Nathan CF, Kaplan G, Lewis WR, et al. Local and sys-temic effects on intradermai recombinant interfer-ongamma in patients with lepromatous leprosy. N EngiJ Med 1986; 315:6-15.

8. Kaplan G, Klessling R, Teklemarrian S, et al. The re-constitution of cell-mediated immunity in cutaneous le-sions of lepromatous leprosy by recombinant inter-leukin. J Exp Med 1989; 169:893-907.

9. Sehgal VN, Gupta R, Karmakar S, et al. In situ charac-terization of lymphocytic immunophenotypes and inter-leukin-2 receptors (IL-2R) in cutaneous tuberculosisand leprosy: a comparative evaluation. Clin Exp Der-matol 1994;19:312-316.

10. Turk JL. Dissociation between allergy and immunity inmycobacterial infections. Lepr Rev 1983; 54:1-8.

11. Sehgal VN, Bhattacharya SN, Jain S. Immunologicalupgrading with combined immunotherapy andchemotherapy in a lepromatous leprosy patient : a casereport. Lepr Rev 1992; 63:88-89. (Letter)

12. WHO expert committee on leprosy: sixth report. WHOTechnical Report Series no. 768. Geneva: WHO, 1988.

Chemoimmunotherapy:Its Relevance in Contemporary Context (Reply)To the Editor:Virendra N. Sehgal, M.D., has opined that diagnosis of lep-rosy is primarily clinical. Although not diminishing the im-portance of clinical examination, we feel that in addition to aclinical examination, it is important to determine the bacterialindex on slit-skin smears and also carry out a histopathologyexamination to confirm the diagnosis and determine the typeleprosy. This becomes particularly important in cases such asthe one reported here, in which the number of lesions arelimited. Others have also noted that lepromatous leprosy canpresent as a localized form of disease.'"^

We follow the Ridley and Jopling classifications. We arecertainly aware that "LL" denotes lepromatous and the articlenowhere states that LL denotes lepromatous leprosy.

753