A leprosy clinical severity scale for erythema nodosum leprosum: An international, multicentre validation study of the ENLIST ENL Severity Scale

Stephen L Walker, Anna M Sales, C Ruth Butlin, Mahesh Shah, Armi Maghanoy, Saba M Lambert, Joydeepa Darlong, Benjamin Jewel Rozario, Vivek V Pai, Marivic Balagon, Shimelis N Doni, Deanna A Hagge, José A C Nery, Kapil D Neupane, Suwash Baral, Biliom A Sangma, Digafe T Alembo, Abeba M Yetaye, Belaynesh A Hassan, Mohammed B Shelemo, Peter G Nicholls, Diana N J Lockwood, Erythema Nodosum Leprosum International STudy Group, Stephen L Walker, Anna M Sales, C Ruth Butlin, Mahesh Shah, Armi Maghanoy, Saba M Lambert, Joydeepa Darlong, Benjamin Jewel Rozario, Vivek V Pai, Marivic Balagon, Shimelis N Doni, Deanna A Hagge, José A C Nery, Kapil D Neupane, Suwash Baral, Biliom A Sangma, Digafe T Alembo, Abeba M Yetaye, Belaynesh A Hassan, Mohammed B Shelemo, Peter G Nicholls, Diana N J Lockwood, Erythema Nodosum Leprosum International STudy Group

Abstract

Objectives: We wished to validate our recently devised 16-item ENLIST ENL Severity Scale, a clinical tool for measuring the severity of the serious leprosy associated complication of erythema nodosum leprosum (ENL). We also wished to assess the responsiveness of the ENLIST ENL Severity Scale in detecting clinical change in patients with ENL.

Methods: Participants, recruited from seven centres in six leprosy endemic countries, were assessed using the ENLIST ENL Severity Scale by two researchers, one of whom categorised the severity of ENL. At a subsequent visit a further assessment using the scale was made and both participant and physician rated the change in ENL using the subjective categories of "Much better", "somewhat better", "somewhat worse" and "much worse" compared with "No change" or "about the same".

Results: 447 participants were assessed with the ENLIST ENL Severity Scale. The Cronbach alpha of the scale and each item was calculated to determine the internal consistency of the scale. The ENLIST ENL Severity Scale had good internal consistency and this improved following removal of six items to give a Cronbach's alpha of 0.77. The cut off between mild ENL and more severe disease was 9 determined using ROC curves. The minimal important difference of the scale was determined to be 5 using both participant and physician ratings of change.

Conclusions: The 10-item ENLIST ENL Severity Scale is the first valid, reliable and responsive measure of ENL severity and improves our ability to assess and compare patients and their treatments in this severe and difficult to manage complication of leprosy. The ENLIST ENL Severity Scale will assist physicians in the monitoring and treatment of patients with ENL. The ENLIST ENL Severity Scale is easy to apply and will be useful as an outcome measure in treatment studies and enable the standardisation of other clinical and laboratory ENL research.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Box plot of the 10…
Fig 1. Box plot of the 10 item scale by expert classification showing medians, interquartile ranges and minimum and maximum scores.
Fig 2. Bland-Altman plot of the two…
Fig 2. Bland-Altman plot of the two scores derived from the 10 item EESS at the first assessment.
Fig 3. ROC curve for those with…
Fig 3. ROC curve for those with mild ENL and those with either moderate or severe ENL.
Fig 4. Box plot of 10 item…
Fig 4. Box plot of 10 item EESS scores for mild compare with moderate and severe ENL.
The line in red indicates the cut off between mild ENL and more severe disease.
Fig 5. Change in EESS score and…
Fig 5. Change in EESS score and participant rated improvement.
Fig 6. Change in EESS score and…
Fig 6. Change in EESS score and physician rated improvement.

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