Corticosteroid-Induced hypertension in delayed leprosy reactions: the iceberg phenomenon at Dr. Soetomo Hospital (2015–2024)

Type I leprosy reactions at Dr. Soetomo Hospital (2015–2024) exemplify the "iceberg phenomenon," where systemic delays in detection escalate disability and iatrogenic hypertension burdens. This qualitative study of 127 patients revealed that 70.1% (89/127) presented >8 weeks post-symptom onset with advanced neuritis or deformities, necessitating prolonged high-dose prednisone regimens (mean 52.3±8.1 mg/day for 18.3±4.1 weeks). Critically, 78.6% (70/89) of delayed-presentation patients developed steroid-induced hypertension versus only 10.5% (4/38) in early-presenting counterparts (p<0.001), compounded by inadequate baseline cardiovascular screening (31.5% BP documentation). Thematic analysis identified primary care gaps: 68.5% of providers overlooked early neural inflammation, while 87% of patients lacked hypertension risk counseling before corticosteroid initiation. Delayed steroid therapy correlated with a 4.1-fold higher permanent disability risk (95% CI: 2.3–7.4) and 3.2-fold increased treatment interruptions due to hypertensive complications (95% CI: 1.8–5.7). These findings underscore an urgent need for integrated interventions—including primary healthcare training in early reaction recognition, protocolized cardiovascular monitoring during corticosteroid administration, and community education—to mitigate intersecting morbidity from leprosy reactions and avoidable hypertension.