DR9.1-6 | Leprosy — Assignment

CLINICAL SCENARIO

This written assignment asks you to apply your knowledge of leprosy classification, MDT regimens, lepra reactions, and disability management to a real-world clinical scenario. You will demonstrate your ability to classify a patient correctly, justify your treatment choice, manage a reaction that occurs during treatment, and formulate a comprehensive counselling plan for a patient facing leprosy-related stigma and disability.

Clinical scenario: A 40-year-old male agricultural labourer presents with 6 skin lesions — 4 hypopigmented patches on the trunk (complete anaesthesia on 2, partial anaesthesia on 2) and 2 erythematous plaques on the left forearm (partial anaesthesia). Slit-skin smear from both earlobes and two active lesions shows BI = 2+ at the left earlobe. There is thickening of the left ulnar nerve at the medial epicondyle.

(a) Apply the WHO operational classification (PB vs MB) to this patient, stating the specific criteria you used.
(b) Identify the most likely Ridley-Jopling category and justify your answer with the clinical features listed above.
(c) Explain why the two classification systems are used for different purposes and why they cannot be substituted for each other.

Based on your classification in Section 1:

(a) Write a precise MDT prescription for this patient, naming each drug, its dose (supervised monthly dose AND daily self-administered dose), and the total duration of treatment.
(b) List TWO clinically important adverse effects of each drug in the regimen and explain how you would counsel the patient about them.
(c) Describe the NLEP monitoring protocol: when should you reassess this patient after starting MDT, and what specific findings would prompt you to reconsider the regimen?

Four months into treatment, the patient returns urgently. He reports that over the past 48 hours his left forearm patches have become intensely red and swollen, and his left ulnar nerve is acutely tender and weak. He has no new skin nodules and no fever.

(a) Identify the type of lepra reaction occurring, providing two clinical features that support your diagnosis.
(b) Explain the immunological mechanism underlying this reaction.
(c) Write a step-by-step management plan, including: whether to continue or stop MDT, first-line drug and dose, duration of treatment, and criteria for tapering.
(d) State one absolute contraindication you would check before considering thalidomide in any patient with this type of reaction (and explain why it does not apply to this specific case).

After completing MDT, the patient has residual claw deformity of the right ring and little fingers (from ulnar nerve damage), and his wife reports that his family is reluctant to share meals with him, and two neighbours have asked him to avoid the community well.

(a) Assign a WHO disability grade for the right hand and explain your grading.
(b) Describe two key principles of plantar ulcer prevention if the patient also has anaesthetic feet.
(c) You now counsel the patient and his family. Write a structured counselling note covering: (i) curability and non-infectivity after completing MDT, (ii) addressing the specific social stigma concerns raised, and (iii) one concrete action the patient can take to prevent further nerve damage during daily work.

PEER REVIEW

Review your peer's assignment against the rubric criteria. For each section, provide: (1) one specific strength — what they did well, (2) one specific constructive suggestion for improvement, and (3) your numeric score (0, 8, 15, 20, or 25) with a one-sentence justification. Total peer review score = sum of four sections. Be specific, evidence-based, and professional in your comments.