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DR9.1-6 | Leprosy — Graded Quiz
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A 35-year-old farmer presents with 4 hypopigmented patches (all anaesthetic) on the trunk and a positive slit-skin smear (BI = 1+) from the left ear lobe. Under WHO/NLEP guidelines, which regimen should he receive?
Correct. One positive smear at any site = MB classification, irrespective of lesion count. MB-MDT = 3 drugs × 12 months.
A positive slit-skin smear at ANY site = MB, regardless of lesion count. This patient has only 4 lesions (which would be PB by count alone) but the positive smear overrides the count — MB-MDT × 12 months is mandatory.
Incorrect. A positive slit-skin smear at any site classifies the patient as MB — it overrides the ≤5-lesion count. MB-MDT = Rifampicin + Dapsone + Clofazimine × 12 months.
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A patient with BT leprosy, currently on PB-MDT for 3 months, presents with acutely swollen and tender left ulnar nerve, new weakness of intrinsic hand muscles, and existing skin patches that are now erythematous and oedematous. Temperature and systemic symptoms are absent. What is the most appropriate immediate management?
Correct. Type 1 reversal reaction in BT: continue MDT (essential) and start prednisolone immediately. Acute neuritis requires same-day corticosteroids to prevent permanent nerve damage.
BT leprosy + inflamed existing patches + acute neuritis = Type 1 (reversal) reaction. NEVER stop MDT. Corticosteroids (prednisolone) are the first-line treatment and must be started the same day — acute neuritis is a nerve-saving emergency.
Incorrect. Stopping MDT during any lepra reaction is contraindicated. Type 1 reaction (BT + inflamed patches + acute neuritis) requires immediate corticosteroids while continuing MDT.
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During a neurological examination of a leprosy patient, you find clawing of the ring and little fingers of the right hand. Which nerve is most likely damaged, and at which anatomical landmark is it most vulnerable in leprosy?
Correct. Ulnar nerve damage at the medial epicondyle → clawing of ring and little fingers (4th/5th digits). The ulnar nerve is palpated at this landmark in all leprosy examinations.
Ulnar nerve damage (at the medial epicondyle) causes clawing of the ring and little fingers (4th and 5th digits) + intrinsic hand muscle wasting. Median nerve damage causes clawing of the index and middle fingers + thenar wasting. These patterns help identify the damaged nerve.
Incorrect. Claw hand affecting the ring and little fingers indicates ulnar nerve damage. The ulnar nerve is vulnerable at the medial epicondyle of the elbow in leprosy.
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A patient with LL leprosy on MB-MDT for 8 months develops multiple painful, shiny erythematous nodules over the arms and legs, associated with fever (38.5°C), malaise, and bilateral ankle swelling. Blood tests show elevated ESR and CRP. No nerve tenderness is noted. What is the diagnosis and appropriate management?
Correct. New tender nodules + fever + raised inflammatory markers in LL = ENL (Type 2). Treatment: prednisolone ± clofazimine, and MDT must continue.
ENL (Type 2): new tender erythematous nodules + systemic features (fever, raised inflammatory markers) in BL/LL leprosy. Treatment: corticosteroids (prednisolone) ± clofazimine for severe/recurrent ENL. MDT must NEVER be stopped. Thalidomide is highly effective but absolutely contraindicated in women who may become pregnant.
Incorrect. LL leprosy + new tender nodules + systemic inflammation = ENL (Type 2 reaction). Treatment is prednisolone ± clofazimine, continuing MDT throughout.
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A leprosy patient has an BI of 4+ on slit-skin smear and completed MB-MDT 18 months ago. He now presents with new skin lesions and a BI of 2+ at the same sites. What is the most likely explanation?
Correct. New lesions + rising BI after completing MDT = relapse. The patient must be re-classified (PB or MB based on current status) and retreated with a full MDT course.
Post-MDT, BI should fall by approximately 1 log unit per year. A rising BI after MDT completion + new lesions = relapse. Relapse requires full re-classification and complete retreatment with the appropriate MDT course. Monotherapy is never used.
Incorrect. A rising BI with new lesions after completing MDT indicates relapse — the patient must be re-classified and retreated with a full MDT course.
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A patient with leprosy presents with inability to close the right eye completely, corneal exposure, and loss of eyebrow (madarosis). What grade of WHO disability is present for the right eye, and what is the immediate risk?
Correct. Lagophthalmos = WHO Grade 2 disability. The exposed, anaesthetic cornea is at immediate risk of ulceration and blindness without protective intervention.
WHO Disability Grade 2 = visible deformity/damage including lagophthalmos (inability to close the eye). Lagophthalmos exposes the anaesthetic cornea to trauma, ulceration, and blindness. Immediate ophthalmology referral and protective eye care (lubricating eye drops, eye patch) are essential.
Incorrect. Inability to close the eye (lagophthalmos) = WHO Grade 2 disability. This is an ocular emergency — the anaesthetic cornea is at risk of ulceration and blindness.
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Under the National Leprosy Eradication Programme (NLEP), what is the elimination target defined as, and what was India's official declared status?
Correct. NLEP defines elimination as prevalence <1 per 10,000. India declared national-level elimination in 2005, though sub-national endemic pockets persist.
NLEP elimination target = prevalence < 1 case per 10,000 population. India declared elimination at the national level in December 2005. However, several states and sub-national areas continue to report higher endemic levels, and India still contributes ~50% of global new cases annually.
Incorrect. The WHO/NLEP elimination target is prevalence <1 per 10,000 population, not zero cases. India declared national-level elimination in 2005.
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A patient presents with a single, well-defined hypopigmented patch, 3 cm diameter, on the forearm. The patch has complete anaesthesia and the nearest peripheral nerve (radial cutaneous) is thickened. Which Ridley-Jopling category does this MOST likely represent, and why?
Correct. A single, well-defined, anaesthetic patch with nearby nerve thickening = TT. Strong CMI clears bacilli but damages the local nerve — a hallmark of the tuberculoid pole.
TT (tuberculoid) leprosy: few (1-5), small, well-defined, hypopigmented lesions with definite anaesthesia. Strong CMI destroys bacilli, producing well-demarcated lesions but also causing nerve damage at adjacent peripheral nerves. LL has numerous, poorly-defined, symmetric lesions.
Incorrect. A single, well-defined, highly anaesthetic patch with adjacent nerve thickening is characteristic of tuberculoid (TT) leprosy — the result of a vigorous CMI response.
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A patient with anaesthetic feet from leprosy develops a painless plantar ulcer. What is the single most important preventive instruction for this patient regarding footwear?
Correct. MCR (Microcellular Rubber) footwear distributes plantar pressure evenly, preventing new pressure ulcers in anaesthetic feet. Daily self-inspection is equally important.
Anaesthetic feet: daily self-inspection for cracks/ulcers, Microcellular Rubber (MCR) footwear for pressure distribution, and total-contact casting for active ulcers. Warm water soaking is dangerous in anaesthetic feet as it softens skin and increases ulcer risk. MCR footwear is the cornerstone of disability prevention in leprosy.
Incorrect. MCR footwear is the standard of care for insensitive feet in leprosy — it distributes pressure to prevent ulcer formation. Warm water soaking softens skin and is dangerous for anaesthetic feet.
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In a patient with Borderline Lepromatous (BL) leprosy, which set of clinical features would confirm this Ridley-Jopling classification?
Correct. BL: multiple asymmetric plaques, partial anaesthesia, satellite lesions, positive smear. This reflects partial CMI — more impaired than BT but not as absent as LL.
BL: multiple asymmetric lesions with partial anaesthesia, satellite lesions, positive smear (BI 1-4+). LL: diffuse symmetric infiltration, madarosis, high BI (4-6+). BB: 'Swiss cheese' lesions, intermediate features. TT: single well-defined anaesthetic patch.
Incorrect. BL features: multiple asymmetric lesions, partial anaesthesia, satellite lesions, positive smear. Diffuse symmetric infiltration + madarosis + high BI = LL; 'Swiss cheese' pattern = BB; single patch = TT.
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