Cutaneous Tuberculosis Indian Medical PG Practice Questions and MCQs
Practice Indian Medical PG questions for Cutaneous Tuberculosis. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Cutaneous Tuberculosis Indian Medical PG Question 1: Apple jelly nodule on diascopy is a feature of:
- A. Aspergillosis
- B. Lupus vulgaris (Correct Answer)
- C. Erysipelas
- D. Rhinoscleroma
Cutaneous Tuberculosis Explanation: ***Lupus vulgaris***
- An **apple jelly nodule** on diascopy is a classic clinical sign of **lupus vulgaris**, a severe form of cutaneous tuberculosis.
- Diascopy reveals the characteristic yellowish-brown discoloration due to **tuberculous granulomas** in the dermis.
*Aspergillosis*
- This is a fungal infection that typically affects the **respiratory tract** and less commonly the skin, especially in immunocompromised individuals.
- Skin lesions in aspergillosis are usually **necrotic ulcers** or plaques, not apple jelly nodules on diascopy.
*Erysipelas*
- This is a **superficial bacterial infection** of the skin and subcutaneous tissue, typically caused by *Streptococcus pyogenes*.
- It presents as a bright red, swollen, raised lesion with a **distinct border**, and does not produce apple jelly nodules.
*Rhinoscleroma*
- This is a chronic, progressive granulomatous disease affecting the **upper respiratory tract**, caused by *Klebsiella rhinoscleromatis*.
- It leads to **hard, nodular masses** in the nose and pharynx, often described as ligneous, but does not present as apple jelly nodules on diascopy.
Cutaneous Tuberculosis Indian Medical PG Question 2: A 25-year-old female has been diagnosed to be suffering from tuberculosis categorized as category II (sputum +ve) case of relapse. According to the previous RNTCP (Revised National Tuberculosis Control Programme) guidelines, the treatment regimen recommended under DOTS was:
- A. 3(HRZE)3 + 2(HRE)3 + 4(HR)3
- B. 2(HRSZE)3 + 1(HRZE)3 + 5(HRE)3 (Correct Answer)
- C. 3(HRSZE)3 + 1(HRZE)3 + 6(HRE)3
- D. 2(HRZE)3 + 5(HR)3
Cutaneous Tuberculosis Explanation: ***2(HRSZE)3 + 1(HRZE)3 + 5(HRE)3***
- This regimen reflects the standard **Category II DOTS regimen** under the **previous RNTCP guidelines** for **sputum-positive relapse cases**, which was an 8-month treatment protocol.
- The intensive phase consisted of **2 months of daily Streptomycin, Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol (HRSZE)**, followed by **1 month of daily Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol (HRZE)**, and a continuation phase of **5 months of Isoniazid, Rifampicin, and Ethambutol (HRE)** given three times weekly.
- **Note:** Under current NTEP (National TB Elimination Programme) guidelines, previously treated cases undergo drug susceptibility testing, and fixed Category II regimens are no longer the standard approach.
*3(HRZE)3 + 2(HRE)3 + 4(HR)3*
- This is an incorrect combination of drugs and durations that does not match any standard DOTS category under previous RNTCP guidelines.
- Category II relapse cases required a five-drug intensive phase including Streptomycin, not a four-drug regimen.
*3(HRSZE)3 + 1(HRZE)3 + 6(HRE)3*
- While this option includes the correct five-drug intensive phase, the duration is incorrect—the intensive phase with Streptomycin should be **2 months, not 3 months**.
- The continuation phase of 6 months (instead of 5 months) also makes the total treatment duration longer than the standard 8-month Category II protocol.
*2(HRZE)3 + 5(HR)3*
- This regimen represents the **Category I (new cases) regimen** under previous RNTCP guidelines, which used only four drugs in the intensive phase.
- It **lacks Streptomycin**, which was essential for Category II (relapse/failure/treatment after default) cases, and the continuation phase lacks Ethambutol, which was included in Category II continuation.
Cutaneous Tuberculosis Indian Medical PG Question 3: Which of the following chest X-ray findings is least likely to be associated with tuberculosis in patients with HIV?
- A. Pleural effusion
- B. Hilar lymphadenopathy
- C. Lupus vulgaris (Correct Answer)
- D. Miliary pattern
Cutaneous Tuberculosis Explanation: ***Lupus vulgaris***
* **Lupus vulgaris** is a form of **cutaneous tuberculosis** that affects the skin and is not a chest X-ray finding.
* It is a localized skin lesion, typically on the face or neck, and does not manifest with pulmonary radiographic changes.
*Miliary pattern*
* **Miliary pattern** on chest X-ray appears as diffuse **small nodular infiltrates** (1-3 mm) distributed throughout both lung fields, representing hematogenous dissemination of *Mycobacterium tuberculosis*.
* This finding is common in HIV patients with **disseminated (miliary) tuberculosis** and reflects severely impaired cell-mediated immunity.
* The term "miliary" refers to the millet seed-like appearance of the nodules.
*Pleural effusion*
* **Pleural effusion** is a common manifestation of tuberculosis, especially in immunocompromised individuals like those with HIV, often appearing as blunting of the **costophrenic angles** on chest X-ray.
* It is caused by an inflammatory reaction to mycobacterial antigens in the pleural space.
*Hilar lymphadenopathy*
* **Hilar lymphadenopathy** is a common chest X-ray finding in both primary and reactivated tuberculosis, particularly in HIV-infected patients due to an altered immune response.
* Enlarged lymph nodes near the **hilum** are often prominently visible and can be a sole chest X-ray finding in early or atypical presentations.
Cutaneous Tuberculosis Indian Medical PG Question 4: Which of the following drugs used in anti-tubercular therapy is a potent bactericidal agent that inhibits RNA synthesis?
- A. Pyrazinamide
- B. Ethambutol
- C. PAS
- D. Rifampicin (Correct Answer)
Cutaneous Tuberculosis Explanation: ***Rifampicin***
- **Rifampicin** is a potent **bactericidal** anti-tubercular drug that inhibits bacterial **RNA synthesis** by binding to DNA-dependent RNA polymerase.
- It is effective against both **rapidly dividing** and **metabolically active** *M. tuberculosis* strains.
- Among first-line anti-TB drugs, it is considered the most potent bactericidal agent with sterilizing activity.
*Pyrazinamide*
- **Pyrazinamide** is **bactericidal** against **intracellular** and **slowly replicating** *M. tuberculosis* in acidic environments.
- Its mechanism involves disrupting **mycobacterial membrane metabolism** and **transport functions** under acidic conditions, not RNA synthesis.
- It has unique sterilizing activity against dormant bacilli.
*Ethambutol*
- **Ethambutol** is primarily **bacteriostatic**, inhibiting the synthesis of the **mycobacterial cell wall** by interfering with arabinosyl transferases.
- It prevents the formation of **arabinogalactan**, an essential component of the mycobacterial cell wall.
*PAS*
- **Para-aminosalicylic acid (PAS)** is a **bacteriostatic** drug that inhibits **folic acid synthesis** in *M. tuberculosis*, similar to sulfonamides.
- It is a **second-line agent** used primarily in cases of drug resistance.
Cutaneous Tuberculosis Indian Medical PG Question 5: A farmer has an ulcer on leg with indurated margin and multiple sinuses with discharging granules. The likely diagnosis is -
- A. Lupus vulgaris
- B. Actinomycosis
- C. Scrofuloderma
- D. Mycetoma (Correct Answer)
Cutaneous Tuberculosis Explanation: ***Mycetoma***
- This is the **correct diagnosis** characterized by the classic triad: **tumefaction** (swelling with indurated margin), multiple **draining sinuses**, and discharge of **granules**.
- The **occupational history** (farmer with soil exposure) and **location on the leg** are highly suggestive of mycetoma, particularly common in agricultural workers.
- The granules are **colonies of microorganisms** (either fungi [eumycetoma] or bacteria [actinomycetoma]) aggregated and encased in a cement-like matrix, a distinctive feature of this chronic infection.
- **Key distinguisher**: Mycetoma has a predilection for the **lower extremities**, especially the foot and leg, in individuals with occupational soil exposure.
*Actinomycosis*
- Actinomycosis is a bacterial infection caused by *Actinomyces* species, which also forms abscesses and draining sinuses with characteristic **"sulfur granules."**
- **Why incorrect**: While actinomycosis shares features of sinuses and granules, it most commonly affects the **cervicofacial (50-60%)**, **thoracic**, or **abdominal** regions.
- **Leg involvement is rare** for actinomycosis, making mycetoma the more likely diagnosis in this clinical scenario.
- The occupational history and typical location favor mycetoma over actinomycosis.
*Lupus vulgaris*
- This is a form of **cutaneous tuberculosis** presenting as red-brown plaques or nodules, often with an **"apple-jelly" appearance** on diascopy.
- While it can cause ulcers, it typically does **not present with deep-seated sinuses and discharging granules**, which are pathognomonic for mycetoma.
*Scrofuloderma*
- This is a form of cutaneous tuberculosis that develops from the direct extension of underlying **tuberculous adenitis** or **osteomyelitis** to the skin.
- It presents as cold abscesses that eventually rupture, forming irregular ulcers and sinuses, but typically **lacks the distinct discharging granules** of mycetoma.
- The clinical presentation with granular discharge clearly differentiates mycetoma from scrofuloderma.
Cutaneous Tuberculosis Indian Medical PG Question 6: Not a cutaneous manifestation of tuberculosis:
- A. Exanthematous lesion
- B. Scrofuloderma
- C. Lupus vulgaris
- D. Erythema migrans (Correct Answer)
Cutaneous Tuberculosis Explanation: ***Erythema migrans***
- This **bullseye-shaped rash** is the hallmark cutaneous manifestation of **Lyme disease**, caused by *Borrelia burgdorferi*, not tuberculosis.
- Its presence indicates exposure to **ticks** carrying the spirochete and is a distinct entity from mycobacterial infections.
*Exanthematous lesion*
- While not a specific term for TB, some forms of tuberculosis can present with a morbilliform or **exanthematous rash**, especially during disseminating or paradoxical reactions.
- These are non-specific skin rashes that can occur in response to various infections, including but not exclusively tuberculosis.
*Scrofuloderma*
- This is a direct extension of tuberculosis from an underlying infected structure, such as a **lymph node (scrofula)** or bone, to the overlying skin.
- It presents as **ulcers** or sinuses with undermining edges discharging pus, and is a definitive cutaneous manifestation of localized TB.
*Lupus vulgaris*
- This is a **chronic, progressive form of cutaneous tuberculosis** characterized by reddish-brown plaques with an "apple-jelly" color on diascopy.
- It typically affects the face and neck and is caused by **hematogenous or lymphatic spread** from an internal TB focus in a patient with moderate to high immunity.
Cutaneous Tuberculosis Indian Medical PG Question 7: Skin TB which involves skin after involving lymph nodes –
- A. Scrofuloderma (Correct Answer)
- B. Lupus erythematosus
- C. Lupus pernio
- D. Lupus vulgaris
Cutaneous Tuberculosis Explanation: ***Scrofuloderma***
- This form of **cutaneous tuberculosis** results from the direct extension of underlying **tuberculosis** affecting structures such as **lymph nodes**, bones, or joints to the overlying skin.
- The skin lesion often appears as an **ulcer** or **sinus tract** with **purulent discharge**, reflecting the underlying infection communicating with the surface.
*Lupus erythematosus*
- Lupus erythematosus is a systemic autoimmune disease that can affect the skin, but it is not a form of **tuberculosis**.
- Skin manifestations range from acute malar rashes to chronic discoid lesions, which are distinct from **tuberculous ulcers**.
*Lupus pernio*
- This is a cutaneous manifestation of **sarcoidosis**, characterized by **violaceous plaques** and nodules typically on the face (nose, cheeks), ears, and fingers.
- It is not a form of **tuberculosis** and does not result from the direct extension of an underlying local infection.
*Lupus vulgaris*
- This is a chronic and progressive form of **cutaneous tuberculosis** that directly affects the skin in individuals with high immunity to the **tubercle bacillus**.
- It presents as **reddish-brown plaques** with an **apple-jelly** nodule appearance on diascopy, and does not typically arise from an underlying lymph node infection extending to the skin.
Cutaneous Tuberculosis Indian Medical PG Question 8: Saddle nose deformity is seen in?
- A. Primary Syphilis
- B. Secondary Syphilis
- C. Tertiary Syphilis (Correct Answer)
- D. Lupus Vulgaris
Cutaneous Tuberculosis Explanation: ***Tertiary Syphilis***
- **Saddle nose deformity** is a characteristic late manifestation of **tertiary syphilis** due to destructive lesions (gummas) affecting the nasal cartilage and bone [1], [2].
- It results from the **collapse of the nasal bridge**, leading to a flattened appearance [2].
*Primary Syphilis*
- Characterized by a **chancre**, a painless ulcer, usually at the site of infection [1].
- This stage does not involve destructive lesions of the nose.
*Secondary Syphilis*
- Presents with a **widespread rash**, lymphadenopathy, and mucous patches [1].
- While systemic, it typically does not cause structural damage like saddle nose deformity.
*Lupus Vulgaris*
- This is a **cutaneous form of tuberculosis**, characterized by chronic, destructive skin lesions.
- While it can cause facial disfigurement, saddle nose deformity is not a typical feature of lupus vulgaris.
Cutaneous Tuberculosis Indian Medical PG Question 9: A patient presents with fever and a rim-enhancing lesion with an air-fluid level on brain CT. What is the most likely diagnosis?
- A. Glioblastoma
- B. Metastasis
- C. Tuberculoma
- D. Brain abscess (Correct Answer)
Cutaneous Tuberculosis Explanation: ***Brain abscess***
- The presence of **fever** points towards an infectious etiology, and a **rim-enhancing lesion with an air-fluid level** on CT is highly characteristic of a brain abscess. The air-fluid level suggests gas-forming organisms or communication with an air-containing structure like a paranasal sinus.
- An abscess is a collection of pus, and the "rim-enhancement" indicates the inflammatory capsule surrounding the infection, while the **air-fluid level** is virtually pathognomonic for an abscess containing gas.
*Glioblastoma*
- While glioblastoma can be a **rim-enhancing lesion**, it is a primary brain tumor and typically does not present with **fever** or an **air-fluid level**.
- It often shows **irregular, thick enhancement** and typically causes significant surrounding edema, but the key differentiating factors here are the fever and air-fluid level.
*Metastasis*
- Brain metastases often present as **multiple, rim-enhancing lesions**, but they are tumors and do not typically cause **fever** (unless very large with extensive necrosis) or exhibit **air-fluid levels**.
- The clinical context (e.g., history of cancer) would be important for metastasis, but the **air-fluid level** strongly differentiates this case.
*Tuberculoma*
- A tuberculoma is a **granulomatous lesion** that can also show **rim enhancement**, especially with central caseous necrosis. However, it typically does not present with an **air-fluid level**.
- While fever can be present in tuberculosis, the **air-fluid level** is the most discriminating feature pointing away from tuberculoma and towards an abscess.
Cutaneous Tuberculosis Indian Medical PG Question 10: A 40-year-old with HIV presents with fever, cough, and hypoxia. Chest X-ray shows bilateral infiltrates. What is the most likely diagnosis?
- A. Tuberculosis
- B. Bacterial pneumonia
- C. Lung abscess
- D. Pneumocystis pneumonia (Correct Answer)
Cutaneous Tuberculosis Explanation: ***Pneumocystis pneumonia***
- In an HIV-positive individual with **fever, cough, hypoxia**, and **bilateral infiltrates** on chest X-ray, *Pneumocystis jirovecii* pneumonia (PJP) is the most likely diagnosis [1].
- PJP is an **opportunistic infection** common in immunocompromised patients, particularly those with **CD4 counts less than 200 cells/mm³** [1], [2].
*Tuberculosis*
- While tuberculosis can occur in HIV patients, it typically presents with **upper lobe cavitary lesions** or localized infiltrates, not diffuse bilateral infiltrates as described [1].
- Granulomas and night sweats are also common, which are not mentioned here.
*Bacterial pneumonia*
- Bacterial pneumonia usually presents with **lobar consolidation** or more localized infiltrates, and while it can cause fever and cough, severe hypoxia with diffuse bilateral infiltrates is less typical in this context [1].
- Immunocompromised patients are susceptible to bacterial pneumonia but the presenting features heavily favor PJP.
*Lung abscess*
- A lung abscess typically appears as a **cavity with an air-fluid level** on chest X-ray, which is not consistent with the described **bilateral infiltrates**.
- It often results from aspiration and is characterized by purulent sputum, which is not mentioned.
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