Leprosy — MCQs
Asymmetrical nerve thickening with several hypoesthetic macules on skin indicates which stage of leprosy:
What is the first symptom of leprosy?
Ridley-Jopling classification includes all except:
A 35-year-old woman presents with hypopigmented and anesthetic patches on her arms, and a positive skin smear for acid-fast bacilli. What is the most likely diagnosis?
Moth-eaten alopecia is seen with:
A patient was diagnosed to have single skin lesion of Leprosy without any AFB positive bacteria from the scrapings. What should be the treatment of this patient according to latest guidelines?
A 53 year-old male presented with erythematous, edematous plaques on his face over pre-existing hypoesthetic patches. He has been experiencing pain for the last 10 days and has been on multibacillary multidrug therapy (MBMDT) for leprosy for the past two months. What is the most likely diagnosis based on the image?
With reference to lepromin test, which one of the following statements is correct?
A patient with leprosy had slightly erythematous, anesthetic plaques on the trunk and upper limbs. He was treated with paucibacillary multidrug therapy (PB-MDT) for 6 months. At the end of 6 months, he had persistent erythema and induration in the plaque. The next step of action recommended by the World Health Organization (WHO) in such a patient is:
Which one of the following statements is correct regarding leprosy?
Leprosy Indian Medical PG Practice Questions and MCQs
Question 1: Asymmetrical nerve thickening with several hypoesthetic macules on skin indicates which stage of leprosy:
- A. Tuberculoid leprosy
- B. Borderline lepromatous
- C. Borderline borderline leprosy
- D. Borderline tuberculoid (Correct Answer)
Explanation: ***Borderline tuberculoid (BT)*** - This stage is characterized by **prominent asymmetrical nerve thickening**, which is a hallmark feature distinguishing it from other borderline forms. - Patients typically present with **several (5-10 or more) asymmetrically distributed hypoesthetic macules or plaques** with well-defined borders, reflecting a strong but not complete cell-mediated immune response. - The combination of asymmetrical nerve involvement with multiple skin lesions is **classic for BT leprosy**, making it more stable than BB and with more lesions than pure TT. *Tuberculoid leprosy (TT)* - Characterized by **very few skin lesions (1-5)**, typically solitary or up to 5 well-demarcated hypopigmented or erythematous macules with complete anesthesia. - While asymmetrical nerve thickening occurs, the key differentiator is the **fewer number of lesions** - "several" macules suggests more than the typical TT presentation. *Borderline borderline (BB)* - Represents the **most unstable form** in the borderline spectrum, with numerous (often 10-30) moderately defined lesions. - Nerve involvement is present but **less prominently asymmetrical** than in BT, with features intermediate between tuberculoid and lepromatous poles. - The emphasis on "asymmetrical nerve thickening" in the question stem points away from BB toward the tuberculoid end of the spectrum. *Borderline lepromatous (BL)* - Marked by **many poorly defined lesions (often >30)** that are becoming more **symmetrically distributed**. - Nerve thickening is less prominent and **more symmetrical** than in BT or BB, reflecting a weaker cell-mediated immune response. - The asymmetrical pattern described in the question is not characteristic of BL.
Question 2: What is the first symptom of leprosy?
- A. Decreased vibration & position sense
- B. Decreased pain (Correct Answer)
- C. Decreased temperature
- D. Decreased light touch
Explanation: Decreased pain - Leprosy primarily targets Schwann cells in peripheral nerves, leading to sensory loss [1]. - The sensation of pain is typically affected earliest, often presenting as areas of numbness [1]. Decreased vibration & position sense - These sensations are typically carried by larger myelinated fibers, which tend to be affected later in the disease progression of leprosy. - While eventually involved, they are not usually the first symptom of sensory loss. Decreased temperature - Temperature sensation is also an early modality affected in leprosy, as it's carried by small, unmyelinated or thinly myelinated fibers [1]. - However, pain is often cited as the very first sensory loss, even preceding temperature changes in some cases. Decreased light touch - Light touch sensation is generally an early loss, similar to pain and temperature, due to damage to nerve fibers in the skin. - But, when distinguishing the absolute first symptom, pain perception often shows impairment even before light touch in affected areas.
Question 3: Ridley-Jopling classification includes all except:
- A. Neuritic (Correct Answer)
- B. Tuberculoid
- C. Borderline borderline
- D. Lepromatous leprosy
Explanation: ***Neuritic*** - The Ridley-Jopling classification focuses on the **polar spectrum** of immune response in leprosy and doesn't include "neuritic" as a distinct classification type within this framework. - While nerve involvement is a hallmark of leprosy, the classification system categorizes patients based on their **clinical and histopathological features** reflecting the host's immune response to *Mycobacterium leprae*. *Tuberculoid* - This is one of the **five main classifications** in the Ridley-Jopling spectrum, representing the pole with a strong cell-mediated immune response. - Characterized by **few lesions**, well-demarcated, and often associated with significant **nerve damage**. *Borderline borderline* - This represents the **mid-spectrum** between tuberculoid and lepromatous poles, indicating an unstable immune response. - Patients in this category often show features of both more resistant and more susceptible forms of the disease, with **moderately numerous lesions** and variable nerve involvement. *Lepromatous leprosy* - This is the other **polar extreme** of the Ridley-Jopling classification, characterized by a weak or absent cell-mediated immune response. - Patients have **numerous, diffuse lesions** with high bacterial loads and widespread nerve damage, though less severe clinically than tuberculoid leprosy initially.
Question 4: A 35-year-old woman presents with hypopigmented and anesthetic patches on her arms, and a positive skin smear for acid-fast bacilli. What is the most likely diagnosis?
- A. Psoriasis
- B. Leprosy (Correct Answer)
- C. Vitiligo
- D. Pityriasis versicolor
Explanation: ***Leprosy*** - The presence of **hypopigmented and anesthetic patches** is pathognomonic for leprosy, indicating nerve involvement - A **positive skin smear for acid-fast bacilli** directly confirms the presence of *Mycobacterium leprae*, the causative agent - This combination of anesthesia with skin lesions and AFB positivity is diagnostic *Psoriasis* - Psoriasis presents with **red, scaly plaques** with well-demarcated borders, typically on extensor surfaces - Does not cause **anesthesia** and is not associated with acid-fast bacilli - Auspitz sign may be present (pinpoint bleeding on scale removal) *Vitiligo* - Causes **complete depigmentation (white patches)** due to melanocyte destruction, not hypopigmentation - Patches are **not anesthetic** - sensation remains intact - An **autoimmune condition** with no involvement of acid-fast bacilli *Pityriasis versicolor* - A **superficial fungal infection** (Malassezia species) causing hypo- or hyperpigmented patches with fine scaling - Patches are **not anesthetic** and maintain normal sensation - **Skin smear shows yeast and hyphae** ("spaghetti and meatballs" appearance), not acid-fast bacilli
Question 5: Moth-eaten alopecia is seen with:
- A. Cylindroma
- B. Syphilis (Correct Answer)
- C. Fungal infection
- D. Leprosy
Explanation: ***Syphilis*** - **Moth-eaten alopecia** is a characteristic but non-specific finding in **secondary syphilis**, occurring due to immune-mediated inflammation targeting hair follicles. - It presents as patchy, non-scarring hair loss, predominantly on the scalp, eyebrows, and beard area. *Cylindroma* - **Cylindroma** is a benign adnexal tumor of the skin, typically presenting as multiple fleshy nodules on the scalp and face. - It is not associated with hair loss patterns like moth-eaten alopecia; rather, large lesions can cause pressure atrophy of hair follicles leading to localized hair loss. *Fungal infection* - **Fungal infections** of the scalp, such as tinea capitis, typically cause patches of **scaling, erythema, and broken hairs**, sometimes leading to **black dot tinea**. - While they can cause patchy hair loss, the description of "moth-eaten" is not the characteristic presentation for fungal infections. *Leprosy* - **Leprosy** can cause hair loss, particularly loss of the **lateral eyebrows** (madarosis) and body hair. - This hair loss is typically due to nerve damage leading to atrophy of hair follicles or direct granulomatous infiltration, not diffuse patchy "moth-eaten" alopecia.
Question 6: A patient was diagnosed to have single skin lesion of Leprosy without any AFB positive bacteria from the scrapings. What should be the treatment of this patient according to latest guidelines?
- A. (Rifampicin + Dapsone) for 12 months
- B. (Rifampicin + Dapsone + Clofazamine) for 6 months
- C. (Rifampicin + Dapsone + Clofazamine) for 12 months
- D. (Rifampicin + Dapsone) for 6 months (Correct Answer)
Explanation: ***(Rifampicin + Dapsone) for 6 months*** - This regimen is the standard **Multi-Drug Therapy (MDT)** for **paucibacillary (PB) leprosy**, which is characterized by a **single skin lesion** and **negative acid-fast bacilli (AFB)** on scrapings. - The 6-month duration is effective in eradicating the infection with high cure rates and low relapse rates. * (Rifampicin + Dapsone) for 12 months* - This 12-month regimen is unnecessarily prolonged for paucibacillary leprosy, increasing the risk of side effects and reducing patient adherence without additional clinical benefit compared to the 6-month regimen. - While Rifampicin and Dapsone are correct drugs for PB leprosy, the duration is not aligned with current WHO guidelines for this specific presentation. * (Rifampicin + Dapsone + Clofazamine) for 6 months* - The addition of **Clofazamine** makes this the regimen for **multibacillary (MB) leprosy**, which presents with multiple skin lesions or positive AFB smears. - This patient's presentation of a **single lesion** and **negative AFB** clearly indicates paucibacillary leprosy, for which Clofazamine is not typically included. * (Rifampicin + Dapsone + Clofazamine) for 12 months* - This is the standard regimen for **multibacillary (MB) leprosy**, due to the presence of Clofazamine and the 12-month duration. - It is not appropriate for a patient with a **single, AFB-negative lesion**, as this presentation denotes paucibacillary leprosy requiring a shorter, two-drug treatment.
Question 7: A 53 year-old male presented with erythematous, edematous plaques on his face over pre-existing hypoesthetic patches. He has been experiencing pain for the last 10 days and has been on multibacillary multidrug therapy (MBMDT) for leprosy for the past two months. What is the most likely diagnosis based on the image?
- A. Type 1 Lepra reaction (Correct Answer)
- B. Erythema Nodosum Leprosum (ENL)
- C. Cellulitis of the face
- D. Erysipelas
Explanation: ***Type 1 Lepra reaction*** - The patient presents with **erythematous, edematous plaques on pre-existing hypoesthetic patches** on the face, along with pain and current treatment with **multibacillary multidrug therapy (MBMDT)**. This clinical picture is classic for a type 1 lepra reaction, which is a **delayed-type hypersensitivity reaction** to *Mycobacterium leprae* antigens, often seen during or after treatment. - The image shows significant **facial edema** and **erythema**, particularly around the eyes and nose, consistent with the acute inflammation of a type 1 reaction affecting existing skin lesions and nerves, leading to pain. *Erythema Nodosum Leprosum (ENL)* - ENL is a **Type 2 lepra reaction**, characterized by the appearance of **painful, tender, erythematous nodules** over normal skin, often affecting the limbs and trunk, not typically pre-existing hypoesthetic patches. - It is an **immune complex-mediated reaction** and usually presents more acutely with systemic symptoms like fever and malaise, along with the characteristic nodules, which are not primarily visible in the photograph as widespread edematous plaques. *Cellulitis of the face* - Cellulitis is a **bacterial infection** of the deep dermis and subcutaneous tissue, presenting as a **spreading, warm, red, tender area** with poorly defined borders, often associated with fever and lymphadenopathy. - While there is erythema and edema, the chronic nature of the underlying hypoesthetic patches, the patient's history of leprosy, and the specific distribution suggest a reaction related to leprosy rather than a typical acute bacterial infection. *Erysipelas* - Erysipelas is a **superficial bacterial skin infection**, typically caused by *Streptococcus pyogenes*, characterized by a **sharply demarcated, raised, red, warm, and tender plaque**, often on the face, with characteristic "peau d'orange" texture. - Although it causes facial erythema and edema, the clearly defined borders of erysipelas are not evident, and the association with pre-existing hypoesthetic patches in a leprosy patient points more strongly towards a lepra reaction.
Question 8: With reference to lepromin test, which one of the following statements is correct?
- A. Lepromin test is strongly positive in tuberculoid leprosy (Correct Answer)
- B. It can be used as a diagnostic test
- C. Its interpretation is done within 24 hours
- D. It is not affected by BCG vaccine
Explanation: ***Lepromin test is strongly positive in tuberculoid leprosy*** - In **tuberculoid leprosy**, the immune system mounts a strong cell-mediated response against *Mycobacterium leprae*, leading to a strongly positive lepromin reaction. - A positive lepromin test indicates a good host immune response and is associated with the **paucibacillary** forms of the disease. *It can be used as a diagnostic test* - The lepromin test is not a diagnostic tool for leprosy; it primarily assesses the host's **cell-mediated immunity** to *Mycobacterium leprae* antigens. - Diagnosis of leprosy relies on **clinical signs**, **skin smears** for acid-fast bacilli, and histopathological examination, not the lepromin test. *Its interpretation is done within 24 hours* - The lepromin test interpretation involves two phases: the **Fernandez reaction** (early reaction at 24-48 hours) and the **Mitsuda reaction** (late reaction at 3-4 weeks). - The most significant and commonly referred result, the **Mitsuda reaction**, is read at **3 to 4 weeks** after injection. *It is not affected by BCG vaccine* - The **BCG vaccine**, which is used to prevent tuberculosis, can induce some cross-reactivity and lead to a positive lepromin test in individuals who have received it. - This cross-reactivity can sometimes confound the interpretation of the lepromin test, as both mycobacteria share common antigens.
Question 9: A patient with leprosy had slightly erythematous, anesthetic plaques on the trunk and upper limbs. He was treated with paucibacillary multidrug therapy (PB-MDT) for 6 months. At the end of 6 months, he had persistent erythema and induration in the plaque. The next step of action recommended by the World Health Organization (WHO) in such a patient is:
- A. Continue Dapsone alone for another 6 months
- B. Biopsy the lesion to document activity
- C. Continue PB-MDT till erythema subsides
- D. Stop antileprosy treatment (Correct Answer)
Explanation: ***Stop antileprosy treatment*** - The persistence of erythema and induration after completing the recommended 6 months of **paucibacillary multidrug therapy (PB-MDT)** for leprosy does not indicate treatment failure or the need for further antileprosy medication. - These residual skin changes are often due to **post-treatment inflammatory responses** or scarring, and the patient is considered cured or released from treatment, according to **WHO guidelines**. *Continue Dapsone alone for another 6 months* - **Monotherapy** is generally discouraged in leprosy due to the risk of **drug resistance**. - **Dapsone** alone is not the recommended treatment for persistent skin changes after completing a full course of **PB-MDT**. *Biopsy the lesion to document activity* - While a biopsy could confirm persistent inflammation, it is generally **not recommended** by **WHO guidelines** as a routine step after successful completion of **PB-MDT**. - The clinical criteria for cure (completion of full MDT) are usually sufficient, and persistent erythema and induration are not necessarily indicative of **bacteriological activity**. *Continue PB-MDT till erythema subsides* - Extending the duration of **PB-MDT** beyond the recommended 6 months based solely on persistent erythema is not indicated according to **WHO guidelines**. - Prolonged treatment can lead to **increased drug toxicity** without providing additional therapeutic benefit in a patient who has completed the standard regimen.
Question 10: Which one of the following statements is correct regarding leprosy?
- A. Nose is the last site of involvement in lepromatous leprosy
- B. Type 1 Leprosy Reaction is also called erythema nodosum leprosum
- C. 'Lion face' appearance is seen in tuberculoid leprosy
- D. Type 2 Leprosy Reaction is an immune complex mediated syndrome also known as erythema nodosum leprosum (Correct Answer)
Explanation: ***Type 2 Leprosy Reaction is an immune complex mediated syndrome also known as erythema nodosum leprosum*** - **Type 2 Leprosy Reaction (ENL)** is indeed an **immune complex-mediated hypersensitivity reaction** seen in cases of **multibacillary leprosy**, primarily **lepromatous leprosy** patients undergoing treatment. - It presents with painful, tender, red subcutaneous nodules, often associated with fever, malaise, arthralgia, and neuritis due to the deposition of **antigen-antibody complexes**. *Nose is the last site of involvement in lepromatous leprosy* - The **nose** is actually one of the **earliest sites of involvement** in **lepromatous leprosy** due to the preference of *Mycobacterium leprae* for cooler tissues. - Initial nasal involvement can lead to nasal stuffiness, epistaxis, and, in advanced stages, destruction of cartilage leading to a **saddle nose deformity**. *Type 1 Leprosy Reaction is also called erythema nodosum leprosum* - **Erythema Nodosum Leprosum (ENL)** is **Type 2 Leprosy Reaction**, not Type 1. - **Type 1 Leprosy Reaction** (also known as **reversal reaction**) is a **delayed-type hypersensitivity reaction** that typically occurs in borderline forms of leprosy, characterized by inflammation of existing skin lesions and nerves. *'Lion face' appearance is seen in tuberculoid leprosy* - The **"lion face" appearance (leontiasis)** is a characteristic feature of **advanced lepromatous leprosy**, not tuberculoid leprosy. - It results from diffuse skin infiltration, thickening of facial skin, and nodule formation, leading to coarse, pendulous folds and a distorted facial appearance.
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