Cutaneous Manifestations of Malaria — MCQs

10 questions

A patient hailing from Delhi presents with fever, arthralgia, and extensive petechial rash for 3 days. Lab investigations revealed a hemoglobin of 9 g/ dL, a white blood cell count of 9000 cells/mm3, a platelet count of 20000 cells/mm3, and a prolonged bleeding time. The clotting time was normal. What is the most likely diagnosis?

Patient: fever, joint pain, rash. Recent history of mosquito bite. Most likely diagnosis in urban area?

Recrudescences are commonly seen in which type of malaria:

A previously healthy child has sudden onset of red spots on body. There is a history of a preceding viral infection 1-4 weeks before the onset.

Which of the following statements regarding diagnosis of malaria are true?

Patient on anti-TB drugs develops tender nodules on shins. Most likely diagnosis is:

Most common precipitant of contact dermatitis is?

Which of the following drug classes is commonly implicated in causing Stevens-Johnson syndrome?

Cutis marmorata occurs due to exposure to –

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Which of the following conditions is characterized by the sign of the groove?

Cutaneous Manifestations of Malaria Indian Medical PG Practice Questions and MCQs

Question 1: A patient hailing from Delhi presents with fever, arthralgia, and extensive petechial rash for 3 days. Lab investigations revealed a hemoglobin of 9 g/ dL, a white blood cell count of 9000 cells/mm3, a platelet count of 20000 cells/mm3, and a prolonged bleeding time. The clotting time was normal. What is the most likely diagnosis?

A. Dengue (Correct Answer)
B. Malaria
C. Scrub typhus
D. Typhoid

Explanation: Dengue - The combination of **fever, arthralgia, extensive petechial rash**, and severe **thrombocytopenia** (platelet count 20,000/mm³) with **prolonged bleeding time** is highly characteristic of severe dengue infection, especially in an endemic area like Delhi [1]. - While leukocytosis (WBC 9000/mm³) is not typical for dengue (usually causes leukopenia), the other features strongly point to dengue hemorrhagic fever [1]. *Malaria* - Typically presents with **intermittent high fever**, chills, and sweats. While it can cause some thrombocytopenia and anemia, the **extensive petechial rash** is not a characteristic feature. - **Thrombocytopenia** in malaria is usually milder than observed here, and prolonged bleeding time is less common [2]. *Scrub typhus* - Caused by Orientia tsutsugamushi, it is characterized by **fever, headache, myalgia, and a characteristic eschar** (necrotic ulcer) at the bite site, which is not mentioned. - While it can cause rash and some thrombocytopenia, the **petechial rash** and such severe thrombocytopenia with prolonged bleeding time are less typical. *Typhoid* - Presents with **sustained high fever**, headache, bradycardia, and sometimes a **rose spot rash** (maculopapular), which is different from a petechial rash. - Typhoid typically causes **leukopenia** and can lead to gastrointestinal complications like intestinal bleeding, but severe thrombocytopenia and extensive petechiae are not common presenting features.

Question 2: Patient: fever, joint pain, rash. Recent history of mosquito bite. Most likely diagnosis in urban area?

A. Dengue
B. Japanese Encephalitis
C. Malaria
D. Chikungunya (Correct Answer)

Explanation: ***Chikungunya*** - **Chikungunya** is a viral disease transmitted by mosquitoes that commonly presents with **fever**, severe **joint pain** (polyarthralgia), and a **rash**, fitting the patient's symptoms. - Its high prevalence in **urban areas** and recent history of **mosquito bites** make it a strong diagnostic consideration. *Dengue* - While Dengue also causes **fever** [1] and a **rash**, it is more typically associated with **severe muscle and bone pain** ("breakbone fever"), and **hemorrhagic manifestations** or shock, which are not mentioned. - **Joint pain** in dengue is usually less debilitating than in chikungunya. *Japanese Encephalitis* - This is a serious **neurological infection** characterized by **fever**, **headache**, seizures, and altered mental status, rather than prominent joint pain and rash. - It primarily affects the **brain** and is less likely to present with this specific symptom triad. *Malaria* - Malaria is characterized by **cyclic fevers**, chills, sweating, and fatigue, but typically **does not present with a rash** [1] or significant joint pain. - It is caused by a **parasite** transmitted by *Anopheles* mosquitoes, and its clinical picture differs from the described symptoms.

Question 3: Recrudescences are commonly seen in which type of malaria:

A. P. vivax
B. P. falciparum (Correct Answer)
C. P. malariae
D. P. ovale

Explanation: ***P. falciparum*** - **Recrudescence** refers to the reappearance of malaria symptoms after a period of remission, due to the survival and subsequent increase of asexual parasites in the blood [1]. - This is common in *P. falciparum* due to the high parasite burden and its ability to sequester in deep capillaries, evading splenic clearance and developing drug resistance. *P. vivax* - *P. vivax* is known for **relapses**, which are caused by the activation of dormant liver stages called **hypnozoites**, rather than a recrudescence of blood-stage parasites [1]. - Relapses can occur months or years after the initial infection, even after the blood-stage parasites have been cleared. *P. malariae* - *P. malariae* is uniquely characterized by infections that can persist for many years, even decades, causing symptoms of **recrudescence**, although less frequently than *P. falciparum* [1]. - It has a prolonged erythrocytic cycle, which can lead to chronic low-level parasitemia and sporadic symptomatic episodes. *P. ovale* - Similar to *P. vivax*, *P. ovale* also causes **relapses** due to the presence of **hypnozoites** in the liver [1]. - While it can manifest with symptoms similar to *P. vivax*, it is generally less common and causes milder disease.

Question 4: A previously healthy child has sudden onset of red spots on body. There is a history of a preceding viral infection 1-4 weeks before the onset.

A. Dengue fever
B. Hemophilia A
C. Idiopathic thrombocytopenic purpura (Correct Answer)
D. Thrombotic thrombocytopenic purpura

Explanation: ***Idiopathic thrombocytopenic purpura (ITP)*** - This presentation, especially in a previously healthy child with a preceding viral infection 1-4 weeks prior, is highly characteristic of **acute ITP**, leading to **purpuric rash** (red spots). - The preceding viral infection often triggers an autoimmune response causing destruction of **platelets**, resulting in **thrombocytopenia**. *Dengue fever* - Dengue fever typically presents with **acute onset of fever**, **headache**, **myalgia**, and a rash that appears 3-4 days after fever onset, often with a shorter incubation period than 1-4 weeks. - While it can cause petechiae due to **thrombocytopenia**, the symptom constellation does not perfectly align with the scenario, particularly the sudden onset of spots without mention of fever or other acute symptoms. *Hemophilia A* - **Hemophilia A** is a **hereditary bleeding disorder** causing deficits in **Factor VIII**, leading to spontaneous bleeding into joints and muscles, and prolonged bleeding after trauma. - It does not present as sudden onset red spots (petechiae/purpura) following a viral infection but rather as larger **hematomas** or **hemarthroses**, and it's a chronic condition, not typically triggered by recent infection. *Thrombotic thrombocytopenic purpura (TTP)* - TTP is characterized by the **pentad of symptoms**: **fever**, **neurological symptoms**, **renal dysfunction**, **microangiopathic hemolytic anemia**, and **thrombocytopenia**. - While it involves thrombocytopenia and can cause purpura, the patient's presentation lacks the other severe systemic features typically associated with TTP, and it's less commonly triggered by a simple viral infection in children.

Question 5: Which of the following statements regarding diagnosis of malaria are true?

A. Thin blood film is used to determine parasite concentration.
B. As the sensitivity of microscopy is low, it is useful to detect parasite load at high concentrations only.
C. Jaswant Singh Bhattacharya (JSB) Stain is used. (Correct Answer)
D. Thick blood film is used to detect plasmodium species causing infection.

Explanation: ***Correct: Jaswant Singh Bhattacharya (JSB) Stain is used.*** - **JSB stain** is a rapid and effective method for staining malaria parasites in blood films, particularly in resource-limited settings where traditional Romanowsky stains might not be readily available. - Its quick staining time (3-5 minutes) and ease of use make it valuable for prompt diagnosis of malaria. - This is the **most clearly correct** statement as JSB stain is definitively used in malaria diagnosis. *Thick blood film is used to detect plasmodium species causing infection.* - A **thick blood film** is primarily used for **detecting** the presence of malaria parasites due to its higher sensitivity in screening larger volumes of blood (concentrates parasites 20-40 times). - However, it is **not ideal for species identification** due to distorted RBC morphology and lysed red blood cells. - The statement is **misleading** - while thick films detect parasites, they are not the preferred method for determining the **specific species**. *Thin blood film is used to determine parasite concentration.* - This statement is **technically correct** - thin blood films ARE used to determine parasite concentration (parasitemia) and for speciation. - However, in the context of this question, **JSB stain is the better answer** as it is more specifically and uniquely associated with malaria diagnosis, whereas thin films have broader applications. - Thin films allow accurate quantification of parasitemia (parasites/µL or percentage of infected RBCs) and species identification due to preserved RBC morphology. *As the sensitivity of microscopy is low, it is useful to detect parasite load at high concentrations only.* - **Incorrect** - Microscopy, particularly with thick blood films, has **high sensitivity** and is considered the gold standard for malaria diagnosis. - Microscopy can detect parasites at concentrations as low as **50-100 parasites/µL** (approximately 0.001% parasitemia). - While operator-dependent, it is certainly not limited to detecting parasites only at high concentrations.

Question 6: Patient on anti-TB drugs develops tender nodules on shins. Most likely diagnosis is:

A. Sweet syndrome
B. Panniculitis
C. Erythema multiforme
D. Erythema nodosum (Correct Answer)

Explanation: ***Erythema nodosum*** - Erythema nodosum is a common **cutaneous adverse drug reaction** to anti-TB medications, presenting with **tender, erythematous nodules** typically on the shins. - It is a form of **panniculitis** (inflammation of subcutaneous fat) specifically associated with various triggers, including infections and drugs, making it highly probable in this context. *Sweet syndrome* - Sweet syndrome (acute febrile neutrophilic dermatosis) presents with **tender, erythematous plaques and nodules** often associated with fever and leukocytosis. - While it can be drug-induced, it typically involves a more widespread skin eruption and prominent systemic symptoms like **fever**, which are not specified here. *Panniculitis* - Panniculitis is a general term for **inflammation of the subcutaneous fat**, and erythema nodosum is a type of panniculitis. - This option is too broad; while accurate, "Erythema nodosum" is the **most specific and likely diagnosis** given the patient’s presentation in the context of anti-TB drug use. *Erythema multiforme* - Erythema multiforme is characterized by **target lesions** (concentric rings of erythema and edema) and often involves mucous membranes. - The description of **tender nodules on shins** does not fit the characteristic morphology of erythema multiforme.

Question 7: Most common precipitant of contact dermatitis is?

A. Gold
B. Silver
C. Iron
D. Nickel (Correct Answer)

Explanation: ***Nickel*** - **Nickel** is the most frequent cause of **allergic contact dermatitis**, commonly found in jewelry, belt buckles, and zippers. - Exposure leads to a **Type IV hypersensitivity reaction**, characterized by erythema, itching, and vesiculation. *Gold* - While gold can cause contact dermatitis, it is **far less common** than nickel allergy. - Reactions to gold are often seen with prolonged skin contact, such as with jewelry. *Silver* - **Silver** is a **rare cause** of allergic contact dermatitis. - Allergic reactions to silver are typically observed in individuals with extensive exposure, such as jewelers. *Iron* - **Iron** is **not a common precipitant** of contact dermatitis. - Allergic reactions to iron are exceedingly rare, as iron is an essential element found naturally in the body.

Question 8: Which of the following drug classes is commonly implicated in causing Stevens-Johnson syndrome?

A. Antibiotics (Correct Answer)
B. Corticosteroids
C. Antifungals
D. Proton pump inhibitors

Explanation: ***Antibiotics*** - **Antibiotics**, particularly **sulfonamides** (e.g., sulfamethoxazole-trimethoprim) and **beta-lactams** (e.g., penicillins, cephalosporins), are among the most common drug classes implicated in causing **Stevens-Johnson Syndrome (SJS)**. - SJS is a severe **idiosyncratic drug reaction**, and many antibiotics can trigger this immune-mediated response. - **Note:** Other major causative drug classes include **anticonvulsants** (carbamazepine, phenytoin, lamotrigine), **allopurinol**, and **NSAIDs**, but among the options listed, antibiotics are the most commonly implicated. *Corticosteroids* - **Corticosteroids** are typically used in the **treatment** of SJS to suppress the immune response and reduce inflammation, not to cause it. - While they have their own set of side effects, initiating SJS is not one of their known adverse reactions. *Antifungals* - Although some **antifungals** can cause adverse drug reactions, they are **not typically associated** with SJS compared to antibiotics, anticonvulsants, or allopurinol. - The risk of SJS with antifungal medications is generally very low. *Proton pump inhibitors* - **Proton pump inhibitors (PPIs)** are generally well-tolerated and are **rarely implicated** as a cause of SJS. - Their primary side effects are usually gastrointestinal and not severe dermatological reactions.

Question 9: Cutis marmorata occurs due to exposure to –

A. Cold temperature (Correct Answer)
B. Dust
C. Hot temperature
D. Humidity

Explanation: ***Cold temperature*** - **Cutis marmorata** is a physiological response to **cold temperatures**, characterized by a mottled, reticulated vascular pattern on the skin. - This occurs due to **vasoconstriction** of the small arteries and arterioles, alongside **vasodilation** of the venules, creating the characteristic marbled appearance. *Dust* - Exposure to **dust** typically causes **irritation**, allergic reactions, or respiratory issues, such as **dermatitis**, **contact urticaria**, or **asthma**. - It does not directly lead to the characteristic vascular changes seen in cutis marmorata. *Hot temperature* - **Hot temperatures** generally cause **vasodilation** in the skin to facilitate **heat dissipation**, leading to redness and warmth. - This is the opposite physiological response to cutis marmorata, which involves vasoconstriction. *Humidity* - **Humidity** primarily affects **skin hydration** and the rate of perspiration, potentially exacerbating certain skin conditions like **eczema** or **fungal infections**. - High or low humidity does not directly induce the vascular changes that result in cutis marmorata.

Question 10: Which of the following conditions is characterized by the sign of the groove?

A. Lymphogranuloma venereum (Correct Answer)
B. Granuloma inguinale
C. Syphilis
D. Chancroid

Explanation: **Explanation:** **Lymphogranuloma venereum (LGV)** is caused by the **L1, L2, and L3 serovars of *Chlamydia trachomatis***. The "Sign of the Groove" (Greenblatt’s sign) is a pathognomonic clinical finding in the secondary stage of LGV. It occurs when the inguinal and femoral lymph nodes enlarge simultaneously, separated by the rigid **inguinal ligament**. This creates a visible depression or "groove" between the two groups of inflamed lymph nodes. **Analysis of Incorrect Options:** * **B. Granuloma Inguinale (Donovanosis):** Caused by *Klebsiella granulomatis*. It presents with painless, beefy-red, velvety ulcers. It is characterized by "pseudobuboes" (subcutaneous granulation tissue) rather than true lymphadenopathy. * **C. Syphilis:** Primary syphilis presents with a painless, indurated "hard chancre." While it causes bilateral inguinal lymphadenopathy, the nodes are discrete, rubbery, and do not form a groove. * **D. Chancroid:** Caused by *Haemophilus ducreyi*. It presents with painful, soft ulcers and painful inflammatory buboes that are usually unilateral and may suppurate, but they do not form the characteristic groove sign. **High-Yield Clinical Pearls for NEET-PG:** * **Stages of LGV:** Primary (painless papule/ulcer), Secondary (Inguinal syndrome with the Groove sign), and Tertiary (Genito-anorectal syndrome/Elephantiasis). * **Diagnosis:** Frei test (historical), NAAT (current gold standard), and **Donovan bodies** (safety-pin appearance) are seen in Donovanosis, NOT LGV. * **Treatment:** Doxycycline (100 mg BID for 21 days) is the drug of choice for LGV.

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