Tropical Dermatology Practice Questions

Q: What is the treatment for lepra reaction with acute neuritis?

Prednisolone. **Explanation:** The management of lepra reactions (Type 1 and Type 2) depends heavily on the presence of nerve involvement. **Acute neuritis** is a medical emergency in leprosy because it can lead to permanent paralysis and deformity within hours or days. **1. Why Prednisolone is Correct:** Systemic corticosteroids, specifically **Prednisolone**, are the gold standard for treating acute neuritis in both Type 1 (Reversal) and Type 2 (ENL) reactions. Corticosteroids act by reducing intraneural edema and suppressing the cell-mediated immune response that causes nerve damage. Prompt initiation of steroids (usually starting at 40–60 mg/day) is essential to prevent irreversible nerve trunk damage. **2. Why the other options are incorrect:** * **Thalidomide:** While highly effective for severe **Type 2 reactions (ENL)**, it is slow to act on nerve inflammation and is **not** the first-line treatment for acute neuritis. It is also contraindicated in Type 1 reactions and pregnancy. * **Clofazimine:** This drug has anti-inflammatory properties and is used as a steroid-sparing agent in chronic ENL, but its onset of action is too slow (weeks) for the management of acute neuritis. * **Dapsone:** This is a bacteriostatic component of Multi-Drug Therapy (MDT). It has no role in managing acute immunological reactions and can occasionally trigger them. **High-Yield Clinical Pearls for NEET-PG:** * **Type 1 Reaction:** Delayed hypersensitivity (Type IV); seen in BT, BB, BL leprosy. * **Type 2 Reaction (ENL):** Immune complex-mediated (Type III); seen in BL and LL leprosy. * **Silent Neuritis:** Nerve damage occurring without pain or tenderness; also treated with Prednisolone. * **MDT Policy:** Never stop MDT during a lepra reaction; continue the standard regimen alongside steroids.

Q: An 8-year-old boy presents with a 6-month history of an ill-defined, hypopigmented, slightly atrophic macule on the face. What is the most likely diagnosis?

Indeterminate leprosy. **Explanation:** The correct diagnosis is **Indeterminate Leprosy**. In the context of the NEET-PG exam, any solitary, ill-defined, hypopigmented macule in a child living in an endemic area should be considered leprosy until proven otherwise. **Why Indeterminate Leprosy is correct:** Indeterminate leprosy is the earliest clinical stage of the disease. It typically presents as a **single, ill-defined, hypopigmented macule** with minimal or no sensory loss (as nerve damage is not yet advanced). While atrophy is more common in late-stage tuberculoid leprosy, early trophic changes or subtle texture alterations can occur. In pediatric cases, the face is a common site of involvement. **Why other options are incorrect:** * **Pityriasis alba:** Presents as multiple, scaly, hypopigmented patches with fuzzy borders, usually associated with atopy. It does **not** cause atrophy. * **Morphoea (Localized Scleroderma):** While it causes atrophy, the initial stage is usually a violaceous or "lilac" patch that progresses to a firm, ivory-white sclerotic plaque. It is not primarily a hypopigmented macule. * **Calcium deficiency:** This is a common **myth**. Nutritional deficiencies (like Vitamin A or Calcium) do not cause localized, atrophic hypopigmented macules on the face. **Clinical Pearls for NEET-PG:** * **Cardinal Signs of Leprosy:** Hypopigmented/reddish patch with (1) definite loss of sensation, (2) thickened nerves, or (3) positive skin smear for AFB. * **Indeterminate Leprosy Histology:** Shows non-specific lymphocytic infiltration around skin appendages and nerves; Lepra bacilli are rarely found. * **Prognosis:** Most cases of indeterminate leprosy in children self-heal, but some progress to the determinate spectrum (TT, BT, BB, BL, or LL).

Q: What is the drug of choice for Erythema Nodosum Leprosum?

Steroids. **Explanation:** **Erythema Nodosum Leprosum (ENL)**, also known as a **Type 2 Lepra Reaction**, is a Type III hypersensitivity reaction (immune-complex mediated) occurring primarily in Lepromatous (LL) and Borderline Lepromatous (BL) leprosy. **Why Steroids are the Correct Answer:** Systemic **Corticosteroids (Prednisolone)** are the **first-line drug of choice** for managing ENL. They are preferred because they provide rapid control of acute inflammation, stabilize lysosomal membranes, and prevent nerve damage. In the context of NEET-PG, unless the question specifically asks for the "most effective" or "drug for recurrent/chronic ENL," steroids remain the standard initial treatment. **Analysis of Incorrect Options:** * **B. Thalidomide:** While Thalidomide is the **most effective** drug for ENL and the treatment of choice for chronic/recurrent cases, it is not the first-line choice due to its severe **teratogenicity** (phocomelia) and restricted availability. * **C. Clofazimine:** This drug has anti-inflammatory properties and is used as a **steroid-sparing agent** in chronic ENL. However, it has a slow onset of action (takes 4–6 weeks) and is not suitable for acute management. * **D. Aspirin:** Used only for very **mild** cases of ENL to manage pain and fever; it cannot control the systemic immune response in moderate to severe reactions. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Type 2 reaction involves Arthus-type phenomenon with deposition of Ag-Ab complexes and TNF-α release. * **Clinical Feature:** Characterized by tender, evanescent, erythematous nodules, fever, and systemic involvement (neuritis, orchitis, iridocyclitis). * **Thalidomide Contraindication:** Strictly contraindicated in women of childbearing age. * **MDT Status:** During a lepra reaction, **never stop** the Multi-Drug Therapy (MDT).

Q: Which of the following oral structures are not affected in Leprosy?

Gingiva. **Explanation:** Leprosy, specifically the **Multibacillary (Lepromatous)** spectrum, frequently involves the oral cavity due to the systemic dissemination of *Mycobacterium leprae*. The primary factor determining the site of involvement is **temperature**; the bacilli prefer cooler areas of the body. **Why Gingiva is the correct answer:** The **gingiva** is rarely affected in leprosy. While the oral mucosa can harbor lepromas, the gingival tissue is relatively resistant compared to other oral structures. In clinical practice, even in advanced Lepromatous Leprosy (LL), the gingiva remains largely spared, making it the most appropriate "except" choice for this question. **Analysis of Incorrect Options:** * **Hard Palate:** This is the **most common** site of oral involvement in leprosy. It often presents with chronic congestion, followed by the formation of "lepromas" (nodules) which may ulcerate or lead to perforation. * **Soft Palate and Uvula:** These are frequently involved after the hard palate. Infiltration can lead to scarring, fibrosis, and a "shrunken" appearance of the uvula. * **Tongue:** The tongue is a common site for lepromatous lesions, typically presenting as **"Glossitis centralis"** or nodules on the dorsum. It may also show "cobblestone" appearance or macroglossia. **High-Yield Clinical Pearls for NEET-PG:** * **Most common oral site:** Hard Palate. * **Sequence of involvement:** Hard palate > Soft palate > Tongue > Uvula. * **Temperature Sensitivity:** Oral lesions occur because the air passing through the mouth cools the mucosa, creating an environment below $37^\circ C$ favorable for *M. leprae*. * **Facies Leprosa (Bergen Syndrome):** Includes atrophy of the anterior nasal spine, atrophy of the maxillary alveolar process, and endonasal inflammatory changes.

Q: The following presentation is called:

Mycetoma. ***Mycetoma*** - The image displays a foot with **swelling, nodule formation, and draining sinuses** with visible grains, which is characteristic of mycetoma. - Mycetoma is a **chronic, progressive granulomatous disease** of the skin, subcutaneous tissue, fascia, and bone, often affecting the foot. *Black foot disease* - This is a form of **peripheral vascular disease** caused by **chronic arsenic poisoning**, typically leading to **gangrene** and eventually amputation. - The image does not show the typical features of **ischemia or gangrene** associated with Black foot disease. *Myrmecia* - This is a type of **wart or verruca** that is specifically characterized by a **plantar wart with a central core of black dots** (thrombosed capillaries). - The image shows a more widespread inflammatory process with nodules and sinuses, not a localized wart. *Tinea pedis* - Also known as **athlete's foot**, this is a **superficial fungal infection** of the skin of the foot, typically presenting with **scaling, itching, redness, and sometimes blisters**. - The clinical presentation in the image, with deep-seated nodules and draining sinuses, is not consistent with a superficial fungal infection.

Q: A 65-year-old beggar comes to your OPD with following presentation in upper part of foot Gram stain of discharge was performed. All are true about the condition shown except:

Massive inguinal lymphadenopathy. ***Massive inguinal lymphadenopathy*** - Mycetoma typically has **minimal or no lymph node involvement**, even with extensive lesions. - The lack of significant lymphatic spread is a characteristic feature that differentiates it from other chronic inflammatory conditions. *Most common site is dorsum of foot* - The **foot**, particularly the **dorsum**, is indeed the most common site for mycetoma due to trauma and direct inoculation. - This anatomical location is highly exposed to the environment, increasing the risk of spore implantation. *Granules are aggregates of organized vegetative, septate hyphae* - Mycetoma is characterized by the presence of **"granules"** within the lesions, which are indeed **compact aggregates of fungal hyphae** (for eumycetoma) or bacterial filaments (for actinomycetoma). - These granules can be visualized in discharge or biopsy and are crucial for diagnosis and differentiating between eumycetoma and actinomycetoma. *Amphotericin B has limited role in eumycetoma* - **Amphotericin B** is generally **ineffective** against most causes of eumycetoma, which are difficult to treat with antifungals. - Treatment for eumycetoma often requires more aggressive, **long-term therapy with azoles** (e.g., voriconazole, itraconazole) and surgical debridement, highlighting the limited utility of Amphotericin B.

Q: The image shows:

Madura foot. ***Madura foot*** - The image shows multiple **sinuses** and **abscesses** with evidence of pus discharge on a swollen, deformed foot, which is characteristic of **Madura foot** or **mycetoma**. - This condition is a chronic granulomatous infection of subcutaneous tissues, often caused by **fungi (eumycetoma)** or **bacteria (actinomycetoma)**, and typically affects the foot after minor trauma. *Neuropathic ulcer* - **Neuropathic ulcers** are typically well-demarcated, painless ulcers occurring on pressure points of the foot, often surrounded by calloused skin, and usually present as single lesions. - They do not typically present with the widespread inflammatory swelling, multiple sinuses, and granule discharge seen in the image. *Myrmecia* - **Myrmecia** refers to a specific type of common wart caused by **Human Papillomavirus (HPV)**, characterized by a single, large, deep lesion with surrounding smaller satellite warts. - This condition is a dermal lesion and does not involve the widespread tissue destruction, multiple draining sinuses, and swelling associated with Madura foot. *Sporotrichosis* - **Sporotrichosis** is a subcutaneous fungal infection that often presents as a **lymphocutaneous spread**, with a primary ulcer or nodule and a chain of secondary nodules along lymphatic channels. - While it can cause skin lesions, it typically does not present with the extensive osteomyelitis, soft tissue destruction, and characteristic "grains" or sinus tracts seen in advanced Madura foot.

Q: A 12-week pregnant woman on multidrug therapy for leprosy presents with type 2 lepra reaction. What is the treatment of choice for this patient?

Continue MDT and add oral steroids. ***Continue MDT and add oral steroids*** - **Type 2 lepra reactions (erythema nodosum leprosum)** are inflammatory complications of leprosy and require systemic anti-inflammatory treatment. **Oral corticosteroids** are the mainstay for managing these reactions, particularly in pregnant patients where other immunomodulators are contraindicated. - **Multidrug therapy (MDT)** for leprosy should be continued throughout the reaction, even during pregnancy, to ensure eradication of *Mycobacterium leprae* and prevent drug resistance. Interrupting MDT can lead to relapse and increased neurological damage. *Antibiotics* - This option is incorrect because the type 2 lepra reaction is an **immunological complication** of leprosy, not a bacterial infection requiring additional antibiotics beyond the standard MDT. - The symptoms are due to the immune system's response to dying bacteria, not a new or secondary bacterial infection. *Stop MDT and start oral steroids* - Stopping MDT is inappropriate as the underlying **leprosy infection** still needs to be treated to prevent further progression and drug resistance. - While steroids are crucial for managing the reaction, stopping MDT would compromise the **curative treatment** for leprosy. *Thalidomide* - **Thalidomide** is highly effective in treating **erythema nodosum leprosum (ENL)**. - However, it is an absolute **contraindication** during pregnancy due to its severe **teratogenicity**, causing severe birth defects.

Question 1

All the features of peripheral neuritis in a patient with Hansen's disease EXCEPT?

Accepted Answer

Decreased tendon reflexes

Answer

Predominant sensory involvement

Answer

Mutilations

Answer

Peripheral nerve thickening

Question 2

What is the treatment for lepra reaction with acute neuritis?

Accepted Answer

Prednisolone

Answer

Thalidomide

Answer

Clofazimine

Answer

Dapsone

Question 3

An 8-year-old boy presents with a 6-month history of an ill-defined, hypopigmented, slightly atrophic macule on the face. What is the most likely diagnosis?

Accepted Answer

Indeterminate leprosy

Answer

Pityriasis alba

Answer

Morphoea

Answer

Calcium deficiency

Question 4

What is the drug of choice for Erythema Nodosum Leprosum?

Accepted Answer

Steroids

Answer

Thalidomide

Answer

Clofazimine

Answer

Aspirin

Question 5

Which of the following oral structures are not affected in Leprosy?

Accepted Answer

Gingiva

Answer

Tongue

Answer

Hard Palate

Answer

Soft Palate

Question 6

The following presentation is called:

Accepted Answer

Mycetoma

Answer

Black foot disease

Answer

Myrmecia

Answer

Tinea pedis

Question 7

A 65-year-old beggar comes to your OPD with following presentation in upper part of foot Gram stain of discharge was performed. All are true about the condition shown except:

Accepted Answer

Massive inguinal lymphadenopathy

Answer

Most common site is dorsum of foot

Answer

Granules are aggregates of organized vegetative, septate hyphae

Answer

Amphotericin B has limited role in eumycetoma

Question 8

The image shows:

Accepted Answer

Madura foot

Answer

Neuropathic ulcer

Answer

Myrmecia

Answer

Sporotrichosis

Question 9

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?

Accepted Answer

Type 1 Lepra reaction

Answer

Erythema Nodosum Leprosum (ENL)

Answer

Cellulitis of the face

Answer

Erysipelas

Question 10

A 12-week pregnant woman on multidrug therapy for leprosy presents with type 2 lepra reaction. What is the treatment of choice for this patient?

Accepted Answer

Continue MDT and add oral steroids

Answer

Antibiotics

Answer

Stop MDT and start oral steroids

Answer

Thalidomide

Tropical Dermatology — MCQs

Tropical Dermatology — MCQs

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