---

LEPROSY (Hansen's Disease) - Complete Long Case for Dermatology Residency

---

PART 1: DETAILED HISTORY TAKING

Opening Statement

---

A. PRESENTING COMPLAINTS

• Skin patch/lesion with or without numbness
• Thickened nerves
• Weakness of hands or feet
• Deformity of fingers/toes
• Nodules on face/ears/body
• Painless wounds or ulcers on hands/feet

---

B. HISTORY OF PRESENTING ILLNESS

1. Skin Lesions - Ask in detail:

2. Neural Symptoms - Ask systematically:

3. Reactional Episodes:

4. Systemic Review:

---

C. PAST HISTORY

---

D. DRUG HISTORY

• Current medications: MDT blister packs (rifampicin, dapsone, clofazimine)?
• Thalidomide (if given for ENL)
• Corticosteroids (if on reaction management)
• Dapsone hypersensitivity syndrome history
• Allergies to sulfonamides (cross-reactivity with dapsone)

---

E. FAMILY HISTORY

---

F. PERSONAL & SOCIAL HISTORY

---

G. REVIEW OF SYSTEMS (Specific to Leprosy)

• Eyes: redness, photophobia, watering, decreased vision (corneal ulcer from lagophthalmos)
• Nose: stuffiness, epistaxis, collapse of nasal bridge
• Throat: hoarseness
• Musculoskeletal: joint pains, bone pain, pathological fractures (absorption of phalanges in LL)
• Genitourinary: testicular pain/swelling, sexual dysfunction (LL)
• Psychological: depression, anxiety, suicidal ideation (especially due to social stigma)

---

PART 2: CLINICAL EXAMINATION

A. GENERAL EXAMINATION

1. General appearance - well/ill, nutritional status, signs of disability
2. Vital signs - temperature (fever in ENL), pulse, BP
3. BMI / nutritional status (malnutrition impairs immunity)
4. Lymphadenopathy - axillary, inguinal (in MB/LL; also in ENL)
5. Gynecomastia (testicular infiltration in LL)
6. Eye examination (see below in specific examination)

---

B. SPECIFIC SKIN EXAMINATION

Step 1: Count and describe each lesion

• Face (cheeks, forehead, chin)
• Upper limbs (arms, forearms - but NOT axillae)
• Trunk (front and back)
• Buttocks
• Lower limbs (thighs, legs - but NOT groin, perineum, scalp)
• Ears (helix, earlobe) - early nodules in LL
• Eyebrows - madarosis (outer 1/3 loss first in LL)

Step 2: Sensory Testing Over Lesions

1. Touch - Use a wisp of cotton wool; touch lightly
2. Temperature - Use test tubes of hot (~40°C) and cold water; ask patient to differentiate
3. Pain/Pinprick - Use a sterile pin; ask if sharp or blunt

• Temperature is affected first (small fiber neuropathy)
• Light touch next
• Pain last
• Sensory loss in a skin lesion is a cardinal sign of leprosy

Step 3: Sweating Test Over Lesions

• Apply iodine solution to the lesion and normal skin
• Cover with starch powder
• Inject pilocarpine SC or ask patient to exercise
• Normal skin turns dark blue-purple (sweating positive)
• Leprosy lesion remains pale (anhidrosis in lesion area)

---

C. NERVE EXAMINATION - DETAILED

Overview - Nerves Commonly Affected in Leprosy

---

NERVE PALPATION TECHNIQUE

• Use the pads of index and middle fingers
• Roll the nerve gently over the underlying bony/firm structure
• Compare both sides
• Assess: size (thickened?), consistency (firm, soft, nodular, beaded), tenderness, warmth (neuritis)
• Do NOT compress hard - this causes unnecessary pain

---

1. GREAT AURICULAR NERVE (GAN)

• Ask the patient to turn the head to the opposite side (this stretches the SCM and makes the nerve more prominent)
• Palpate the posterior surface of the SCM at the junction of its upper and middle third
• The nerve runs obliquely across the muscle surface from posterior to anterior-superior

---

2. ULNAR NERVE

• Primary site: At the medial epicondyle - patient's elbow flexed 90°, palpate in the groove between medial epicondyle and olecranon. Roll the nerve gently.
• Secondary site: Mid-upper arm, at the medial intermuscular septum

• Hand of Benediction sign / Claw hand: Clawing of 4th and 5th fingers (ring and little fingers) due to weakness of 3rd and 4th lumbricals (also intrinsic minus hand). Ask patient to straighten all fingers - if they cannot fully extend the ring and little finger IP joints, ulnar claw is present.
• Froment's sign: Ask patient to hold a piece of paper between thumb and index finger. Weakness of adductor pollicis (ulnar) causes thumb to flex at IP joint (FPL compensates). Positive = flexion of thumb IP joint.
• Card test: Ask patient to hold card between adjacent fingers (abduction/adduction) - weakness of interossei
• Interossei wasting: Look for guttering (hollowing) between metacarpal heads on the dorsum of hand
• Hypothenar wasting: Flat or wasted hypothenar eminence (abductor digiti minimi)
• Grip strength: Reduced due to intrinsic muscle weakness

• Medial 1.5 fingers (little and half of ring finger) - dorsal and palmar aspects
• Medial border of hand and palm

---

3. MEDIAN NERVE

• At the wrist: palpate medial to the tendon of flexor carpi radialis (FCR) and lateral to palmaris longus at the wrist crease
• Also palpable in the forearm between FDS and FDP

• Pen cap test / Thumb-index pinch test: Ask to make a circle with thumb and index finger. Weakness of FPL and FDP index (anterior interosseous branch) causes rectangular shape rather than circular (OK sign test).
• Thenar wasting: Flat thenar eminence - loss of abductor pollicis brevis
• Opposition test: Ask to oppose thumb to little finger - lost in median nerve palsy
• Bottle sign: Patient cannot fully oppose thumb and index finger around a bottle - indicative of thenar wasting

• Radial 3.5 fingers (thumb, index, middle, radial half of ring)
• Thenar eminence

---

4. RADIAL NERVE (Cutaneous Branch)

• Wrist extension, finger extension
• Wrist drop if radial nerve trunk involved

---

5. COMMON PERONEAL NERVE (Lateral Popliteal Nerve)

• Neck of fibula: The nerve wraps around the fibular neck from the posterior aspect of the knee to the anterior aspect. Place fingers just below and behind the fibular head and roll gently.
• The nerve is most superficial here and this is the most common site of leprosy involvement.

• Foot drop: Ask patient to walk - high-stepping gait
• Dorsiflexion: Ask patient to pull toes up toward the shin against resistance
• Eversion: Ask patient to evert the foot against resistance
• Toe extension: Ask to extend toes

• Dorsum of foot (superficial peroneal)
• First web space (deep peroneal)

---

6. POSTERIOR TIBIAL NERVE

• Behind the medial malleolus between the medial malleolus and the Achilles tendon
• The nerve lies posterior to the artery (remember: NAV - Nerve, Artery, Vein - posterior to anterior behind medial malleolus)

• Intrinsic foot muscles - toe flexion, abduction/adduction of toes
• Plantar flexion (mainly tibial nerve, but also S1)

• Plantar surface of foot (medial and lateral plantar nerves)
• Medial and lateral toes
• Heel (calcaneal branches)

---

7. FACIAL NERVE

• Ask patient to close eyes tightly - look for incomplete closure (lagophthalmos)
• Look for Bell's phenomenon (eye rolls up when trying to close - protective reflex)
• Measure the gap of lagophthalmos in mm
• Ask to raise eyebrows (temporal branch), smile (buccal/zygomatic), show teeth (buccal/marginal mandibular)
• Corneal reflex - reduced/absent if trigeminal also involved

---

8. SUPRA-ORBITAL NERVE (Branch of Trigeminal V1)

---

D. EYE EXAMINATION

1. Visual acuity - Snellen chart
2. Cornea - look for corneal anesthesia (touch with wisp of cotton wool), pannus, ulceration, scarring
3. Iris/pupil - signs of iritis (perilimbal injection, constricted pupil, posterior synechiae, irregular pupil), beaded anterior chamber (pearls = lepromas)
4. Eyelids - lagophthalmos, madarosis, ectropion, entropion
5. Conjunctiva - tarsal nodules
6. Sclera - scleritis (in ENL)
7. Pupillary reactions - sluggish pupil if autonomic involvement

---

E. EAR EXAMINATION

• Inspect the helix and earlobe - early lepromas in LL appear here
• Thickening/nodularity of earlobes
• Palpate for GAN thickening

---

F. NOSE EXAMINATION

• Collapse of nasal bridge (saddle nose) - destruction of nasal septum cartilage in LL
• Nasal mucosa: epistaxis, septal perforation
• Atrophied nostrils

---

G. HAND EXAMINATION

1. Look (dorsum first):
   • Claw hand (4th and 5th finger) - ulnar nerve
   • Ape thumb deformity - median nerve (thenar wasting, thumb falls back in same plane as fingers)
   • Combined claw (all fingers) - both ulnar and median
   • Wrist drop - radial nerve
   • Trophic changes: dry skin, fissures, ulcers (especially on digits)
   • Shortening/absorption of fingers (LL, advanced)
   • Contractures
   • Interosseous guttering on dorsum of hand
2. Look (palmar surface):
   • Thenar wasting (median)
   • Hypothenar wasting (ulnar)
   • Palmar fissures/trophic changes
3. Feel: Warmth, tenderness, swelling
4. Move: As described in nerve examination section

---

H. FOOT EXAMINATION

1. Inspection:
   • Foot drop - dropped posture, high stepping gait
   • Trophic ulcers: usually on pressure points (ball of foot, heel, metatarsal heads)
   • Fissures, callus
   • Absorption/shortening of toes
   • Claw toes (intrinsic muscle weakness)
2. Sensation: Test dorsum and plantar surface; monofilament if available
3. Pulses: Peripheral vascular disease mimics and coexists in some patients

---

I. MUSCULOSKELETAL EXAMINATION

• Charcot joints: painless deformity of joints (rare, due to repeated trauma without sensation)
• Wasting of intrinsic hand and foot muscles
• Contractures of digits
• Shortening and auto-amputation of digits (LL - advanced)

---

PART 3: INVESTIGATIONS

---

1. SLIT-SKIN SMEAR (SSS) - MOST IMPORTANT INVESTIGATION

1. Select sites: both earlobes, chin, forehead, and the edge of the most active skin lesion (total 4-6 sites)
2. Clean the site with spirit and let dry
3. Make a small fold of skin between thumb and forefinger - this blanches the area and reduces bleeding
4. Use a fresh disposable lancet or scalpel (#15 blade)
5. Make a small incision 5mm long and 2-3mm deep in the dermis (NOT too deep - dermis only)
6. Scrape the walls of the incision firmly to obtain tissue fluid and cells
7. Spread the material evenly on a glass slide (circular smear, 5-7mm diameter)
8. Allow to air dry, fix with methanol
9. Stain with Ziehl-Neelsen (modified - using 5% H2SO4 not HCl) or Fite-Faraco stain
10. Examine under oil immersion (100x)

• Bacillary Index (BI): Logarithmic scale 0-6+ (Ridley's scale)
  • 0 = no bacilli in 100 fields
  • 1+ = 1-10 bacilli in 100 fields
  • 2+ = 1-10 bacilli in 10 fields
  • 3+ = 1-10 bacilli in 1 field
  • 4+ = 10-100 bacilli per field
  • 5+ = 100-1000 bacilli per field
  • 6+ = >1000 bacilli / clumping per field
• Morphological Index (MI): Percentage of solid-staining (viable) bacilli. Normal bacteria stain solid (viable, infective). Fragmented/granular = dead bacilli (good response to treatment).
• Globi: Round clumps of bacilli - seen in LL (Virchow's lepra cells)

• Positive SSS = definitive diagnosis; confirms MB leprosy
• Negative SSS does not exclude leprosy (PB cases are negative)
• Used for classification into PB/MB
• MI used to monitor treatment response (solid forms decrease with effective therapy)
• BI used to monitor for relapse (should fall by 1 unit/year on MDT)

---

2. SKIN BIOPSY AND HISTOPATHOLOGY

1. Select the active border of the most representative lesion
2. Include normal skin and transition zone at the edge
3. Full-thickness punch biopsy (4-6mm), ensure it reaches subcutaneous fat
4. Fix in 10% formalin
5. Request Fite-Faraco stain (optimal for M. leprae - uses peanut oil/xylene in decolorization step to preserve AFB staining, unlike standard Ziehl-Neelsen which may decolorize leprae organisms)
6. Also request H&E stain and S-100 stain (to highlight nerve involvement)

---

3. LEPROMIN (MITSUDA) TEST

• Integral lepromin (Dharmendra antigen): heat-killed M. leprae
• Mitsuda lepromin: crude preparation from infected human/armadillo tissue

1. Inject 0.1 mL of standard lepromin intradermally on the flexor aspect of forearm
2. Read results at two time points:
   • Fernandez reaction (early): Read at 24-48 hours - indicates delayed hypersensitivity (like tuberculin)
   • Mitsuda reaction (late): Read at 28 days - the main clinically used reading

• Correlates with CMI status and position on Ridley-Jopling spectrum
• TT: Strongly positive (++/+++)
• BT: Positive (+/++)
• BB: Weakly positive or negative
• BL: Negative
• LL: Strongly negative
• NOT a diagnostic test (positive in BCG vaccinated, tuberculosis contacts)
• Useful as a prognostic indicator
• Not routinely done in Nepal; used in research/classification settings

---

4. SENSORY TESTING - FORMAL METHODS

• Nylon filaments of graded stiffness
• Apply perpendicular to skin until filament bends; patient reports sensation
• Map areas of sensory loss

---

5. VOLUNTARY MUSCLE TESTING (VMT)

• Ulnar nerve: First dorsal interosseous, abductor digiti minimi, hypothenar muscles
• Median nerve: Abductor pollicis brevis (APB) - ask patient to point thumb straight up perpendicular to palm and resist downward pressure
• Radial nerve: Wrist extensors, finger extensors
• Common peroneal: Tibialis anterior (dorsiflexion), extensor hallucis longus, peronei (eversion)
• Posterior tibial: Intrinsic foot muscles
• Facial nerve: Orbicularis oculi, orbicularis oris, frontalis

---

6. WHO DISABILITY GRADING

---

7. NERVE CONDUCTION STUDIES (NCS) / ELECTROMYOGRAPHY

• Objective assessment of large fiber neuropathy
• Confirms axonal vs. demyelinating pattern
• Useful in pure neural leprosy (no skin lesions)
• May show abnormalities before clinical deficits appear
• Not routinely available at district level in Nepal

---

8. HIGH-RESOLUTION ULTRASONOGRAPHY (HRUS) OF NERVES

• A 2026 systematic review [PMID: 41773898] confirms HRUS is accurate for detecting peripheral nerve enlargement in leprosy
• Shows increased cross-sectional area of affected nerves
• Ulnar nerve at medial epicondyle: enlargement starts at the ulnar sulcus, reaches maximum 4 cm above medial epicondyle
• Non-invasive, real-time assessment; useful in pure neural leprosy
• Increasingly available at teaching hospitals in Nepal

---

9. PCR FOR M. LEPRAE

• Detects M. leprae DNA in tissue, blood, skin
• Useful in pure neural leprosy or pauci-bacillary cases where SSS and biopsy are negative
• Sensitivity ~50% in PB cases; higher in MB
• Not widely available in Nepal; used at reference centers

---

10. SEROLOGY

• Anti-PGL-1 (phenolic glycolipid 1) antibody: Positive in 90% of LL, only 50% of TT
• Fluorescent Leprosy Antibody (FLA-ABS) test
• Poor sensitivity in PB leprosy
• Not routinely used for diagnosis; mainly for research/contact screening

---

11. ADDITIONAL INVESTIGATIONS

---

PART 4: DIFFERENTIAL DIAGNOSIS

Primary Differentials for Hypopigmented/Anesthetic Patch:

Primary Differentials for Thickened Nerves:

For Nodular Lesions in LL:

For Erythematous Lesions (Borderline):

For ENL (Type 2 Reaction):

---

PART 5: MANAGEMENT AS PER NEPAL GUIDELINES

---

A. CLASSIFICATION FOR TREATMENT

---

B. MDT REGIMEN - NEPAL/WHO STANDARD (Updated 2024)

PB-MDT (1-5 lesions) - Duration: 6 months

MB-MDT (>5 lesions) - Duration: 12 months

---

C. IMPORTANT COUNSELING POINTS BEFORE MDT

1. Rifampicin: Turns urine, sweat, tears orange-red - normal; soft contact lenses staining; hepatotoxicity (monitor LFTs)
2. Clofazimine: Causes skin discoloration (brownish-black, especially in darker skin); takes months to years to resolve after stopping; also causes GI discomfort, ichthyosis
3. Dapsone: May cause hemolytic anemia - test G6PD before starting; methemoglobinemia; peripheral neuropathy (uncommon); dapsone hypersensitivity syndrome (rare, first 6 weeks)
4. Explain that the disease is curable and MDT kills bacteria within days - patient is non-infectious very quickly after starting treatment
5. Address stigma - leprosy is NOT highly contagious; routine household contact is generally safe

---

D. MANAGEMENT OF LEPROSY REACTIONS

Type 1 Reaction (Reversal Reaction)

• Indication for treatment: Nerve function impairment OR severe skin inflammation
• First-line treatment: Prednisolone 40-60 mg/day (1 mg/kg/day), taper over 6 months minimum
• If no nerve involvement: NSAIDs may be sufficient for skin inflammation alone
• Continue MDT throughout reactions - do not stop MDT
• Monitor nerve function regularly during and after steroid treatment
• Long-term steroid: add methotrexate 7.5-15 mg weekly as steroid-sparing agent

Type 2 Reaction (Erythema Nodosum Leprosum - ENL)

• Mild: NSAIDs, chloroquine
• Moderate to severe: Prednisolone 40-60 mg/day; taper as symptoms resolve
• Severe/recurrent ENL: Thalidomide 100-400 mg/day (NOT in women of childbearing age - teratogenic)
• Continue MDT throughout ENL treatment
• Treat associated features: fever (antipyretics), orchitis (scrotal support), iritis (topical steroids + atropine, ophthalmology referral)
• Clofazimine has anti-inflammatory properties - increase to 300 mg/day during ENL (may reduce steroid dependence)

---

E. MANAGEMENT OF DISABILITIES

Eye Care (Grade 1/2):

• Lagophthalmos: Artificial tears; taping the eyelid at night; protective glasses; if severe - lateral tarsorrhaphy
• Iritis/iridocyclitis: Topical steroids + atropine (ophthalmology referral urgent)
• Regular ophthalmologic review
• Patient education: visual inspection of eyes daily; report redness or pain immediately

Hand Care:

• Soaking in warm water + moisturizing oils daily (clofazimine causes dry skin)
• Protective footwear and gloves
• Wound care for trophic ulcers (debridement, dressing)
• Physiotherapy: passive and active exercises to prevent contracture
• Splinting for claw hand
• Reconstructive surgery if stable disability: tendon transfers for claw hand, foot drop correction

Foot Care:

• Custom footwear (molded shoes with soft insoles)
• Daily inspection of feet; patient education (they cannot feel injuries)
• Plantar ulcer management: complete offloading; regular debridement; wound care

---

F. POST-EXPOSURE PROPHYLAXIS (SDR-PEP)

• Single Dose Rifampicin (SDR-PEP): Given to household and close contacts of newly diagnosed leprosy patients
• Adult dose: Rifampicin 600 mg single dose
• Reduces risk of developing leprosy by approximately 57% in contacts
• Exclusion criteria: Already on rifampicin-containing treatment (e.g., active TB), known rifampicin allergy, children <2 years
• Nepal National Program mandates contact screening and SDR-PEP as per 2021-2025 strategy

---

G. CONTACT TRACING AND SCREENING (Nepal Guidelines)

1. Identify and examine all household contacts (those living in the same house)
2. Identify and examine close social contacts (regular close contact for >6 months)
3. Screen for skin patches, nerve thickening, and sensory loss
4. Offer SDR-PEP to eligible contacts
5. Register contacts in the Nikusth online platform (Nepal's digital leprosy surveillance system)
6. Re-examine contacts annually for 5 years

---

H. BCG VACCINATION

• BCG provides 28-60% protection against leprosy
• Already part of Nepal's routine immunization program
• Additional BCG dose used in some high-burden provinces as adjunct prophylaxis

---

I. DISABILITY PREVENTION AND REHABILITATION

• Regular disability assessment at each follow-up visit
• Teaching self-care (skin moisturization, daily inspection, protective footwear)
• Physiotherapy referral
• Psychological support and counseling
• Vocational rehabilitation
• Leprosy welfare allowance (provided by Government of Nepal to registered disabled patients)
• Anti-stigma education for community and family

---

J. FOLLOW-UP SCHEDULE

---

PART 6: VIVA QUESTIONS AND QUIZ (WITH ANSWERS)

---

SECTION A: VIVA QUESTIONS

---

1. Hypopigmented or erythematous skin patch with definite sensory loss
2. Thickened/enlarged peripheral nerve with sensory loss and/or motor weakness
3. Positive slit-skin smear (SSS) for acid-fast bacilli

---

---

---

• TT (Tuberculoid): Strong cell-mediated immunity (CMI); few well-formed epithelioid granulomas; no bacilli; IFN-γ and IL-2 dominant; lepromin strongly positive
• BT (Borderline Tuberculoid): Good CMI; similar to TT with grenz zone
• BB (Mid-Borderline): Unstable; moderate CMI; foamy macrophages; moderate bacilli; "punched-out" lesions
• BL (Borderline Lepromatous): Poor CMI; foamy histiocytes; many bacilli; lepromin negative
• LL (Lepromatous): No effective CMI; Virchow's foam cells; abundant globi; IL-4, IL-5, IL-10 dominant (Th2 response); lepromin strongly negative

---

---

---

1. Urgent ophthalmology referral
2. Topical corticosteroid eye drops (e.g., prednisolone acetate 1% hourly initially)
3. Cycloplegic drops (atropine 1%) to dilate pupil, prevent posterior synechiae
4. Systemic corticosteroids if severe
5. Continue MDT
6. Treat underlying ENL with prednisolone/thalidomide

---

---

• Absent in TT: Granulomas extend up to the epidermis - reflects vigorous CMI
• Present in BT, BL, LL: Degree of grenz zone widens toward the lepromatous pole
• Significance: Differentiates TT from BT histologically; important in classification; reflects the immune status of the host

---

---

1. Ask the patient to close both eyes gently
2. Observe if there is a gap between upper and lower eyelids
3. Measure the gap in mm using a ruler
4. Check for Bell's phenomenon (protective upward rolling of eye when trying to close)
5. Check corneal sensation (V1 - trigeminal) with wisp of cotton
6. Grade:
   • Grade 1 disability: Lagophthalmos present but no corneal damage
   • Grade 2 disability: Corneal ulceration, opacity, or vision <6/60

---

---

---

---

• 0 = No bacilli in 100 oil immersion fields
• 1+ = 1-10 bacilli in 100 fields
• 2+ = 1-10 bacilli in 10 fields
• 3+ = 1-10 bacilli per field
• 4+ = 10-100 bacilli per field
• 5+ = 100-1000 bacilli per field
• 6+ = >1000 bacilli per field or many clumps (globi)

---

SECTION B: MCQ QUIZ (WITH ANSWERS)

---

• A) Ulnar nerve
• B) Great auricular nerve
• C) Median nerve
• D) Common peroneal nerve

---

• A) 24 hours
• B) 48-72 hours
• C) 28 days
• D) 14 days

---

• A) IFN-γ and IL-2
• B) IL-4, IL-5, IL-10
• C) TNF-α and IL-12
• D) IL-17 and IL-22

---

• A) MB leprosy
• B) PB leprosy
• C) Indeterminate leprosy
• D) Histoid leprosy

---

• A) Type IV (delayed) hypersensitivity
• B) Type I (IgE-mediated) hypersensitivity
• C) Type III (immune complex) hypersensitivity
• D) Type II (cytotoxic antibody) hypersensitivity

---

• A) Ziehl-Neelsen stain
• B) Giemsa stain
• C) Fite-Faraco stain
• D) PAS stain

---

• A) Tuberculoid (TT)
• B) Borderline Tuberculoid (BT)
• C) Mid-borderline (BB)
• D) Lepromatous (LL)

---

• A) Absent (infiltrate reaches epidermis)
• B) Present (clear zone of papillary dermis separates infiltrate from epidermis)
• C) Variable - present in some areas only
• D) Replaced by lichenoid infiltrate

---

• A) 6 months
• B) 24 months
• C) 12 months
• D) 18 months

---

• A) Temporal branch of facial nerve
• B) Zygomatic branch of facial nerve
• C) Buccal branch of facial nerve
• D) Trigeminal nerve V2 branch

---

• A) Facial nerve
• B) Ulnar nerve
• C) Median nerve
• D) Posterior tibial nerve

---

• A) 25-30% reduction in risk
• B) 40-50% reduction in risk
• C) 57% reduction in risk
• D) 80% reduction in risk

---

• A) Scalp
• B) Axillae
• C) Face
• D) Groin

---

• A) Tuberculoid leprosy
• B) Borderline tuberculoid leprosy
• C) Lepromatous leprosy
• D) Indeterminate leprosy

---

• A) Thalidomide 400 mg/day
• B) Prednisolone 1 mg/kg/day
• C) Clofazimine 300 mg/day
• D) Stop MDT immediately

---

SUMMARY TABLE: KEY DIFFERENCES IN LEPROSY SPECTRUM

---

---

LEPROSY (Hansen's Disease) - Complete Long Case for Dermatology Residency

Updated Edition with IAL, Ridley-Jopling & Nepal Guidelines

• Ridley DS & Jopling WH (1966). Classification of Leprosy According to Immunity: A Five-Group System. Int J Lepr 34(3):255-273
• IAL (Indian Association of Leprologists) - New Indian Classification (1981) / IAL Textbook of Leprosy concepts via Practical Manual of Leprosy
• International Textbook of Leprosy (internationaltextbookofleprosy.org)
• Andrews' Diseases of the Skin, 13th ed. (Clinical Dermatology)
• Dermatology, 2-Volume Set 5e (Bourke, Coulson, English et al.)
• Fitzpatrick's Dermatology, 9th ed.
• Park's Textbook of Preventive & Social Medicine, 26th ed.
• Red Book 2021 (AAP)
• Nepal National Leprosy Strategy 2021-2025

---

CLASSIFICATIONS - THE ESSENTIAL FRAMEWORK

1. RIDLEY-JOPLING (R-J) CLASSIFICATION (1966) - Gold Standard for Clinical & Research Use

Jopling's key insight (1966): The borderline group is immunologically unstable - borderline patients can shift toward TT (upgrading/reversal) or toward LL (downgrading), unlike the stable polar forms TT and LL. This instability is the biological basis for Type 1 (reversal) reactions.

2. NEW INDIAN CLASSIFICATION (IAL, 1981)

IAL Key Principle: The Polyneuritis (P) group formally recognizes pure neuritic leprosy as a distinct category - important because Nepal has a high burden of pure neuritic leprosy (up to 5% of new cases). The IAL textbook emphasizes that this category should never be missed.

3. WHO OPERATIONAL CLASSIFICATION (Used in Nepal for MDT)

Nepal Program Note: From 2023, WHO updated to uniform 3-drug MDT for both PB and MB (only duration differs: 6 months vs. 12 months). Nepal's National Leprosy Strategy 2021-2025 is aligning to this update.

---

PART 1: DETAILED HISTORY TAKING

APPROACH TO THE PATIENT

---

A. PRESENTING COMPLAINTS

1. Skin patch/discoloration - duration
2. Numbness or altered sensation - location, duration
3. Weakness of hand, foot, or face - duration
4. Thickening or pain in a nerve - location
5. Deformity of fingers, toes, foot
6. Painless wounds or ulcers

---

B. HISTORY OF PRESENTING ILLNESS

1. Regarding Skin Lesion(s)

---

2. Regarding Neural Symptoms - Ask Systematically

---

3. Regarding Leprosy Reactions

---

4. Systemic Review

---

C. PAST HISTORY

---

D. FAMILY AND CONTACT HISTORY

---

E. PERSONAL, SOCIAL & OCCUPATIONAL HISTORY

---

PART 2: CLINICAL EXAMINATION

GENERAL PRINCIPLES (IAL Textbook)

1. Conduct examination in good natural light - preferably sunlight, not fluorescent (which masks subtle hypopigmentation)
2. Fully expose the patient; examine the entire body surface
3. Maintain patient dignity; explain each step
4. Proceed in a systematic head-to-toe sequence
5. Use gloves when palpating lesions
6. Never skip nerve examination - per IAL Practical Manual: "Nerve examination is an integral part of assessing patients with leprosy and should never be skipped"

---

A. GENERAL EXAMINATION

• General appearance: Well/ill, distressed
• Nutritional status, BMI
• Vital signs (fever in ENL, Type 2 reaction)
• Lymphadenopathy: axillary, inguinal (generalized in MB/LL; also in ENL)
• Eyes: general inspection (redness, lagophthalmos visible at a glance)
• Gynecomastia (LL - testicular infiltration → elevated estrogen)
• Gait: high-stepping (foot drop - common peroneal palsy); antalgic gait

---

B. SKIN EXAMINATION

Step 1: Count and Map all Lesions

BB - "Swiss cheese" / "Punched-out" appearance: Fitzpatrick's and Dermatology 2-Volume Set (5e) describe the mid-borderline (BB) lesion as having annular plaques with a "Swiss cheese" or punched-out appearance due to holes of apparently normal skin within the lesion ring. This is characteristic of BB.

LL - "Leonine facies": Diffuse infiltration of the forehead, cheeks, earlobes, and periorbital skin creates a lion-like thickening. Also "varnished" skin appearance. - Dermatology 2-Volume Set 5e

Step 2: Immune (Spared) Sites - Always Check

• Scalp
• Axillae
• Groin and perineum
• Inner aspects of elbows and knees
• Dorsal midline of back (warmer, over spine)

Step 3: Sensory Testing of Lesions

1. Use a light ballpoint pen (plastic body, without cap)
2. Explain and demonstrate to the patient while their eyes are open
3. Touch normal skin first - ask patient to point to where they feel the touch (eyes open, practice)
4. Ask patient to close eyes
5. Touch the lesion and normal skin alternately - randomize timing and location
6. Ask: "Can you feel this?" and "Where is it?" (patient points to location)
7. For inaccessible areas (back, buttocks): ask patient to count each touch

1. Light touch (ballpoint pen or cotton wisp)
2. Temperature (hot and cold test tubes, 40°C and 5°C)
3. Pain/pinprick (sterile pin)

Step 4: Madarosis Assessment

• Inspect eyebrows: outer 1/3 loss first in LL (madarosis)
• Inspect eyelashes: loss later in LL
• Inspect body hair on arms/legs: gradual loss in LL
• Inspect beard area in males

---

C. DETAILED NERVE EXAMINATION

1. Palpation - for thickening, tenderness, consistency
2. Nerve function assessment - sensory AND motor

• Use pads of index and middle fingers
• Palpate the nerve over its most superficial location for at least 5-10 cm of its length
• Detect: beading, nodularity, fusiform thickening
• Compare both sides
• Apply mild to firm pressure and watch for patient response (wincing = tenderness)

GRADING OF NERVE THICKNESS (IAL Practical Manual - 4-grade scale)

GRADING OF NERVE TENDERNESS (IAL Practical Manual - 4-grade scale)

Clinical significance of grading: Grading nerve thickness and tenderness is used for: (a) baseline documentation, (b) communication between leprosy workers, (c) monitoring response to steroids in reactions, (d) detecting silent neuritis. A sudden increase in tenderness grade signals acute neuritis - requires urgent steroid intervention.

---

NERVE-BY-NERVE EXAMINATION

• Ask patient to turn head to the opposite side - this tightens the SCM and makes the GAN more prominent
• Palpate the posterior surface of the SCM at the junction of upper and middle third
• The nerve runs obliquely (posteroinferior to anterosuperior) across the SCM surface
• Normal: barely palpable or impalpable
• Abnormal: firm cord, may be nodular, beaded, visibly enlarged

---

---

• Temporal branch: Frontalis (forehead wrinkling), upper orbicularis oculi
• Zygomatic branch: Orbicularis oculi (lower, eye closure) - most affected in leprosy
• Buccal branch: Orbicularis oris, zygomaticus, nasalis
• Marginal mandibular branch: Depressor anguli oris
• Cervical branch: Platysma

1. Eye closure (lagophthalmos test): Ask patient to close eyes gently. Observe gap between lids - measure in mm. Check Bell's phenomenon (eye rolls upward when patient tries to close; protective reflex - if absent, corneal risk is even higher).
2. Forceful eye closure: Ask to close eyes tightly - assesses residual orbicularis oculi function.
3. Forehead wrinkling: Ask to raise eyebrows - temporal branch.
4. Smile and show teeth: Buccal/zygomatic.
5. Puff cheeks: Buccal branch.
6. Lower lip depression: Marginal mandibular.

• Grade 0: Complete eye closure (normal)
• Grade 1: Incomplete closure - gap <3mm (monitor)
• Grade 2: Gap >3mm with corneal exposure (disability grade 2 if corneal damage)

---

• Patient's elbow flexed to 90-110° (this opens the cubital tunnel and makes the nerve more palpable)
• Palpate in the groove between medial epicondyle and olecranon
• Roll the nerve gently against the bony floor
• Then palpate proximally up the medial upper arm along the medial intermuscular septum

• Claw hand test: Ask patient to straighten all fingers. Ulnar claw = inability to fully extend ring (4th) and little (5th) fingers at IP joints (due to loss of 3rd and 4th lumbricals).
• Card test (interosseous test): Place card between adjacent fingers; patient holds it while you pull. Weakness of interossei = card slides out easily.
• Froment's sign: Hold a piece of paper between thumb and index finger; patient grips while examiner pulls. If adductor pollicis (ulnar) is weak, the thumb IP joint flexes (FPL compensates) = positive Froment's sign.
• Little finger abduction: Ask to spread little finger out (abductor digiti minimi - ulnar).
• Inspect for interosseous guttering (dorsum of hand between metacarpals) and hypothenar wasting.

• Medial 1.5 fingers: little finger + medial half of ring finger (dorsal and palmar)
• Medial border of hand
• Use ballpoint pen or monofilament

---

• At the wrist: palpate medial to FCR tendon, lateral to palmaris longus, at the proximal wrist crease
• Can also be palpated in the mid-forearm between FDS and FDP

• Thumb abduction (APB test): Ask patient to point thumb perpendicular to the palm (toward ceiling). Resist downward pressure. Weakness/absence = thenar wasting from median palsy.
• Pen cap test / "OK sign": Weakness of FPL and FDP index (anterior interosseous nerve) causes inability to make a circle; patient makes a rectangular/rectangular pinch instead.
• Bottle sign: Cannot fully oppose thumb and index around a cylindrical bottle.
• Inspect thenar eminence for wasting (flattening = "ape hand" when combined with thenar + hypothenar wasting).

• Radial 3.5 fingers: thumb, index, middle, radial half of ring (dorsal and palmar distal)
• Thenar eminence (palmar cutaneous branch - outside carpal tunnel)

---

• Radial aspect of the distal forearm, just lateral to the radial artery at the wrist
• Palpate under the brachioradialis tendon, rolling the nerve over the radial styloid

• Wrist extension, finger extension, thumb extension
• Wrist drop if radial nerve proper is involved

• Dorsum of first web space (between thumb and index) - most reliable
• Dorsal thumb and radial 3.5 fingers

---

• Deep peroneal: Tibialis anterior, extensor digitorum longus, extensor hallucis longus; sensory: first web space of foot
• Superficial peroneal: Peroneus longus and brevis; sensory: dorsum of foot

• Stand behind/beside the patient
• Identify the fibular head (prominent bony prominence on lateral knee)
• The nerve wraps around the neck of the fibula, approximately 2-3 cm below the fibular head on the posterior-lateral aspect
• Roll the nerve against the fibula - it should feel like a cord crossing the bone
• Palpate both distally (as it enters lateral compartment) and posteriorly (in the popliteal fossa above the fibular head)

• Foot drop: Ask patient to walk; look for high-stepping gait and slapping of foot
• Dorsiflexion: "Pull your toes and foot up toward your shin" against resistance - tests tibialis anterior (deep peroneal)
• Toe extension: Extend toes against resistance - extensor digitorum longus
• Eversion: "Turn your foot outward (sole faces out)" against resistance - peroneus longus and brevis (superficial peroneal)

• Dorsum of foot (superficial peroneal)
• First web space (deep peroneal)

---

• Find the medial malleolus
• Palpate the groove between the medial malleolus and the Achilles tendon
• The nerve lies posterior to the pulsating posterior tibial artery
• Roll the nerve gently; it is softer and less prominent than the artery

• Intrinsic foot muscles (abductors/flexors of toes): Ask patient to flex and spread toes
• Observe for claw toes (intrinsic minus foot)
• Plantar flexion (S1 primarily, but tibial nerve contributes)

• Entire plantar surface of the foot (medial and lateral plantar nerves)
• Medial and lateral toes (plantar aspect)
• Heel (medial calcaneal branch)

---

---

NERVE FUNCTION ASSESSMENT - QUICK CLINICAL PROTOCOL

1. Facial nerve: Eye closure (complete/incomplete)
2. Ulnar nerve: Little finger abduction (spread 5th finger out)
3. Median nerve: Thumb abduction (point thumb up from palm)
4. Common peroneal (lateral popliteal): Foot dorsiflexion (pull toes up)

1. Ulnar and median sensory territory in hand (palmar surface at little finger and index finger)
2. Plantar surface of foot (posterior tibial territory)
3. Over skin lesions (using ballpoint pen)

---

D. EYE EXAMINATION

1. Visual acuity - Snellen chart; finger counting if severe
2. Lagophthalmos - measure gap in mm; test Bell's phenomenon
3. Cornea - clarity (ulcer, scarring, pannus); corneal anesthesia (V1 testing with cotton wisp from lateral approach)
4. Iris/pupil - irregular pupil, posterior synechiae, Koeppe nodules (iris lepromas), constricted/sluggish pupil
5. Conjunctiva - perilimbal injection (ciliary flush in iritis); tarsal nodules
6. Sclera - scleritis (ENL)
7. Eyelids - madarosis (loss of brows/lashes), ectropion/entropion

---

E. NOSE AND THROAT EXAMINATION

• Nose: Saddle deformity (nasal bridge collapse - septal destruction in LL), nostril atrophy, epistaxis
• Throat: Hoarseness (laryngeal leprosy - LL), palpate neck for GAN

---

F. HAND AND FOOT EXAMINATION

• Inspect dorsum: claw (ulnar/combined), wrist drop (radial), interosseous guttering, trophic changes
• Inspect palm: thenar and hypothenar wasting, callus, fissures, trophic ulcers
• Test all digits for sensation
• Assess grip strength

• Inspect dorsum: foot drop, trophic changes, digital deformities
• Inspect sole: plantar ulcers (at pressure points - metatarsal heads, heel, ball of foot); callus, fissures
• Assess plantar sensation (posterior tibial territory)
• Check pulses

---

PART 3: INVESTIGATIONS (SEQUENCE AND SIGNIFICANCE)

INVESTIGATION 1: SLIT-SKIN SMEAR (SSS)

1. Clean site with spirit, allow to dry completely
2. Pinch skin firmly between thumb and forefinger to blanch - reduces bleeding and concentrates tissue fluid
3. Make a 5mm incision, 2-3mm deep (dermis only)
4. Scrape incision walls firmly 3-4 times with the blade edge
5. Spread material as a uniform circular smear (5-7mm diameter) on a grease-free glass slide
6. Air-dry, fix with methanol
7. Stain: Fite-Faraco (preferred) or modified ZN (5% H₂SO₄)
8. Examine 100 oil-immersion fields (100×)

• Bacillary Index (BI): Ridley's scale 0-6+ (log scale)
• Morphological Index (MI): % solid-staining (viable) bacilli

---

INVESTIGATION 2: SKIN BIOPSY & HISTOPATHOLOGY

• From the most active, representative lesion
• Include the active edge (not the healed center)
• Full-thickness punch biopsy (4-6mm) to subcutaneous fat
• Request Fite-Faraco + H&E + S-100 stain

Jopling's original description (1966): In TT, "foci of well-developed epithelioid cells with or without Langhans giant cells, encompassed by a zone of dense lymphocyte infiltration. The granuloma extends up to the epidermis without a subepidermal zone." In BT, "the best point of distinction is that there is a clear subepidermal zone, although it may be very narrow."

---

INVESTIGATION 3: LEPROMIN (MITSUDA) TEST

• Dharmendra antigen (integral, heat-killed suspension) - more standardized
• Mitsuda antigen (crude, from infected tissue)

1. Inject 0.1 mL intradermally into the flexor forearm
2. Fernandez reaction: Read at 48 hours - erythema and induration (measures sensitization similar to tuberculin)
3. Mitsuda reaction: Read at 28 days - papule/nodule (measures granuloma-forming CMI capacity)

---

INVESTIGATION 4: SENSORY TESTING (FORMAL)

---

INVESTIGATION 5: VOLUNTARY MUSCLE TESTING (VMT)

• Orbicularis oculi (facial/zygomatic)
• APB = Abductor pollicis brevis (median)
• ADM = Abductor digiti minimi + 1st dorsal interosseous (ulnar)
• Tibialis anterior (common peroneal)
• EHL = Extensor hallucis longus (deep peroneal)

---

INVESTIGATION 6: WHO DISABILITY GRADING

---

INVESTIGATION 7: ADDITIONAL INVESTIGATIONS

---

PART 4: DIFFERENTIAL DIAGNOSIS

---

PART 5: MANAGEMENT AS PER NEPAL GUIDELINES

A. CLASSIFICATION AND TREATMENT

PAUCIBACILLARY (PB) - 6 months

MULTIBACILLARY (MB) - 12 months

---

B. MANAGEMENT OF REACTIONS

Type 1 (Reversal) Reaction

• Prednisolone 40-60 mg/day (1 mg/kg/day), minimum 6-month tapering course
• Starting dose: 40 mg/day for 2 weeks, then gradually taper (reduce by 5 mg every 2-4 weeks based on response)
• Steroid-sparing: methotrexate 7.5-15 mg/week if prolonged course or steroid dependence
• Analgesics for nerve pain
• Splint affected limb in acute neuritis (prevents contracture)
• Continue MDT throughout

Type 2 (ENL) Reaction

• Mild: NSAIDs + chloroquine 300 mg/day
• Moderate-severe: Prednisolone 40-60 mg/day (shorter taper than Type 1, typically 4-8 weeks)
• Severe/recurrent/chronic ENL: Thalidomide 100-400 mg/day (start at 400 mg for 4 days, taper; NOT in women of childbearing age)
• Clofazimine 300 mg/day (anti-inflammatory in ENL; takes 4-6 weeks; reduces steroid dependence in chronic ENL)
• Treat orchitis: bed rest, scrotal support, NSAIDs
• Iritis: Urgent ophthalmology + topical prednisolone + atropine
• Continue MDT throughout

Silent Neuritis

---

C. DISABILITY PREVENTION AND SELF-CARE (Nepal Program)

1. Eye care: Artificial tears 4-6 times/day; protective glasses; visual inspection daily
2. Hand care: Warm water soaking + oil massage (prevents dryness from clofazimine); wound inspection daily; protective gloves for hot objects
3. Foot care: Custom molded footwear; daily plantar inspection with a mirror; no barefoot walking
4. Wound management: Regular debridement + dressings for plantar ulcers; complete offloading
5. Physiotherapy: Active and passive exercises; splinting for acute neuritis
6. Reconstructive surgery: Tendon transfers for claw hand (NLEP programs in Nepal); tarsal tunnel decompression; nerve abscess drainage

---

D. CONTACT MANAGEMENT - SDR-PEP (Nepal 2021-25 Strategy)

• Screen all household and close contacts
• Eligible contacts receive Single Dose Rifampicin (SDR-PEP):
  • Adults: 600 mg single oral dose
  • Children 6-14 years: 450 mg single oral dose
  • Children 2-5 years: 150-300 mg single oral dose
  • Exclude: Active TB, already on rifampicin, rifampicin allergy, children <2 years
• Efficacy: ~57% risk reduction in contacts
• Register in Nepal's Nikusth online platform
• Re-screen contacts annually for 5 years

---

E. FOLLOW-UP

• Monthly: supervised rifampicin; examine for reactions, new lesions; dispense daily drugs
• VMT/sensory testing: every 3 months during MDT; at completion
• Disability grading: at diagnosis and completion
• Post-treatment: MB every 6-12 months for 5 years; PB for 2 years
• BI monitoring: 6 monthly in MB (should fall ~1 unit/year)

---

PART 6: VIVA QUESTIONS & QUIZ (IAL/Jopling-Integrated)

---

VIVA QUESTIONS

---

1. Clinical: Number, size, distribution, and character of skin lesions; nerve involvement pattern
2. Bacteriological: Bacillary Index (BI) from SSS/biopsy; Morphological Index (MI)
3. Immunological: Lepromin (Mitsuda) test result at 28 days
4. Histopathological: Nature and organization of granuloma; presence/absence of grenz zone; nerve involvement pattern; giant cells

---

1. Consolidating borderline groups BT + BB + BL → single "Borderline (B)" category
2. Including maculoanesthetic leprosy within tuberculoid (T) - previously a separate category in the older Indian classification (Madrid, 1953)
3. Formally recognizing Polyneuritis (P) as a separate category = pure neuritic leprosy without skin lesions
4. Adding Indeterminate (I) as a starting point

---

• Upgrading (toward TT): Increasing CMI - causes Type 1 (Reversal) reaction. The sudden increase in CMI leads to inflammatory destruction of existing lesions and nerves. This is the mechanism of reversal reaction and is most severe in BL patients (greatest antigen load during upgrading).
• Downgrading (toward LL): Decreasing CMI (due to continued antigen exposure, malnutrition, immunosuppression) - causes downgrading reaction (clinically similar to reversal).

---

---

• Bacillary Index (BI): Ridley's 0-6+ logarithmic scale measuring density of AFB in SSS. Used to confirm MB leprosy at diagnosis; monitor bacteriological response. BI falls approximately 1 unit per year on effective MDT. A BI that fails to fall or rises = drug resistance or relapse.
• Morphological Index (MI): Percentage of solid-staining (intact) bacilli - represents viable, infective organisms. Normal bacteria stain solid; dead or dying bacteria fragment and stain as beaded/granular. On effective MDT, MI drops to zero within weeks to months - first evidence of bacteriological response. Rising MI (especially >1%) after apparent cure = relapse, often with drug-resistant organisms.

---

1. Do NOT stop MDT
2. Prednisolone 1 mg/kg/day (40-60 mg) orally - START IMMEDIATELY - every hour of delay increases risk of permanent nerve damage
3. Splint the affected limb in functional position to prevent contracture (wrist in neutral/slight dorsiflexion; foot in 90° dorsiflexion)
4. Analgesia for nerve pain
5. Admit if bilateral, severe, or if corneal exposure
6. Arrange urgent ophthalmology if lagophthalmos
7. Taper prednisolone slowly over minimum 6 months
8. Document VMT baseline; repeat every 2 weeks

---

---

• Scalp
• Axillae
• Groin and perineum
• Inner aspects of elbows and knees
• Mid-back (over spine)
• Webspaces of toes (in early disease)

• Face, ears, earlobes (especially LL)
• Buttocks, upper arms, thighs
• Hands, feet

---

• After dapsone monotherapy with resistance (hence called "histoid" due to histiocyte spindle cell pattern)
• After irregular/incomplete MDT
• Occasionally de novo

• Firm, shiny, dome-shaped papules and nodules (1-15mm)
• Yellow-red to skin-colored
• Appear on normal background skin (unlike regular LL where skin is diffusely infiltrated)
• Favor buttocks, lower back, face, bony prominences
• May resemble dermatofibromas or molluscum contagiosum

• Spindle-shaped histiocytes arranged in whorls, storiform pattern, or tight circles
• Bacilli extremely abundant, aligned along the long axis of spindle cells
• BI 6+ (maximum)
• Solid-staining bacilli (high MI) - indicates viable, potentially drug-resistant organisms
• Distinct from surrounding tissue

• High bacillary load → highly infectious
• Suggests dapsone resistance → test MI and folP1 gene mutation
• Treat with full MB-MDT; if dapsone resistant, use alternative regimen (Rifampicin + Ofloxacin + Minocycline - ROM)

---

---

MCQ QUIZ (IAL/Jopling Additions)

---

• A) Lancet, 1962
• B) Int J Leprosy, 1966
• C) BMJ, 1970
• D) JAMA, 1968

---

• A) Indeterminate (I)
• B) Tuberculoid (T)
• C) Borderline (B)
• D) Polyneuritis (P)

---

• A) TT and LL
• B) Borderline (BT, BB, BL)
• C) Indeterminate only
• D) LL only

---

• A) 24 hours (Fernandez reaction)
• B) 72 hours
• C) 7 days
• D) 28 days

---

• A) The grenz zone is absent in lepromatous leprosy
• B) The grenz zone is present in TT because the infiltrate does not reach the epidermis
• C) In TT, granulomas extend to the epidermis WITHOUT a grenz zone; in BT there is a clear (though narrow) subepidermal zone
• D) The grenz zone is only seen in histoid leprosy

---

• A) Clofazimine monotherapy failure
• B) Rifampicin resistance
• C) Dapsone monotherapy or dapsone resistance
• D) Treatment with thalidomide

---

• A) IFN-γ and TNF-α
• B) IL-4, IL-5, IL-10 (Th2 dominant)
• C) IL-12 and IL-17
• D) IL-2 and IL-23

---

• A) Posterior tibial nerve
• B) Sural nerve
• C) Saphenous nerve
• D) Common peroneal (lateral popliteal) nerve

---

• A) Fitzpatrick's only
• B) IAL Practical Manual of Leprosy
• C) Park's only
• D) Red Book

---

• A) Tuberculoid leprosy
• B) Lepromatous leprosy
• C) Borderline tuberculoid leprosy
• D) Histoid leprosy

---

• A) Both are caused by acid-fast bacilli
• B) Both affect the same Province 2 (Terai) of Nepal and produce hypopigmented patches
• C) PKDL also causes nerve thickening
• D) PKDL has positive Mitsuda test

---

• A) Lepromatous plaque
• B) Tuberculoid plaque
• C) ENL nodule
• D) Histoid nodule

---

• A) Patients with polyneuropathy from dapsone
• B) Patients with ENL causing multiple nerve involvement
• C) Pure neuritic leprosy - peripheral nerve involvement without skin lesions
• D) Patients with leprosy and co-existing diabetic neuropathy

---

QUICK REFERENCE: JOPLING'S KEY MNEMONICS & PEARLS

---

1. Ridley DS, Jopling WH. Classification of leprosy according to immunity: a five-group system. Int J Lepr. 1966;34(3):255-273.
2. IAL - All India Leprosy Workers Conference. New Indian Classification. Lepr India. 1982;54:22-32.
3. IAL Practical Manual of Leprosy (Kar HK, Kumar B eds.). Chapter on nerve examination and grading.
4. International Textbook of Leprosy - Clinical Diagnosis chapter (internationaltextbookofleprosy.org)
5. Andrews' Diseases of the Skin, 13th ed. (Clinical Dermatology), Chapter 17.
6. Dermatology 2-Volume Set, 5e (Bourke et al.), Chapter 75.
7. Fitzpatrick's Dermatology, 9th ed., Chapter 159.
8. Park's Textbook of Preventive & Social Medicine, 26th ed., Chapter on Leprosy.
9. Nepal National Leprosy Strategy 2021-2025.
10. WHO Leprosy Guidelines & Fact Sheet (who.int).
11. An update of the diagnosis, treatment, and prevention of leprosy (PMC11346855)
12. High-Resolution Ultrasonography for Detecting Peripheral Neuropathy in Leprosy: A Systematic Review and Meta-Analysis (PMID 41773898)

---

LEPROSY - COMPLETE MUSCLE EXAMINATION & SYSTEMIC EXAMINATION

Supplementary Section for the Long Case

---

SECTION A: VOLUNTARY MUSCLE TESTING (VMT) - COMPLETE GUIDE

Background and Purpose

• At diagnosis (baseline)
• Every month during MDT (monthly supervised dose visit)
• At every 3 months as minimum (WHO)
• At treatment completion
• At any point when patient reports new weakness, pain, or reaction
• Post-treatment follow-up every 6-12 months (MB: 5 years; PB: 2 years)

---

MRC GRADING SCALE (Modified for Leprosy VMT)

• Any grade change of 1 or more = significant nerve function impairment (NFI)
• A drop from 5 to 4 is significant - do NOT dismiss it
• A drop from 4 to 3 = urgent intervention needed (steroid)
• Grade 0 or 1 = permanent damage likely if not treated immediately

---

MUSCLE TESTING NERVE BY NERVE

---

1. FACIAL NERVE - ORBICULARIS OCULI (Zygomatic Branch)

1. Inspect at rest: Look for asymmetry of eyelid position, any visible gap between lids
2. Gentle closure test: Ask patient: "Close your eyes gently as if sleeping"
   • Normal: lids meet completely with no gap
   • Abnormal: gap visible between upper and lower lid = lagophthalmos
3. Measure the gap: Use a millimeter ruler to measure the inter-lid gap
4. Forced closure test: Ask: "Now close your eyes as tightly as you can"
   • Grade 5: complete tight closure (lashes buried)
   • Grade 4: complete closure but not tight
   • Grade 3: eyelids close but with visible effort/asymmetry
   • Grade 2: partial closure only; significant gap remains
   • Grade 1: minimal movement of lids
   • Grade 0: no movement
5. Bell's phenomenon: While asking patient to close eyes, observe eye movement
   • Normal Bell's: eye rolls upward (protective - cornea moves away)
   • Absent Bell's: cornea remains exposed even when trying to close = catastrophic risk of ulceration
6. Test both sides and compare

• Corneal reflex (V1/trigeminal): Touch limbus with fine cotton wisp from lateral side (so patient cannot see it coming). Normal = blink. Absent/reduced = corneal anesthesia on top of lagophthalmos = EMERGENCY
• Corneal fluorescein test: If ophthalmology equipment available - instill fluorescein, examine under blue light for corneal erosions

• Grade 0: Complete closure - no disability
• Grade 1: Incomplete closure but no corneal damage (disability grade 1)
• Grade 2: Lagophthalmos + corneal damage/ulcer/opacity/VA <6/60 (disability grade 2)

---

2. ULNAR NERVE - MOTOR TESTING

• Hypothenar group: Abductor digiti minimi (ADM), Flexor digiti minimi, Opponens digiti minimi
• Interossei (all 4 dorsal, 3 palmar)
• 3rd and 4th lumbricals
• Adductor pollicis
• Deep head of Flexor pollicis brevis
• Palmaris brevis

1. Ask patient to place hand flat on table, palm down
2. Instruct: "Spread your little finger out to the side, away from the other fingers"
3. Resist this movement by pressing the little finger back toward the ring finger
4. Grade 5: full abduction against full resistance
5. Grade 4: full abduction against reduced resistance
6. Grade 3: full abduction against gravity alone (horizontal) but no added resistance
7. Grade 2: barely moves little finger
8. Grade 1: tendon flickers but no movement
9. Grade 0: no movement

• Ask patient to straighten all fingers simultaneously on a flat surface
• Ulnar claw: Ring (4th) and little (5th) fingers cannot fully extend at PIP and DIP joints - they remain flexed
• Caused by loss of 3rd and 4th lumbricals (which extend IP joints via extensor mechanism)
• "Intrinsic minus" hand - loss of intrinsic muscle action
• The index and middle fingers (with intact 1st and 2nd lumbricals from median nerve) are NOT clawed

• Card test: Place a card between adjacent fingers; patient holds it while you pull the card
• Alternate: Ask patient to abduct (spread) all fingers simultaneously against resistance
• Visible guttering between metacarpals on dorsum of hand = interosseous wasting

• Ask patient to grip a piece of paper between thumb and index finger (lateral pinch)
• Examiner pulls the paper away
• Positive: Thumb IP joint flexes (FPL from median compensates for weak adductor pollicis) = ulnar palsy
• Negative: Thumb IP joint remains extended (adductor pollicis working normally)

• Inspect palmar surface: flattened hypothenar eminence
• Palpate: soft, atrophic bulk compared to normal side

• Inspect dorsum of hand: depression/hollowing between metacarpals (especially 1st web space - first dorsal interosseous wasting)

---

3. MEDIAN NERVE - MOTOR TESTING

• Thenar group: Abductor pollicis brevis (APB), Opponens pollicis, Flexor pollicis brevis (superficial head)
• 1st and 2nd lumbricals
• Pronator teres, Pronator quadratus
• Flexor carpi radialis, Palmaris longus
• Flexor digitorum superficialis (all 4)
• Flexor digitorum profundus (index + middle - via anterior interosseous nerve)
• Flexor pollicis longus (via anterior interosseous nerve)

1. Ask patient to place hand flat on table, palm up
2. Instruct: "Point your thumb straight up toward the ceiling, perpendicular to your palm"
3. Resist downward pressure on the thumb nail/distal phalanx
4. Grade 5: full elevation against full resistance
5. Grade 4: full elevation against reduced resistance
6. Grade 3: full elevation against gravity alone
7. Grade 2: slight movement
8. Grade 1: flicker of APB seen/palpated at thenar base
9. Grade 0: no movement

• Inspect: flattened thenar eminence ("ape hand" = thenar flat + thumb falls back into plane of fingers)
• Palpate: soft bulk over thenar area

• Ask patient to touch the tip of the little finger with the tip of the thumb (full opposition)
• Weakness = cannot reach little finger or does so with IP flexion instead of true CMC rotation

• Ask patient to make the "OK" sign (circle with thumb and index finger)
• Normal: perfect circle
• AIN palsy: rectangular/triangular shape (cannot flex index DIP or thumb IP)
• Less commonly affected in leprosy than APB

• Patient cannot wrap thumb and index around a cylindrical bottle due to thenar weakness

• "Ape hand": Thenar + hypothenar both flat, thumb in same plane as fingers, no opposition
• Complete claw hand: All four fingers clawed (ulnar provides ring+little; median provides index+middle via 1st+2nd lumbricals)
• Total intrinsic minus hand: Severe combined palsy

---

4. RADIAL NERVE - MOTOR TESTING

• Brachioradialis, Extensor carpi radialis longus (above spiral groove)
• Extensor carpi radialis brevis, Extensor digitorum communis, Extensor carpi ulnaris (via posterior interosseous nerve/PIN)
• Extensor pollicis longus, Extensor pollicis brevis, Abductor pollicis longus (PIN)
• Extensor indicis proprius (PIN)

• Ask patient to extend wrist (cock up wrist) against resistance applied to dorsum of hand
• Grade the movement 0-5 as per MRC scale
• Wrist drop = inability to extend wrist (extensor carpi radialis/ulnaris paralysis)

• Ask patient to extend fingers at MCP joints (not IP joints - tested by lumbricals/interossei)
• Weakness or inability = extensor digitorum communis palsy

• Ask to move thumb away from hand in the plane of the palm (abductor pollicis longus = radial)
• Ask to extend thumb (extensor pollicis longus = PIN)

---

5. COMMON PERONEAL (LATERAL POPLITEAL) NERVE - MOTOR TESTING

• Deep peroneal branch: Tibialis anterior, Extensor digitorum longus, Extensor hallucis longus (EHL), Peroneus tertius
• Superficial peroneal branch: Peroneus longus, Peroneus brevis

1. Patient seated, foot hanging freely
2. Instruct: "Pull your foot and toes up toward your shin"
3. Resist by pressing down on the dorsum of the foot
4. Grade 0-5 per MRC scale

• Ask patient to turn sole of foot outward (evert) against resistance
• Weakness = superficial peroneal nerve; foot tends toward inversion at rest if peronei paralyzed

• Ask patient to extend big toe and all toes upward against resistance
• EHL tested separately: "point big toe toward ceiling"

• Ask patient to walk: observe for high-stepping gait (patient lifts knee high to clear the dropped foot)
• Listen for foot slap (foot slaps ground due to loss of controlled plantarflexion at heel-strike)
• At rest: foot hangs in plantarflexion and inversion (tibialis anterior + extensors paralyzed; unopposed gastrocnemius + tibialis posterior)

---

6. POSTERIOR TIBIAL NERVE - MOTOR TESTING

• Intrinsic foot muscles: Flexor digitorum brevis, Abductor hallucis, Flexor hallucis brevis, Lumbricals, Interossei (via medial and lateral plantar nerves)
• Flexor digitorum longus, Tibialis posterior, Flexor hallucis longus (more proximal branches)

• Ask patient to flex (curl) toes against resistance
• Ask patient to abduct/adduct toes (intrinsic muscles)
• Weakness = intrinsic muscle wasting → claw toes

• Inspect for clawing of all toes (intrinsic minus foot - similar to hand)
• Hyperextension at MTP + flexion at IP joints

• Always test plantar sensation at multiple sites using ballpoint pen or monofilament (10g SWMT)
• Medial plantar: ball of foot, great toe
• Lateral plantar: 5th metatarsal head, lateral toe
• Calcaneal: heel

---

SUMMARY VMT CHART (For clinical documentation)

• Grade 5→4 on any test: increase frequency of monitoring to monthly; consider early steroid if progressive
• Grade 5→3 or lower, or any acute drop: START PREDNISOLONE IMMEDIATELY
• Any new weakness during reaction: EMERGENCY - same-day steroid

---

SECTION B: COMPLETE MUSCLE & WASTING ASSESSMENT (LOOK-FEEL-MOVE)

HANDS - SYSTEMATIC SEQUENCE

• Palpate thenar and hypothenar eminences: compare bulk, firmness, atrophy
• Palpate first dorsal interosseous: thumb and index on either side of 1st metacarpal - compare bulk
• Palpate dorsal interosseous gutters: run finger between metacarpals, note depression
• Skin temperature: asymmetric coolness = autonomic fiber damage (sympathetic)
• Skin moisture: anhidrosis = autonomic damage
• Check pulses (radial, ulnar): vascular supply affects trophic changes

1. Full finger extension (spread on flat surface)
2. Full finger flexion (make a fist)
3. Thumb opposition to each finger tip
4. Grip strength (ask to squeeze examiner's two fingers)
5. Key pinch (hold paper between thumb and lateral index)
6. Precision pinch (pulp to pulp - pick up small object)

• Check PIP and DIP joint range of motion
• Assess for fixed flexion contracture (cannot passively extend)

---

FEET - SYSTEMATIC SEQUENCE

• Palpate all plantar pressure points: look for callus over active ulcer (masked ulcer)
• Probe any ulcer depth and track (sinus tract)
• Palpate dorsal foot for tendon function
• Check temperature asymmetry (autonomic neuropathy)
• Check foot pulses (dorsalis pedis, posterior tibial)

• Dorsiflexion: ask to pull toes/foot up
• Plantarflexion: ask to push foot down
• Eversion and inversion
• Toe flexion and extension
• Walk: inspect gait pattern (steppage gait, foot slap, antalgic)

---

GAIT ANALYSIS IN LEPROSY

---

SECTION C: SYSTEMIC EXAMINATION - ORGAN BY ORGAN

---

1. EYE EXAMINATION (In sequence)

• Snellen chart for each eye separately
• If <6/60: count fingers, hand movement, light perception
• Grade 2 disability if VA <6/60

• Madarosis: Outer 1/3 eyebrow loss (LL - earliest sign); progresses to lash loss; eventual total loss
• Lagophthalmos: Measure inter-lid gap in mm (see VMT section above)
• Entropion: Inward turning of lid (chronic inflammation)
• Ectropion: Outward turning of lid (facial nerve palsy)
• Ptosis: Drooping (rare)
• Tarsal nodules: Palpate tarsal plate for nodular infiltration (LL)

• Corneal sensation (V1): Fine cotton wisp from lateral approach (outside visual field); normal = blink; reduced/absent = corneal anesthesia
• Corneal clarity: Look for opacity, ulcer, pannus (vascular infiltration from limbus), interstitial keratitis
• Pearls: Bilateral milky-white corneal opacities (lepromas within corneal stroma) - pathognomonic of LL
• Avascular keratitis: Infiltration without vessels in early leprosy
• Exposure keratitis: Punctate epithelial erosions from lagophthalmos

• Perilimbal injection (ciliary flush) = active iritis/uveitis
• Tarsal conjunctival nodules
• Conjunctival anesthesia (V1)

• Slit-lamp examination ideally: Flare and cells (iritis), posterior synechiae (adhesions of iris to lens)
• Iris pearls (Koeppe nodules): Miliary lepromas on iris surface - pathognomonic of LL; appear as tiny white dots on the iris near the pupil margin
• Iris atrophy: From chronic iritis
• Hypopyon: Pus in anterior chamber (severe iritis)
• Pupil: Irregular, constricted, sluggish (from iritis); may be irregular due to posterior synechiae

• Scleritis / Episcleritis: In ENL (Type 2 reaction) - sectoral or diffuse redness, tenderness
• Scleral nodules: In LL

• Optic neuritis (rare)
• Retinal changes

---

2. EAR EXAMINATION

• Helix and earlobe: Earliest and most common site for lepromas in LL - inspect for nodules, thickening, soft rubbery swelling of the earlobe
• Great auricular nerve: Palpate (see nerve examination section)
• Hearing: Ask about tinnitus or hearing loss (ENL can cause inner ear involvement rarely)

---

3. NOSE EXAMINATION

• Saddle nose deformity: Collapse of nasal bridge due to destruction of nasal cartilage and bone in LL
• Atrophied nostrils: Narrowed nostrils (advanced LL)
• Loss of nasal spine: Loss of nasal tip support

• Nodules/infiltrations: On nasal mucosa, septum (earliest internal manifestation in LL)
• Septal perforation: From necrosis of septum (LL) - look for crusting, hole in septum
• Active epistaxis: Friable, highly vascularized nodular mucosa in active LL
• Atrophic rhinitis pattern: In advanced LL - dry, crusted, patchy mucosa

---

4. MOUTH AND THROAT EXAMINATION

• Hard palate: Lepromatous nodules on hard palate (LL) - rare but recognized
• Uvula and soft palate: Infiltration in advanced LL
• Upper incisor teeth: Can be lost in advanced LL due to maxillary bone involvement
• Larynx (indirect laryngoscopy or ENT referral):
  • Nodules on vocal cords → hoarseness (symptom of laryngeal leprosy in LL)
  • Epiglottic infiltration
  • Subglottic stenosis (rare, advanced)

---

5. LYMPH NODE EXAMINATION

• Inguinal lymphadenopathy: Generalized in MB/LL (part of reticuloendothelial involvement)
• Axillary lymphadenopathy: Less common
• During ENL reactions: Lymphadenitis as part of systemic Type 2 reaction
• Characteristics: Usually soft, non-tender in LL infiltration; tender during ENL

---

6. TESTICULAR AND GENITAL EXAMINATION

• Inspect genitalia for skin lesions (leprosy can involve scrotal skin)
• Palpate both testes: size, consistency, tenderness
• Check for epididymo-orchitis (ENL)
• Inspect for gynecomastia (bilateral tender breast tissue in males)

---

7. MUSCULOSKELETAL EXAMINATION

• Swelling, redness, warmth (active synovitis)
• Range of motion (reduced = contracture, arthritis)
• Stability (Charcot joint = hypermobile, disorganized)

• Moth-eaten trabecular pattern in phalanges
• Tapered, pencil-like terminal phalanges
• Concentric absorption (whole digit shortens)
• Articular destruction in Charcot joints

• Thenar bulk: Palpate at rest; pinch thickness
• Hypothenar bulk: As above
• Intrinsic hand muscles (dorsal interossei): Ask patient to spread fingers while you feel the 1st dorsal interosseous between thumb and index
• Intrinsic foot muscles: Palpate plantar foot for flesh bulk
• Tibialis anterior: Palpate lateral aspect of shin; ask to dorsiflex - feel belly contract
• Peroneal muscles: Lateral compartment; ask to evert - feel belly contract
• Calf (gastrocnemius/soleus): Assess for wasting (posterior tibial nerve)
• Thenar, hypothenar, and interosseous wasting graded 0-3: Grade 0 = normal bulk; Grade 1 = slight wasting; Grade 2 = moderate wasting; Grade 3 = severe wasting with guttering

---

8. SKIN TROPHIC CHANGES - COMPLETE ASSESSMENT

• Grade 0: No ulcer
• Grade 1: Open ulcer (superficial - dermis/subcutaneous)
• Grade 2: Deep ulcer (to fascia, tendon, joint, or bone)
• Grade 3: Healed ulcer with scar (inactive)

---

9. AUTONOMIC NERVOUS SYSTEM EXAMINATION

---

10. DEEP TENDON REFLEXES

• Reflexes may be reduced or absent in affected nerve distribution (axonal neuropathy)
• Ankle jerk (S1): affected if posterior tibial nerve involved
• Knee jerk: usually preserved unless femoral nerve involved (uncommon)
• Reflexes are typically NORMAL or only mildly reduced in leprosy - profound areflexia should prompt reconsideration of the diagnosis (consider Guillain-Barré, CMT, etc.)
• Upper limb reflexes: generally preserved; biceps/triceps normal

---

11. LYMPH NODE, LIVER, AND SPLEEN

• Generalized, soft lymphadenopathy in MB/LL (lepromatous infiltration of nodes)
• Tender lymphadenopathy during ENL reactions (lymphadenitis)

• Mild hepatomegaly: occurs from reticuloendothelial infiltration; usually asymptomatic
• Mild splenomegaly: from same mechanism
• Secondary amyloidosis (chronic MB leprosy) → hepatosplenomegaly + proteinuria/renal failure

• Hepatomegaly: percuss and palpate liver
• Splenomegaly: ballottement and palpation
• Signs of liver disease (jaundice from rifampicin hepatotoxicity)

---

12. RENAL SYSTEM

• Secondary amyloidosis: From chronic lepromatous leprosy → renal amyloid
• Clinical sign: Peripheral edema, proteinuria, nephrotic syndrome
• Glomerulonephritis: Per Andrews': "Occurs in more than 5% and perhaps as many as 50% of Hansen disease patients; not correlated with bacillary load or ENL"
• Examine for: pedal edema, periorbital edema, frothy urine history
• Dipstick urine: test for proteinuria at baseline in all MB patients

---

SECTION D: COMPLETE EXAMINATION CHECKLIST FOR LEPROSY LONG CASE

GENERAL (5 min)

• General appearance, nutritional status
• Vitals (fever in ENL)
• Gait (observe entering the room)
• Gynecomastia
• Lymphadenopathy

SKIN (10 min)

• Count all lesions; map on body diagram
• Describe each: color, size, border, surface, distribution, sweating, hair
• Test sensation over each lesion (ballpoint pen, temperature, pin)
• Histamine test if needed (confirm neurological involvement)
• Trophic changes (hands, feet, lesional areas)

NERVES (15 min)

• GAN (both sides)
• Supra-orbital nerve (both sides)
• Ulnar nerve at medial epicondyle (both sides)
• Median nerve at wrist (both sides)
• Superficial radial nerve at wrist (both sides)
• Common peroneal at fibular neck (both sides)
• Posterior tibial at medial malleolus (both sides)
• Sural nerve along Achilles (both sides)
• Grade thickness (0-3) and tenderness (0-3) for each

MOTOR/MUSCLE VMT (10 min)

• Facial: eye closure (both sides, measure gap)
• Ulnar: 5th finger spread (grade 0-5, both sides)
• Median: thumb perpendicular (APB, grade 0-5, both sides)
• Radial: wrist extension (grade 0-5, both sides)
• Common peroneal: foot dorsiflexion (grade 0-5, both sides)
• Posterior tibial: toe flexion (grade 0-5, both sides)
• Froment's sign
• Claw hand assessment
• Foot drop assessment

HANDS (5 min)

• Claw deformity (which fingers, bilateral?)
• Thenar wasting
• Hypothenar wasting
• Interosseous guttering
• Trophic changes, ulcers, scars, contractures
• Grip strength, pinch strength

FEET (5 min)

• Foot drop, toe deformities
• Plantar ulcers (site, depth, size, discharge)
• Plantar sensation map (monofilament/ballpoint pen)
• Callus, fissures, trophic changes

EYE (5 min)

• VA both eyes
• Lagophthalmos (measure gap)
• Bell's phenomenon
• Corneal reflex (V1)
• Corneal clarity
• Anterior chamber (pupil, iris, synechiae)
• Madarosis
• ENL: iritis, scleritis

SYSTEMIC (5 min)

• Nose: saddle deformity, septal perforation, nodules
• Ears: earlobe nodules, GAN
• Throat: hoarseness, laryngeal involvement
• Testes: size, tenderness (males, especially LL)
• Gynecomastia
• Lymph nodes
• Liver/spleen
• Feet: pulses, Charcot joints
• Reflexes

DISABILITY GRADING (2 min)

• Grade eyes: 0 / 1 / 2
• Grade hands: 0 / 1 / 2
• Grade feet: 0 / 1 / 2
• Record maximum disability grade (worst of three)

---

SECTION E: ADDITIONAL VIVA QUESTIONS ON MUSCLE/SYSTEMIC EXAMINATION

---

• Ulnar nerve damage → loss of 3rd & 4th lumbricals + all interossei + hypothenars
• Median nerve damage → loss of 1st & 2nd lumbricals + thenaars

---

---

---

---

1. Sensory loss (posterior tibial nerve): Patient cannot feel trauma, heat, or pressure on plantar surface
2. Repeated microtrauma and hyperkeratosis: Abnormal gait from motor changes + daily weight-bearing on insensate foot → callus buildup → pressure underneath callus increases
3. Ulceration and deep penetration: Pressure necrosis under callus → ulcer tracks deep to fascia, tendon, bone → osteomyelitis → Charcot joint → digit or foot loss if untreated

• Painless (patient often unaware)
• Located at maximum pressure point
• Surrounded by hyperkeratotic callus
• May be covered by callus - probe the callus to find hidden ulcer
• Often infected secondarily (diabetic foot mimicry)

---

---

COMPLETE CASE HISTORY

Long Case - Dermatology

---

---

PATIENT IDENTIFICATION DATA

---

CHIEF COMPLAINTS

1. Three hypopigmented patches over the trunk - 6 months
2. Reduced/absent sensation over the patches - 5 months
3. Mild itching absent; no pain over the patches

---

HISTORY OF PRESENT ILLNESS

---

DETAILED QUESTIONNAIRE ON NEURAL SYMPTOMS

• He admits to occasional mild numbness and tingling sensation in the right hand (ulnar side - little and ring fingers) since approximately 3 months, which he initially dismissed as "pressure from sleeping on his arm at night." The tingling is intermittent and not severe.
• He denies any burning, shooting, or electric-shock-like pain in the hands or feet.
• He denies any difficulty distinguishing hot from cold with hands or feet, though on directed questioning he recalls "once or twice not feeling a hot vessel properly" while cooking.
• He has not burned or injured himself without feeling it (no significant history of unnoticed trauma).
• He denies numbness over feet or plantar surface.

• He denies any weakness of hand grip.
• He denies difficulty spreading fingers or picking up small objects.
• He denies wrist drop or inability to extend the wrist.
• He denies foot drop or difficulty walking or lifting his foot.
• He denies inability to close either eye fully.
• He has not noticed any deformity of the fingers, toes, hands, or feet.

• He denies direct pain or tenderness along any nerve in the arms, legs, or face.
• He has not noticed any swelling or thickening of any nerve in the arm or neck himself.

---

REGARDING LEPROSY REACTIONS

• He denies any sudden redness, swelling, or warmth of the existing patches.
• He denies appearance of new, inflamed patches suddenly.
• He denies sudden worsening of any previously described numbness.

• He denies appearance of new, painful, red raised nodules over normal-looking skin.
• He denies fever, joint pains, or body aches accompanying the skin condition.
• He denies painful swelling of testes.
• He denies redness or pain in eyes.

---

REVIEW OF SYSTEMS

---

PAST HISTORY

• Diabetes mellitus: Denied. No history of polyuria, polydipsia, or polyphagia. No family history of diabetes.
• Tuberculosis: Denied. No history of prolonged cough, evening fever, night sweats, or significant weight loss. Not on any TB treatment. BCG vaccination scar present on left upper arm (childhood vaccination per Nepal EPI programme).
• Hypertension: Denied.
• Leprosy (previous episode): Denied.
• Other chronic illness: Denied.

---

DRUG HISTORY

• Current medications: None regular.
• Past medications: Self-applied clotrimazole cream (OTC) for 6 weeks - no improvement.
• Drug allergies: No known drug allergies. No known allergy to sulfonamides (important before prescribing dapsone). He has never taken rifampicin, dapsone, or clofazimine.
• Traditional/herbal medicine: He applied mustard oil (तोरीको तेल) over the patches, believing it would help; no change noted.
• Alcohol and tobacco: He drinks locally brewed alcohol (tongba/rakshi) approximately 1-2 times per week - moderate social use. He smokes 5-6 cigarettes per day (bidi) - 10 pack-years. Both are relevant for compliance and peripheral neuropathy co-morbidity.

---

FAMILY HISTORY

• Father: Alive, 68 years. Healthy. No skin patches or nerve thickening known.
• Mother: Alive, 63 years. Has type 2 diabetes (on oral hypoglycaemics). No skin problems.
• Siblings: Two brothers. Elder brother (45 years) - healthy. Younger brother (35 years) - lives in the same household. On directed questioning, Ram mentions his younger brother had a "whitish patch" over his left forearm about 18 months ago which "went away on its own." This is highly suspicious for prior indeterminate or paucibacillary leprosy or contact exposure - needs screening urgently.
• Wife (35 years): No skin complaints. Lives in same household. Contact screening mandatory.
• Children: Two children (son 12 years, daughter 8 years). No skin complaints reported. Both must be screened.
• Family history of leprosy: No confirmed history. However, the younger brother's history is suspicious.

---

PERSONAL HISTORY

---

SOCIAL HISTORY

• Lives in a 3-room house with wife, two children, and younger brother (total 5 members) in Ward No. 7, Bhaktapur.
• House is semi-permanent structure (brick and mud). Ventilation is moderate - windows present but small.
• Household crowding present (5 members in 3 rooms) - relevant for transmission risk.
• Has access to piped water and basic sanitation.
• Bhaktapur is NOT a high-endemic district (Province 2/Terai is the highest burden area in Nepal). However, leprosy cases do occur in Bagmati Province.

• Farmer and agricultural labourer. Works with soil and plants daily.
• Also does occasional daily-wage construction work in Bhaktapur.
• No occupational exposure to known leprosy sources beyond community.

• Travelled to Saptari (Province 2, Terai - endemic area) for agricultural work for approximately 3 months, 2 years ago. This is highly significant - Province 2 has the highest leprosy burden in Nepal. He stayed in crowded worker accommodations.
• No travel outside Nepal.

• He is very concerned about stigma. He is aware that "kustharog" (the Nepali colloquial term for leprosy) carries severe social stigma, including fear of abandonment, discrimination in the community, and impact on his children's marriage prospects.
• He has not told anyone except his wife about the suspected diagnosis.
• He is willing to take treatment but fears side effects of "strong medicines."
• His wife is supportive.
• He has moderate health literacy. He understands the disease is curable but needs reassurance.

---

SOCIOECONOMIC HISTORY

• Income: He earns approximately NPR 500-700/day as daily-wage agricultural/construction labour. Income is irregular.
• Socioeconomic class: Lower-middle class.
• Health insurance: Enrolled under Nepal's Rastriya Swasthya Bima Karyakram (National Health Insurance), though coverage for some diagnostics may be limited.
• Access to MDT: He is within reach of Bhaktapur Hospital (within 5 km). MDT is free under Nepal's National Leprosy Programme.
• Treatment compliance risk factors: Irregular income, alcohol use, anxiety about stigma, poor health literacy regarding leprosy reactions. Will need enhanced counselling.

---

IMMUNIZATION HISTORY

• BCG: Received in childhood (scar present left deltoid). This is relevant as BCG provides 28-60% protection against leprosy.
• Other childhood vaccines received as per Nepal's EPI programme.

---

PRELIMINARY SUMMARY (Clinical Summary for Presenting the Case)

---

PROVISIONAL DIAGNOSIS

• 3 skin lesions on the trunk (1-5 lesions = PB by WHO classification)
• Anaesthesia in the patches (cardinal sign of leprosy)
• Possible mild ulnar nerve involvement (tingling - right hand)
• No systemic features, no reaction, no MB features (no nodules, no madarosis, no leonine facies)
• Travel history to endemic Province 2
• Household contact with suspicious skin patch history (younger brother)
• Failure to respond to antifungals confirms it is not tinea versicolor/pityriasis versicolor

---

DIFFERENTIAL DIAGNOSES

---

PLAN FOR INVESTIGATIONS

1. Slit-skin smear (SSS) - from all 3 lesion edges + both earlobes + chin. Stain with Fite-Faraco. Report BI and MI. (Expected: likely negative = PB, but if positive, reclassify as MB)
2. Skin biopsy - from the most active, well-defined border of the left upper back lesion. Request: H&E + Fite-Faraco + S-100 stain.
3. Nerve function assessment:
   • Sensory: ballpoint pen test over all lesions AND hands AND feet
   • VMT: facial (eye closure), ulnar (5th finger spread), median (APB), peroneal (dorsiflexion)
   • Nerve palpation (GAN, ulnar, median, radial, common peroneal, posterior tibial)
4. WHO Disability Grading (eyes, hands, feet) at baseline
5. Blood investigations before MDT:
   • CBC (baseline; dapsone monitoring)
   • G6PD levels (male patient - risk of haemolytic anaemia with dapsone)
   • LFTs (rifampicin hepatotoxicity monitoring)
   • RFTs (baseline)
   • Fasting blood sugar (rule out diabetic neuropathy as co-morbidity; mother has T2DM)
   • CXR (rule out TB before starting rifampicin; BCG scar present)
6. Urine dipstick (baseline proteinuria screening)

---

COUNSELLING PLAN

1. Explain the diagnosis in simple Nepali: "Timro yeh kustharog ho, joh upachar garna sakiyo. Ausadhi liera yeh ramro huna sakcha." ("This is leprosy, which is curable. With medicine it can be healed.")
2. Reassure: Leprosy is NOT highly contagious; routine household contact is generally safe; once treatment starts, patient is not significantly infectious within days.
3. Explain MDT: 3 drugs, 6 months (PB), free at hospital.
4. Warn about side effects: orange-red urine (rifampicin - normal), skin darkening (clofazimine - temporary), possible mild anaemia (dapsone - test G6PD first).
5. Explain reactions: what to watch for (sudden redness/swelling of patches, new painful nodules, sudden weakness, eye redness) and that reactions need URGENT medical attention.
6. Stress: come monthly for supervised rifampicin dose; do NOT miss doses.
7. Organize contact screening for: wife, son (12 yr), daughter (8 yr), younger brother (suspicious past skin lesion).
8. Offer younger brother SDR-PEP (Rifampicin single dose) if eligible and if current leprosy diagnosis confirmed.
9. Register case in Nepal's Nikusth digital surveillance platform.
10. Address stigma actively; involve ANM/health worker for community support if needed; maintain strict confidentiality.

---