Question

A patient who has been on MBMDT presents with inflammation over pre-existing lesions and nerve involvement. What will be the best approach of treatment?

• A. Stop ALT and start steroids
• B. Stop ALT and start thalidomide
• C. Continue ALT and start steroids
• D. Continue ALT and give thalidomide

Hint:

In lepra reactions, anti-leprosy treatment is never stopped; the reaction is managed by adding specific anti-inflammatory agents.

Answer 1

The Correct Option is C

Step 1: Identify the clinical presentation.
The patient is on MBMDT (Multi-Bacillary Multi-Drug Therapy for leprosy -- comprising Rifampicin, Clofazimine, and Dapsone). He presents with:
- Inflammation over pre-existing skin lesions
- Nerve involvement
This is a classic description of a Lepra Reaction.

Step 2: Classify the Lepra Reaction.
There are two types of lepra reactions:
- Type 1 (Reversal Reaction): Inflammation and swelling of pre-existing skin lesions + nerve tenderness and loss of function. Caused by sudden increase in cell-mediated immunity (CMI) against Mycobacterium leprae. Common in borderline leprosy.
- Type 2 (Erythema Nodosum Leprosum -- ENL): New painful subcutaneous nodules + systemic symptoms (fever, malaise). Common in lepromatous and borderline lepromatous leprosy.

The given description (inflammation over pre-existing lesions + nerve involvement) fits Type 1 Lepra Reaction.

Step 3: Management principle.
In both Type 1 and Type 2 lepra reactions, the anti-leprosy treatment (ALT/MDT) must be continued -- it is NEVER stopped during a reaction. Stopping MDT increases the bacterial load and worsens the prognosis.

Step 4: Specific treatment for Type 1 reaction.
Corticosteroids (e.g., prednisolone) are the treatment of choice for Type 1 lepra reaction, especially when nerve involvement is present (to prevent permanent nerve damage).

Conclusion: Continue ALT and start steroids.