1. A coolie aged 20 yrs.

reports to PHC with hypo pigmented patches on left

forearm. Explain the measures you will undertake as a Medical Officer at the
individual, family and community level.
Solution:
Presentation in leprosy-
Hypopigmented Anaesthetic patches
Loss of eyebrows
Thickening of nerves
Examination of the patient; Inspection of the body surface for any evidence of
leprosy, palpation of peripheral nerves for thickening and tenderness

Test for loss of sensation for heat cold, pain and light touch
See for paresis or Paralysis of muscles of hand and feet leading to disabilities or
deformities
Clinical Classification: WHO Classification based on no.of skin lesion
Paucibacillary – single skin lesion
Bacillary – multiple skin lesion
Multi bacillary – Leprosy

Features Paucibacillary Bacillary multiple Multi bacillary –

Single skin lesion skin lesion Leprosy

Skin lesions 1 2 to 5 More than 5

(a symmetrical) (symmetrical)
Nerve involvement No Only More than
1 nerve 1 nerve trunk
Skin Smear Negative Negative Positive

Treatment regimen:
Paucibacillary- single skin lesion- Rifampicin-600 mg, Single dose
Ofloxacin- 400 mg, Single dose
Minocycline- 100 mg, Single dose
Paucibacillary – multiple skin lesion-
Rifampicin- 600 mg, once a month supervised for 6 months
Dapsone 100 mg daily, Self administered for 6 months
Multi bacillary-Leprosy-
Rifampicin- 600 mg, once a month supervised for 12 months
Dapsone 100 mg daily, Self administered for 12 months
Clofazamine 300 mg once a month supervised and 50 mg daily self administered
for 12 months
2. You are in an area that is moderately endemic for leprosy. What do you do when
a school teacher reports you that one of the boy in the class has developed a
hypopigmented patch on the left forearm ?
Ans : SOLUTION
I. Collection of baseline data
- Name, age, sex of the patient
- Total number of persons having similar complaints
- Hygiene practices
- Source of infection
II. Confirmation of diagnosis
A. History : well defined patch – tubeculoid
Ill defined patch – lepromatous
In between – borderline
If anaesthesia is present, think of leprosy. If anaesthesia is absent, think of other
conditions. Hypo or hyperpigmentation.
Ask for any deformity, if present – borderline
Ask for glove and stocking anaesthesia – lepromatous anaesthesia
Past history : ask for H/o progressiveness
History of appearance, disappearance and reappearance of patches
Personal history : Hygiene practices, smoking, alcohol intake history of contact.
Family history : History of family members having leprosy
History of contact with leprosy patient for a long time.
B. Clinical examination:
Mucocutaneous examination
- No. of patches 2-5 (paucibacillary) BI < 2
( tuberculoid, borderline, intermediate)
> 5 (multibacilliary) BI > 2
(borderline-borderline, borderline lepromatous, lepromatous, single lesion).
Type of lesion: symmetrical (tuberculoid BT)
Asymmetrical lepromatous (BB, BL)
Test for anaesthesia :
Pin test : loss of deep touch
Heat and cold test : loss of sensation, sensory impairment
Sweat test : absent in leprosy
Pigmentation : hypo or hyperpigmentation
Infiltration : head – eyebrows, earlobes, cheeks, legs and hands. Look for glove and
stocking type of anaesthesia.
C. Peripheral nerve examination:
 Ulnar nerve
 Lateral popliteal nerve
 Median nerve
  Dorsal branch of radial nerve
 Temporal nerve
 Posterior tibial nerve
 Greater auricular nerve
 Pure neuritic (MB) 1 nerve with 1 patch
D. Paresis or paralysis of hands and feet :
Leads to disability or deformity
Borderline tuberculoid, borderline lepromatous, borderline-borderline.
E. Investigation:
- Slit skin smear examination ,Nasal scrapings
Bacteriological index : WHO grading
Negative : no bacilli found in 100 fields
1+ : 1/<1 bacillus in each field
2+ : Bacilli in all fields
3+ : many bacilli in all fields
Add ‘6’ to entry if globi is present.
BI is calculated by totaling the number of positive given to each smear and
dividing this number by the number of smears collected.
Minimum of sites :
4 from skin lesions
1 nasal swab
2 smears each earlobe
Morphological index :
Criteria for calling the bacilli solid rods are :
- Uniform staining
- Parallel sides
- Rounded ends
- Length 5 times that of width
Biopsy reveals accurate classification (wedge biopsy)
Foot pad culture:
Histamine test : 0.1ml of 1:1000 solution of histamine phosphate and
chlorohydrate is injected intradermally into hypopigmented patches or anaesthetic area.
Loss of flare response in leprosy as nerve is destroyed.
III. REGISTRATION OF CASES
IV TREATMENT :
Paucibacillary- single skin lesion- Rifampicin-600 mg, Single dose
Ofloxacin- 400 mg, Single dose
Minocycline- 100 mg, Single dose
Paucibacillary – multiple skin lesion-
Rifampicin- 600 mg, once a month supervised for 6 months
Dapsone 100 mg daily, Self administered for 6 months
Multi bacillary-Leprosy-
Rifampicin- 600 mg, once a month supervised for 12 months
Dapsone 100 mg daily, Self administered for 12 months
Clofazamine 300 mg once a month supervised and 50 mg daily self administered
for 12 months
V. SURVEILLANCE :
- Paucibacillary – once a year for 2 years
- Multibacillary – once a year for 5 years after the completion of treatment.
VI. ADVICE TO PATIENTS :
- Protect affected part from heat, pressure
- Wear soft chappals – MCR (micro cellular rubber)
- Treatment without delay
- Practice personal hygiene and protection
i. Covering of eyes while sleeping if facial nerve is involved.
ii. Examine eye daily for foreign body conjunctivitis
iii. Cover eyes while walking in the dust
iv. Apply olive oil to hands and legs while sleeping to avoid dryness of skin and
cracking.
v. Cleaning of dead skin by washing legs in lukewarm water and scraping.
- Repeated changing of hands while drinking hot beverages.
- Touching hot objects by covering of hands with cloth.

VII. ADVISE TO FAMILY

- Health education to relieve stigmatized family.
- Motivate to take drugs regularly.
- Dapsone prophylaxis for child, on contact (1-4mg /kg x 3 yrs)
- Protection from droplet infection
- Screening of family members
3. In a hostel 10 students are suffering from scabies
a. How will you diagnose it?
b. What is the treatment?
Solution:
1) Diagnosis is done by-
a) Chief complaint
b) Examination findings
a) Chief complaints are-
1) Intractable itching which gets worse at night & after a hot bath
2) Burrows with characteristic & pathognomonic these are present in the
deeper parts of corneal layer, epidermis
3) It may present as papules, vesicles, excoriation & crusted lesions
4) Sites of distribution of lesions are interdigital spaces, front of forearm
region of genitallia, buttocks, and axilla
5) Confirmation is done by isolation of the mite Sarcoptes scabies hominis
from the skin debris under the microscope

2) Treatment
a) Before treating, the patient is given a good scrub bath with soap & hot
water. Then apply 5% permethrine cream with the help of paint brush to
whole body & allow it to dry. After 12 hrs, bath is given then clothes are
changed & washed.
All the family members must be treated as scabies is household infection
and affects all the family members. It is the household which needs to be
treated. Beds and linen be washed and sun dried
b) Single injection of Ivermectine 200 mg/kg. 1m
c) Methotrexate in Norwegian Scabies
d) Sulfur ointment 10% for adults & 5% for children
4. Many cases of scabies have been reported in a family in a village. Outline in
measures you will take to control the infection ? Or (Many cases of scabies are
observed in a certified school among 100 inmates children 6-14 yrs).
Ans.
Baseline data collection
- Name of the cases
- Age
- Sex
Confirmation of diagnosis :
Proper history - Itching
- Nocturnal itching
- Sharing clothes, beds, towels
- Other members suffering simultaneously
Clinical examination – Distribution
of lesions
Nature
Investigations – Demonstration of parasites from cutaneous lesions.
Prevention and control : using scabicide
I. Elimination of reservoir :
- 1% gammexane (lindane) or (BHC)
It is highly irritant so that it has to be mixed with coconut oil 2 applications in a week.
- 25% benzyl benzoate emulsion – every lesion should be ruptured. Scrub bath on the
1st day to open up the burrows with the help of paint brush, apply it over the body
below chin.
II. Breaking the channel transmission :
- By avoiding close physical contact.
- Disinfection of all clothes, bed spreads, towels by washing in hot water and dried in
hot sun preferably followed by iron.
III. Protection of susceptibles :
- Blanket treatment : giving treatment simultaneously for all members of family.
- Maintaining high standard of personal hygiene.
- Treatment of other members affected.
5. Gopi is a 26 year old male who works as a truck driver. He has been hospitalized
with a compliant of intermittent fever of 3 mths. duration and cough of 2 mths.
duration Gopi has also been suffering from diarrhoea for the last two months and
has developed persistent swellings in the neck, axilla and groin. Mention how you
will investigate and manage this patient if under your care.
Ans : Collection of baseline data
Name, age, sex, occupation
Confirmation of diagnosis:
Ask for History:
Major signs :
 Weight loss  10% of body weight.
 Chronic diarrhea for >1mth.
 Prolonged fever for > 1mth (intermittent or constant).
Minor signs :
 Persistent cough for > 1mth.
 Generalized pruritic dermatitis.
 History of herpes zoster.
 Oropharyngeal candidiasis.
 Chronic progressive or disseminated herpes simplex infection.
 Generalized lymphadenopathy.
2 of the major signs in combination with
INVESTIGATIONS :
 HIV ELISA
 Western Blot
 CD4 Lymphocyte count.
 Complete hemogram.
Treatment :
ART should be initiated in all adults with HIV, regardless of WHO clinical stage and at
any CD4 cell count.
Antiretrovirial treatment :
First-line ART for adults should consist of two nucleoside reverse- transcriptase
inhibitors (NRTls) plus a non- nucleoside reverse transcriptase inhibitor (NNRTI) or an
integrase inhibitor (INSTI) :
2 NRTIs + NNRTI
: Zudovudine + Lamivudine + Nevirapine
AZT 3TC NVP
300mg BD + 150 mg BD + 200 mg BD.
Or
Tenofovir + Lamivudine + Efavirenz
TDF + 3TC (or FTC) + EFV