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1. ESTHER NIMISHA

2. 1) LEPROSY REACTION
2) ADVERSE EFFECT OF ANTI-LEPROTIC
DRUGS
3) DISABILITIES & DEFORMITIES
4) PSYCHO-SOCIAL PROBLEMS

3. -acute episodic exacerbation & remission of
symptoms and signs of inflammation during active
stage of leprosy & directly related to leprosy.
-reactions are due to heightened immunological
response of the host to M.lepre or its breakdown
products.
-two types:a) type 1
b) type 2

4. -due to rapid change in CMI either for better or for
worse.
-seen in BT,BB & BL.
-also called upgrading or reversal reaction due to
rapid increase in CMI as better response to t/t.

5. -due to antigen-antibody reaction in presence of
complment and not due to change in CMI
-it is seen in LLp & LLs and rarely in BL

6. -treat neuritis
-rest to the part affected
-analgesic
-if severe then steroid (anti inflammatory doses) can
be given
-if tenderness and thickening of nerve
persisting,perineural infiltration with triamcinolone.

7. -bed rest
-analgesics and antipyretics
-systemic steroid ,starting at 40 mg/day ,tapering at
2 wks interval
-oral thalidomide (300-400 mg/day),tapering after
the lesion subsides

8. DRUGS MINOR MAJOR
1. RIFAMPICIN RED URINE JAUNDICE
GIT UPSET HEPATITIS
FLU LIKE SYNDROME SHOCK
2. DAPSONE GIT UPSET DAPSONE SYNDROME
DRUG RASH EARLY SJS
ANAEMIA HEMOLYTIC ANAEMIA
AGRANULOCYTOSIS
3. CLOFAZAMINE GIT UPSET ACUTE PAIN
ABDOMEN
DISCOLOURATION OF SKIN
ICHTHYOSIS

9.  Disabilities such as loss of sensation and
deformities of hands/feet/eyes occur because:
◦ Late diagnosis and late treatment with MDT
◦ Advanced disease (MB leprosy)
◦ Leprosy reactions which involve nerves
◦ Lack of information on how to protect
insensitive parts

10.  The affected person finds it difficult or impossible
to perform some activities at home or at workplace
b/c of some impairment.
 Onlyabout 10-15% of leprosy affected person
develop significant deformities and disabilities.

11. 1) Specific deformities:
- b/c of local infection with M.Leprae
- seen most often in the face(loss of eyebrow,nasal
deformity),less often in the hand and only occassionly
in the feet.
2) Paralytic deformities:
- result from damage to motor nerve.
-seen most often in the hand(claw finger),less
often in the feet &occassionly in the
face(lagopthalomos,facial palsy)

12. 3)Anesthetic deformity :
- Occur as a consequence of neglected injuries in
part rendered insensitive b/c of damage to
sensory nerve.
- Found most often on the feet and
hand(ulceration,scar contrature,shortening of
digits,multilation &skeletal disorganization of foot)

13. GRADE HAND & FEET EYES
0 NO DISABILITY FOUND NO DISABILITY FOUND
1 NON VISIBLE DAMAGE NO GRADE 1 FOR EYE
(LOSS OF SENSATION)
2 VISIBLE DAMAGE Inability to close,obvious
(wounds,ulcer,deformity due to redness,visual
muscle weakness,loss of tissue impairement,blindness.
such as foot drop,clawhand,loss or
partial resorption of fingers/toes)

14. 1)STAGE OF PARASITIZATION
- A few M.leprae found in the nerve,but no other damage
2)STAGE OF TISSUE RESPONSE
- Bacilli recognised, host tissue response present.range
from indeterminate through tuberculoid and borderline to
lepromatous
3)STAGE OF CLINICAL INVOLVEMENT
-Nerve clinically thickened with or without associated pain
or tenderness.
-no nerve funtion deficit (NFD)detected clinically
-
-

15. 4)STAGE OF NERVE DAMAGE
-clinically detectable NFD present,Recovery
possible.
5)STAGE OF NERVE DESTRUCTION
-conducting elements destroyed
-irreversible NFD
-long standing muscle paralysis with severe
wasting.

16.  Refer to all the action taken to achieve the sole
aim of preventing damage to nerve trunk of the
limbs and the eyelids & thereby prevent
permanent loss of sensibility and muscle paralysis
involving these part.
 M/n can be divided into;
a) No neuritis and no NFD
b) With neuritis but no NFD
c) With no neuritis but with NFD
d) With neuritis and NFD

17. a) NO NEURITIS,NO NFD
-Pt has no problem at present & so no active nerve care
is necessary.
-but,if there is risk of developing neuritis(BB or BL
leprosy with thickening of more than two nerve trunk
and past history of reaction or neuritis),pt should be
warned of that possibility & asked to report without
delay.

18. b) NEURITIS PRESENT,NO NFD
-In case of moderate neuritis,start with 30 mg
prednisolone daily and then reduce the dose by
5mg/wk.
-In severe cases,higher dose(40,60,even 80 mg per
day depending on severity),bring the dosage to
30 mg in course of 2-3 wk & maintain the dose for
3 month before tapering the dose down.

19. -In BT cases,if there is no improvement within 24-72
hrs of starting t/t or if condition worsens,despite
steroid,it suggest that drug is not reaching site of
inflammation b/c of ischemia,immediate surgical
decompression should be done.
-in BL& LL,where ENL is likely cause of neuritis,one
can wait for 6wk &consider decompression,if there
has been no significnt clinical improvement.

20. c) NO NEURITIS,NFD PRESENT
-M/n depends on;
1)Whether the NFD is capable of recovery.
2)Depends on anti leprosy t/t status of the pt.
-Recovery will not be possible if nerve has been
destroyed by inflammatory process.
-Recovery may be possible if NFD is of recent
onset,incomplete&no obvious and severe muscle
wasting.

21. a) No neuritis,NFD present &considered
irreversible;
M/m:Ignore NFD .train the pt in disability prevention
practice,provide physiotherapy & reconstructive
surgery ,if possible.
b) No neuritis,NFD present but considered
reversible,pt has had MDT
M/m:start with 30 mg of predinosolone daily for 90
days or as long as NFD shows
improvement,tepered off over 30 days.

22. c)No neuritis,NFD present but considered
reversible,pt has not had MDT
m/n:provide MDT and monitor NFD (In many cases
nerve function improves with anti leprosy
chemotherapy)
- If NFD has not improved in 3 month,start standard
course of steroid.
- Continue with steroid as long as improvement
continues,taper off steroid after 3 mnth or wen
there is no further improvement.

23. d)NFD present,considered reversible,onset or
worsening of NFD while under MDT
-start standard course of steroid.
-monitor NFD monthly.
-continue with the steroid as long as improvement
continues,taper off steroid after 3 mnth or when
there is no further improvement which ever is
later.

24. d)NFD present,neuritis present
m/n;start high dose of steroid(40-80 mg /day)
-reduce to maintence dose (30 mg/day)over 2-4 wks
or continue as long as there is improvement or for
at least 3 mnth whichever is later,then taper off,
-surgicl decompression need to be done, if there is
no significant improvement in neuritis with 3-7
days of starting steroid.

25. -Nerve trunk thickens in leprosy:
a)Accumulation of granuloma cell within the
fascicle,
b)Thickening of neural investment,
-Two consequence result from excessive
enlargement of nerve:
a)External compression
b)Internal compression

26. It is indicated:
- when medical &ancillary method are being used
&found inadequate to control the inflammatory
process,
- other indication is intractable nerve pain where
continues steroid therapy has become neccessary
just for relief of pain,

27. -In most cases,these are cold abscess with
caseation and colliquative necrosis,
-’hot abscess’ occur in ENL related acute neuritis&
are usually microscopic,
a)If nerve shows no NFD:w/w.Evacuate the abcess
&excise only if overlying skin is likely to
breakdown &form sinuses,
b)If nerve considered irrecoverable damaged:same
t/t
c)If NFD considered likely to recover:evacuate
&excise the abscess

28. impairment Direct consequence Late consequence
Damage to somatic Loss of sensibility Anesthetic
sensory fibers deformity(ulcer,hand
deformity,shortening of
digits)
Damage to motor nerve Muscle paralysis and contrature
paralytic deformity
Damage to sudomotor Dry skin Deep cracks,hand
autonomic fibers infection
Lepra rkn Inflammatory Severe fixed
edema,osteoporosis, deformity(intrinsic plus
pathological fracture finger,bizarre deformity)

29. 1) LOSS OF SENSIBILITY
-pt is deprived of an important source of information
-deprives the hand of its protective mechanism
-motor activity becomes clumsy.
2) DRYNESS OF PALMER SKIN
-due to destruction of autonomic sudomotor fibers;
-dry skin crack frequently especially at digital
creases,

30.  Cracks and fissures  Soak in water
 Apply cooking
oil/Vaseline
 Injury care -Precaution against burn
- Against cut &penetrating
wound
-covering with thick towel.
-using utensils with
insulated handle

31. c) PARALYTIC DEFORMITIES OF THE HAND
-occur due to destruction of motor fibers in the major
nerve trunk.
ULNAR PALSY
-occur when lumbrical &interossei muscles , which
balance long extensor & flexor at the MCP and PIP
jt are paralysed.

32. -when both ulnar and median nerve are paralysed,
pt has total claw hand(intrinsic zero hand)
-it lies curled up beside the palm
-it doesnot lift off the palm to oppose the other digits

33. a) PHYSICAL MEASURES
- best exercise to put all jt thr’ their range of
movement several times a day.
b) SPECIFIC EXERCISE
- to hold his clawed finger with his thumb and
index finger in total flexion at MCP jt and move
PIP jt up and down.

34. 1) ADDUCTOR BAND SPLINT
2) GUTTER SPLINT
3) FINGER LOOP SPLINT
GRIP –AIDS
- Epoxy resin grip applied on article of work helps
,hold the object & increase efficiency in working
environment.

35. 1) LASSO INSERTION
-attaching the motor tendon slip distally to the
fibrous flexor sheath provide correction by
augmenting flexing force at MCP jt to counter
extending force.
2) ZANCOLLI’S OPERATION
-shortening anterior capsule of the jt and flexor
pulley advancement

36. 1) PLANTER ULCERATION
2) DROP FOOT
3) FIXED DEFORMITY OF TOES & FEET
4) TARSAL DISORGANIZATION
PLANTER ULCER
-found in 10% of leprosy pt.
-80% cases occur in ball of foot at MTP jt region
-5-10% in the mid lateral part of sole.
-5-10%in the heel.

37. 1) INJURIES FROM WITHOUT
2) INFECTION THROUGH A FISSURE IN THE SKIN
3) BREAKDOWN OF TISSUE FROM WITHIN(DUE
TO WALKING)
STAGES IN THE DEVELOPMENT OF ULCER:
1) STAGE OF THREATENED ULCERATION
2) STAGE OF CONCEALED ULCERATION
3) STAGE OF OPEN ULCERATION

38. 1)STAGE OF THREATENED ULCERATION:
-foot should be rested in a splint
-no wt bearing on the affected foot
2)STAGE OF NECROSIS BLISTER:
-blister is padded well
-if danger of breaking open,it is snipped & sealed
with adhesive plaster and a below knee POP.
-cast removed after 3 wks & asked to use protective
footwear.

39. 1)ACUTE ULCER:are frankly infected,purulent,
covered with slough and are acutely inflammed.
2)CHRONIC ULCER:indolent ulcer with heaped up
hyperkeratotic edge,serosanguineous discharge &
covered with pale granulation tissue.
a) SIMPLE
b) COMPLICATED

40.  ACUTE ULCER:
-absolute bed rest
-elevate the foot
-Eusol bath,irrigation,dressing
-limit surgery to drinage proced
-antibiotic if needed
-treat as chronic ulcer after acu
te phase subside.

41. 1) SIMPLE :
-Scraping floor of the ulcer
-sticking plaster or vaseline gauze
dressing.
-below knee POP cast or bulky
dressing.
-protective footwear+foot care
trainig.

42.  COMPLICATED:
-Ulcer debribment
-physiological rest by below
knee POP cast
-protective footwear on POP
removal
-corrective deformity,if necc.
-identify other complication
& treat accordingly
-skin graft of large ulcer.

43.  RECURRENT:
- improve quality of scar(scar rev
ision using exision and suture
local flap,distant flap,free flap)
- reduce load on scar by footwear
modification or corrective surg
-eradicate infection.

44. 1) PROTECTIVE FOOTWEAR:
-should have a tough outer sole that will resist
penetration by thorn,nails,glass,
-itself doesnt have any nails,
-upper/straps and buckle should not rub against the
toes or cause undue pressure,
-MCR(microcellular rubber ) m/c used for reducing
the stress generated during walking.

45.  Infected ulcer/Cracks  Clean with soap & water
 Rest & apply antiseptic dressing
 Apply cooking oil/Vaseline
 Wounds/injury
 Soak in water
 Clean and apply clean bandage
 Protect when working/cooking
 Oil massage
weakness/paralysis  Exercises

46. -about 1-2% of leprosy pt develop drop foot
due to damage to common peroneal nerve.
-pt is unable to lift the foot up & it droops down when the
leg is lifted.
-if paralysis is recent,good recovery with steroid.
-drop foot (>1yr), unlikely to recover with steroid therapy &
require surgical correction.

47.  SRINIVASAN OPERATION:
-Two tailed transfer of tibialis posterior to the tendon
of extensor hallucis longus & extensor digitorum
longus in the dorsum of foot.
-when surgical correction are C/I, a drop foot
appliance can be used which hold the foot at rt
angle with the help of strap,stops or springs.

48. -One or more tarsal bone are damaged &
progressively destroyed.
- firstly,due to spread of sec infection from plantar
ulcer,
-calcaneum and cuboid are commonly damaged.
-can be t/t with appropriate antiboitics & surgical
clearance of infected tissue, healing takes place
with bony fusion and stable foot.

49. -secondly, occur as a result of injury,weakened by
osteoporosis from neighbouring infection or
prolonged immobilisation.
-Talus and navicular are m/c affected
-broken bone is not allowed to heel,walking is
continued leading to the breakdown in the skeletal
architecture & soft tissue swelling.
-T/t: immobilization in a plaster cast & rest

50. 1)LOSS OF EYEBROWS(MADAROSIS)
-results from atrophy of hair follicle as a result of
lepromatous infiltration of forehead & eyebrow
region.
-corrective surgery:
a) Transplantation of hair follicle through free grafting
of scalp skin.
b) Transfer of artery pedicled island of scalp.
c) Long pedicled scalp flap.

51. 2) PREMATURE SENILITY
-facial skin is over streatched by heavy LL
-elastic fibres in the dermis and sub dermal region are
destroyed
-’FACE LIFT OPERATION’: here excess skin is excised,
left overskin gets stretched & wrinkles flatten out.

52. 3) MEGA LOBULES:
-elongated ear lobe hangs down lose.
-corrected by excising the infero-medial segment of
lobule using curved incision(cresent wedge
resection)
4)NASAL DEFORMITY:
-ant &antero-inferior part of nasal cavity is
commonly involved in LL

53. -Nose loses its mucosal lining and internal surface
of the nose loses its skeletal support.
-nasal septum is destroyed.
-without skeletal support,nose falls back on the
face.
-internal raw surface adheres to the facial skeleton
leading to ‘SUNKEN NOSE’.

54. -regular irrigation of the nasal cavity.
-smearing the nostril with liquid paraffin,vaseline or
vegetable oil to prevent formation of crust.
-’POST NASAL EPITHELIAL ONLAY GRAFTING
OF GILLES’ ,done for sunken nose deformity.

55. -Due to direct invasion of ocular structure like
conjunctiva,sclera,and choroid by M.leprae.
-deposition of immune complexes in the ciliary apparatus
give rise to acute iridocyclitis.
-damage to upper branch of facial nerve give rise to
weakness of eyelid & lagopthalmos.
-damage to peripheral branches of trigeminal nerve result
in corneal anesthesia.

56.  Redness and pain  Aspirin or paracetamol
 Atropine and steroid
ointment
 Cover with eye pad
 Injury to cornea  Apply antibiotic ointment
 Refer
 Tear substitute eye drops
 Exercises
 Difficulty in closing eye  Dark glasses to protect
 Refer

57. -enlargement of breast in males.
-usually b/l.
-due to hormonal imbalance b/c of testicular and
liver damage.
-simple mastectomy is t/t of choice(WEBSTER’S
OPERATION)

58. -are related to widely held beliefs and prejudices
concerning leprosy & its causes.
-they often develop self stigma,low self esteem &
depression as a result of rejection and hostility,
-need to be referred for proper counselling.