A patient with borderline lepromatous (BL) leprosy on multi-drug therapy develops sudden painful erythematous nodules and plaques with fever, malaise, and nerve tenderness. Histopathology of the nodule shows lymphocytic infiltrate around vessels and nerves without foam cells. The most likely diagnosis and treatment is:
- A Type 2 lepra reaction (ENL); thalidomide or prednisolone
- B Type 1 lepra reaction; prednisolone 40-60 mg/day ✓
- C Lucio phenomenon; plasmapheresis
- D Downgrading reaction; increasing dapsone dose
Explanation
Type 1 (reversal) lepra reaction is a delayed hypersensitivity (Type IV) reaction occurring in borderline leprosy (BT, BB, BL). It presents with sudden painful upgrading of skin lesions and acute neuritis. Histopathology shows lymphocytic infiltrate without foam cells (in contrast to ENL where immune complex deposition and neutrophilic infiltrate are seen with foam cells). Treatment is prednisolone 40-60 mg/day tapered over 6-12 months. ENL (Type 2) involves tender erythematous nodules in LL and BL leprosy mediated by immune complex deposition. The question describes BL with lymphocytic infiltrate, consistent with Type 1 reaction.
Reference: Neena Khanna Illustrated Synopsis of Dermatology & STD, 6th ed.
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Written and medically reviewed by the StethoPrep medical team.