A lepromatous leprosy patient on multibacillary multidrug therapy develops crops of painful erythematous nodules over the trunk and limbs, high-grade fever, and joint pains. Skin smear remains strongly positive. Which drug, acting through inhibition of tumour necrosis factor alpha, is the specific agent of choice for controlling this episode?

• A Prednisolone
• B Clofazimine
• C Chloroquine
• D Thalidomide ✓

Explanation

Erythema nodosum leprosum is a type 2 reaction mediated by immune complexes and TNF-alpha, occurring in multibacillary disease. Thalidomide is the most effective agent because it suppresses TNF-alpha production by monocytes, with rapid resolution of nodules and fever. Its teratogenicity restricts use to non-pregnant patients, so women of childbearing age receive corticosteroids instead. Clofazimine has mild anti-reaction action used for maintenance, but it is too slow for an acute severe episode.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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