A 42-year-old woman from Odisha with borderline tuberculoid leprosy (BT) on MDT for 3 months presents with acute onset of severe pain in both ulnar nerves, erythema over the lesions, and fever. Slit-skin smear remains positive. What is the most appropriate next step in management?

Explanation

## Lepra Reactions: Recognition & Management This patient is experiencing a **Type 1 lepra reaction (reversal reaction)**, which is an immune-mediated complication occurring during or shortly after MDT initiation. ### Type 1 vs Type 2 Lepra Reactions | Feature | Type 1 (Reversal) | Type 2 (ENL) | |---------|-------------------|---------------| | **Timing** | During/after MDT (weeks to months) | After 6+ months of MDT | | **Immunology** | Delayed hypersensitivity (Type IV) | Immune complex (Type III) | | **Lesion involvement** | Existing lesions become inflamed | New nodules, erythema nodosum | | **Nerve involvement** | Acute neuritis, common | Neuritis less common | | **Fever** | May occur | Common | | **Treatment** | Corticosteroids | Corticosteroids ± thalidomide | **Key Point:** Type 1 reactions occur in **borderline forms (BT, BL, LL)** of leprosy; Type 2 reactions occur in **LL and BL forms**. **High-Yield:** Type 1 reaction = inflammation of existing lesions + acute neuritis. Type 2 reaction = new systemic manifestations (nodules, iritis, arthritis). ## Management Algorithm ```mermaid flowchart TD A[Patient on MDT with acute nerve pain<br/>+ erythema of lesions + fever]:::outcome A --> B{Diagnosis?}:::decision B -->|Type 1 reaction| C[Continue MDT]:::action C --> D[Add systemic corticosteroids<br/>Prednisolone 0.5-1 mg/kg/day]:::action D --> E[Taper over 12-16 weeks]:::action B -->|Type 2 reaction| F[Continue MDT]:::action F --> G[Add corticosteroids ± thalidomide]:::action E --> H[Monitor for resolution<br/>of neuritis]:::outcome ``` **Clinical Pearl:** Continuing MDT during lepra reactions is crucial — it does not exacerbate the reaction and is essential for bacillary clearance. Stopping MDT risks relapse and treatment failure. ## Corticosteroid Dosing in Type 1 Reaction 1. **Prednisolone 0.5–1 mg/kg/day** (typically 40–60 mg/day) 2. Continue for 4–6 weeks at full dose 3. **Gradual taper over 12–16 weeks** to avoid rebound 4. Monitor for steroid side effects and complications **Warning:** Abrupt cessation of corticosteroids can precipitate reaction recurrence.