Bacterial Skin Infections Practice Questions

Q: Groove sign:

LGV. ***LGV*** - The **groove sign** is a characteristic clinical finding in **lymphogranuloma venereum (LGV)**, specifically in the inguinal syndrome stage [1]. - It refers to the presence of enlarged, tender **inguinal lymph nodes** separated by the inguinal ligament, creating a "groove" appearance [1]. *Chancroid* - Chancroid typically presents with **painful, ragged-edged ulcers** on the genitalia, often with associated **inguinal lymphadenopathy** (buboes) [1]. - It does not characteristically display the specific **groove sign** seen in LGV. *Genital herpes* - Genital herpes is characterized by **clusters of painful vesicles** that rupture to form shallow ulcers, which then crust over. - While it can cause **inguinal lymphadenopathy**, it does not present with the distinct **groove sign**. *Donovaniasis* - Donovaniasis, or **granuloma inguinale**, is characterized by **painless, progressive ulcerative lesions** that are highly vascular and bleed easily [1]. - It primarily involves subcutaneous tissue and can cause **pseudobuboes** but does not feature the characteristic **groove sign** [1].

Q: Lepromin test is strongly positive in:

Tuberculoid (TT). ***Tuberculoid (TT)*** - The lepromin test measures the host's **cell-mediated immune response** to *Mycobacterium leprae* antigens. - A strong positive reaction indicates a robust immune response and is characteristic of the **tuberculoid pole** of leprosy. *Lepromatous (LL)* - Patients with lepromatous leprosy have a **weak or absent cell-mediated immune response** to *M. leprae* antigens. - This results in a **negative or very weak lepromin test** due to anergy. *Borderline lepromatous (BL)* - This form lies on the spectrum between lepromatous and tuberculoid leprosy, but still leans towards a **poor cell-mediated response**. - The lepromin test is typically **negative or mildly positive**, reflecting anergy and numerous bacilli. *Borderline borderline (BB)* - The borderline forms represent an unstable middle ground, but BB often shows a **weak or negative lepromin test**. - As the disease moves towards the lepromatous pole, the CMI response weakens, making the test less reactive.

Q: A 30-year-old male, Kallu, with a history of sexual exposure presents with a painless indurated ulcer over the penis with everted margins. The diagnosis is:

Syphilis. ***Syphilis*** - The description of a **painless, indurated ulcer with everted margins** (a **chancre**) is the classic presentation of **primary syphilis** [1]. - **Sexual exposure** is the primary mode of transmission for *Treponema pallidum*, the causative agent. *Granuloma inguinale* - Characterized by **painless, progressive ulcerative lesions** without regional lymphadenopathy, often described as "beefy red." - The lesions caused by *Klebsiella granulomatis* are typically **friable** and do not present with the distinct induration and everted margins of a syphilitic chancre. *Chancroid* - Presents with **tender, painful genital ulcers** with irregular, undermined borders and often associated with **tender inguinal lymphadenopathy** [1]. - This contrasts sharply with the **painless** and **indurated** nature of the ulcer described in the patient. *Lymphogranuloma venereum* - Begins with a transient, **small, painless papule or ulcer** at the site of inoculation, which often goes unnoticed leading to delayed diagnosis. - The prominent feature is later development of **unilateral, painful inguinal lymphadenitis** (buboes) and associated systemic symptoms, which are not mentioned in this presentation.

Q: Not a cutaneous manifestation of tuberculosis:

Erythema migrans. ***Erythema migrans*** - This **bullseye-shaped rash** is the hallmark cutaneous manifestation of **Lyme disease**, caused by *Borrelia burgdorferi*, not tuberculosis. - Its presence indicates exposure to **ticks** carrying the spirochete and is a distinct entity from mycobacterial infections. *Exanthematous lesion* - While not a specific term for TB, some forms of tuberculosis can present with a morbilliform or **exanthematous rash**, especially during disseminating or paradoxical reactions. - These are non-specific skin rashes that can occur in response to various infections, including but not exclusively tuberculosis. *Scrofuloderma* - This is a direct extension of tuberculosis from an underlying infected structure, such as a **lymph node (scrofula)** or bone, to the overlying skin. - It presents as **ulcers** or sinuses with undermining edges discharging pus, and is a definitive cutaneous manifestation of localized TB. *Lupus vulgaris* - This is a **chronic, progressive form of cutaneous tuberculosis** characterized by reddish-brown plaques with an "apple-jelly" color on diascopy. - It typically affects the face and neck and is caused by **hematogenous or lymphatic spread** from an internal TB focus in a patient with moderate to high immunity.

Q: A patient has asymptomatic painless burrowing ulcer in the palate. He might be suffering from

Syphilis. ***Syphilis*** - A **painless burrowing ulcer** in the palate, particularly a **gumma**, is characteristic of tertiary syphilis. - While primary syphilis causes a chancre (also painless), the burrowing nature suggests a more advanced stage of the disease. *Actinomycosis* - Often presents as a **chronic, indurated, suppurative lesion** with draining sinuses, sometimes referred to as "lumpy jaw." - It’s typically associated with **yellow sulfur granules** and is usually painful or causes discomfort. *Tuberculosis* - Oral manifestations of tuberculosis are commonly seen as **painful, irregular ulcers** on the tongue or buccal mucosa. - Palatal lesions are less common and tend to be painful, unlike the case described. *Histoplasmosis* - Systemic histoplasmosis can manifest as **painful oral ulcers** or granulomatous lesions, often presenting with symptoms like fever, weight loss, and hepatosplenomegaly. - The ulcers are usually not described as "burrowing" and are typically painful.

Q: Painful matted suppurative lymphadenitis after healing of genital lesion is seen in:

LGV. **LGV** - **Lymphogranuloma venereum (LGV)** is caused by specific serovars of *Chlamydia trachomatis* and is characterized by a transient, painless genital ulcer followed by **painful, matted suppurative lymphadenopathy** in the inguinal region, often forming **buboes** and **fistulas** [1]. - The healing of the initial genital lesion before the onset of prominent lymphadenitis is a classic presentation of LGV [1]. *Syphilis* - While syphilis can cause **painless lymphadenopathy** (buboes), it is typically non-suppurative and does not result in the matted, suppurative nodes or fistula formation seen in LGV [2]. - The initial lesion, a **chancre**, is usually painless and firm [2]. *Donovanosis* - Donovanosis, caused by *Klebsiella granulomatis*, presents with **progressive, ulcerative lesions** that are highly vascular and bleed easily, not discrete genital lesions followed by prominent lymphadenitis [1]. - **Lymphadenitis** is rare; however, subcutaneous granulomas in the inguinal region (pseudobuboes) can occur, but these are not suppurative lymph nodes [1]. *Chancroid* - Chancroid, caused by *Haemophilus ducreyi*, characteristically causes **painful genital ulcers** and **painful, suppurative inguinal lymphadenitis** (buboes) [1]. - However, the lymphadenopathy usually appears concurrently with or shortly after the ulcer, and the ulcers are typically persistent and painful, unlike the transient, often unnoticed lesion of LGV [1].

Q: Apple jelly nodule on diascopy is a feature of:

Lupus vulgaris. ***Lupus vulgaris*** - An **apple jelly nodule** on diascopy is a classic clinical sign of **lupus vulgaris**, a severe form of cutaneous tuberculosis. - Diascopy reveals the characteristic yellowish-brown discoloration due to **tuberculous granulomas** in the dermis. *Aspergillosis* - This is a fungal infection that typically affects the **respiratory tract** and less commonly the skin, especially in immunocompromised individuals. - Skin lesions in aspergillosis are usually **necrotic ulcers** or plaques, not apple jelly nodules on diascopy. *Erysipelas* - This is a **superficial bacterial infection** of the skin and subcutaneous tissue, typically caused by *Streptococcus pyogenes*. - It presents as a bright red, swollen, raised lesion with a **distinct border**, and does not produce apple jelly nodules. *Rhinoscleroma* - This is a chronic, progressive granulomatous disease affecting the **upper respiratory tract**, caused by *Klebsiella rhinoscleromatis*. - It leads to **hard, nodular masses** in the nose and pharynx, often described as ligneous, but does not present as apple jelly nodules on diascopy.

Q: A patient was diagnosed to have single skin lesion of Leprosy without any AFB positive bacteria from the scrapings. What should be the treatment of this patient according to latest guidelines?

(Rifampicin + Dapsone) for 6 months. ***(Rifampicin + Dapsone) for 6 months*** - This regimen is the standard **Multi-Drug Therapy (MDT)** for **paucibacillary (PB) leprosy**, which is characterized by a **single skin lesion** and **negative acid-fast bacilli (AFB)** on scrapings. - The 6-month duration is effective in eradicating the infection with high cure rates and low relapse rates. * (Rifampicin + Dapsone) for 12 months* - This 12-month regimen is unnecessarily prolonged for paucibacillary leprosy, increasing the risk of side effects and reducing patient adherence without additional clinical benefit compared to the 6-month regimen. - While Rifampicin and Dapsone are correct drugs for PB leprosy, the duration is not aligned with current WHO guidelines for this specific presentation. * (Rifampicin + Dapsone + Clofazamine) for 6 months* - The addition of **Clofazamine** makes this the regimen for **multibacillary (MB) leprosy**, which presents with multiple skin lesions or positive AFB smears. - This patient's presentation of a **single lesion** and **negative AFB** clearly indicates paucibacillary leprosy, for which Clofazamine is not typically included. * (Rifampicin + Dapsone + Clofazamine) for 12 months* - This is the standard regimen for **multibacillary (MB) leprosy**, due to the presence of Clofazamine and the 12-month duration. - It is not appropriate for a patient with a **single, AFB-negative lesion**, as this presentation denotes paucibacillary leprosy requiring a shorter, two-drug treatment.

Q: Innumerable, small, normoesthetic and symmetrical skin lesions are present in which type of leprosy:

Lepromatous. ***Lepromatous*** - **Lepromatous leprosy** is characterized by a high bacterial load, leading to **innumerable, symmetrical, and poorly defined skin lesions** distributed bilaterally. - In **early lepromatous disease**, lesions may be **normoesthetic** (normal sensation) or only mildly hypesthetic before significant nerve damage develops. However, as the disease progresses, sensory loss becomes more apparent due to diffuse nerve involvement. - The combination of **innumerable + symmetrical + normoesthetic** lesions is most characteristic of **early lepromatous leprosy**. *Tuberculoid* - **Tuberculoid leprosy** typically presents with **few (1-5), well-demarcated, and often asymmetric** skin lesions. - These lesions show **marked sensory loss early** (anesthetic from onset) due to intense localized immune response and nerve damage. - Does not fit the description of innumerable, normoesthetic lesions. *Borderline tuberculoid* - **Borderline tuberculoid leprosy** features a **moderate number of lesions** (more than tuberculoid but not innumerable), which are usually well-defined. - Lesions show **noticeable sensory impairment** relatively early in the disease course. - Does not present with innumerable lesions. *Borderline lepromatous* - **Borderline lepromatous leprosy** has numerous lesions with varied morphology (macules, papules, plaques). - While extensive, sensory loss is usually **more pronounced** than in pure lepromatous leprosy due to more active nerve inflammation. - The combination of normoesthetic + innumerable + symmetrical is more specific to lepromatous rather than borderline lepromatous.

Q: In the management of leprosy, Lepromin test is most useful for:-

Prognosis. Prognosis - A positive Lepromin test indicates a strong cell-mediated immune response to Mycobacterium leprae, which is associated with the tuberculoid form of leprosy and a better prognosis [1]. - A negative test suggests a poor immune response, seen in lepromatous leprosy [1], which is associated with a more severe, disseminated disease and worse prognosis. Epidemiological investigations - While it reflects immune status, the Lepromin test is not primarily used for identifying active cases or tracking disease transmission in the general population. - Its utility in population-level studies is limited as it doesn't distinguish between past exposure, subclinical infection, or present disease. Treatment - The Lepromin test does not guide the choice of specific medications or the duration of multi-drug therapy (MDT) for leprosy. - Treatment regimens are determined by the classification of leprosy (paucibacillary or multibacillary) based on clinical and bacteriological findings. Herd immunity - Herd immunity applies to vaccine-preventable diseases where a high percentage of the population is immune, indirectly protecting susceptible individuals. - Leprosy is not typically controlled through herd immunity, and the Lepromin test does not assess population-level protection.

Question 1

Groove sign:

Accepted Answer

LGV

Answer

Chancroid

Answer

Genital herpes

Answer

Donovaniasis

Question 2

Lepromin test is strongly positive in:

Accepted Answer

Tuberculoid (TT)

Answer

Lepromatous (LL)

Answer

Borderline lepromatous (BL)

Answer

Borderline borderline (BB)

Question 3

A 30-year-old male, Kallu, with a history of sexual exposure presents with a painless indurated ulcer over the penis with everted margins. The diagnosis is:

Accepted Answer

Syphilis

Answer

Granuloma inguinale

Answer

Chancroid

Answer

Lymphogranuloma venereum

Question 4

Not a cutaneous manifestation of tuberculosis:

Accepted Answer

Erythema migrans

Answer

Exanthematous lesion

Answer

Scrofuloderma

Answer

Lupus vulgaris

Question 5

A patient has asymptomatic painless burrowing ulcer in the palate. He might be suffering from

Accepted Answer

Syphilis

Answer

Actinomycosis

Answer

Tuberculosis

Answer

Histoplasmosis

Question 6

Painful matted suppurative lymphadenitis after healing of genital lesion is seen in:

Accepted Answer

LGV

Answer

Syphilis

Answer

Donovanosis

Answer

Chancroid

Question 7

Apple jelly nodule on diascopy is a feature of:

Accepted Answer

Lupus vulgaris

Answer

Aspergillosis

Answer

Erysipelas

Answer

Rhinoscleroma

Question 8

A patient was diagnosed to have single skin lesion of Leprosy without any AFB positive bacteria from the scrapings. What should be the treatment of this patient according to latest guidelines?

Accepted Answer

(Rifampicin + Dapsone) for 6 months

Answer

(Rifampicin + Dapsone) for 12 months

Answer

(Rifampicin + Dapsone + Clofazamine) for 6 months

Answer

(Rifampicin + Dapsone + Clofazamine) for 12 months

Question 9

Innumerable, small, normoesthetic and symmetrical skin lesions are present in which type of leprosy:

Accepted Answer

Lepromatous

Answer

Tuberculoid

Answer

Borderline tuberculoid

Answer

Borderline lepromatous

Question 10

In the management of leprosy, Lepromin test is most useful for:-

Accepted Answer

Prognosis

Answer

Epidemiological investigations

Answer

Treatment

Answer

Herd immunity

Bacterial Skin Infections — MCQs

Bacterial Skin Infections — MCQs

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