# Situation: The nurse at a Rural Health Unit (RHU) runs the skin clinic of the Leprosy Control Program and follows up the families of clients with leprosy and tuberculosis (TB). In the 4th month of multidrug therapy (MDT), a client's existing patches become red, swollen, and painful, and he has new pain along the ulnar nerve. What should the nurse do?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627124  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: The nurse at a Rural Health Unit (RHU) runs the skin clinic of the Leprosy Control Program and follows up the families of clients with leprosy and tuberculosis (TB).

In the 4th month of multidrug therapy (MDT), a client's existing patches become red, swollen, and painful, and he has new pain along the ulnar nerve. What should the nurse do?

## 보기

1. Stop MDT and refer him, since the drugs are failing
2. Continue MDT and refer him urgently for corticosteroids **✔ 정답**
3. Continue MDT and reassess the nerve at the next monthly dose
4. Stop dapsone, since this is a dapsone hypersensitivity

**정답: 2**

## 해설

Existing lesions that become red, swollen, and painful with new nerve pain are a type 1 (reversal) reaction, an immune flare that can damage nerves quickly. MDT is continued, and the client is referred urgently for corticosteroids such as prednisolone and nerve assessment. A reaction is not treatment failure.

## 심화 해설

The client’s presentation during month 4 of multidrug therapy (MDT) — pre-existing skin patches becoming red, swollen, and painful, along with new pain along the ulnar nerve — is characteristic of a type 1 (reversal) reaction. This is an acute, immune-mediated inflammatory episode that can occur before, during, or after starting MDT and is a major cause of nerve damage and disability in leprosy [1]. The correct nursing action is to continue MDT and refer the client urgently for corticosteroid therapy and nerve assessment.

Why this is a reaction, not treatment failure

A type 1 reaction reflects a sudden increase in cell-mediated immunity against Mycobacterium leprae antigens, not drug resistance or failure of the MDT regimen. The inflamed skin patches and new ulnar nerve pain indicate that the immune system is now aggressively attacking residual bacilli within the skin and peripheral nerves [1][3]. Stopping MDT would remove the antimicrobial backbone that is reducing the bacterial antigen load, potentially worsening the inflammatory process over time. Therefore, option 1 (stop MDT) and option 4 (stop dapsone) are incorrect because the reaction is not caused by the drugs themselves.

Why urgent corticosteroids are needed

The most concerning feature here is the new pain along the ulnar nerve. Leprosy neuropathy can be acute and frequently occurs during reactional episodes [2]. Neuritis can cause irreversible loss of nerve function if left untreated, and the recommended treatment is corticosteroid therapy, usually oral prednisolone at an immunosuppressive dose [2][3]. Delaying referral until the next monthly dose (option 3) risks permanent nerve damage, weakness, and deformity. The nurse at the Rural Health Unit should recognize this as an emergency requiring same-day or urgent referral.

Clinical recognition of type 1 reaction

The key features that distinguish a type 1 reaction from simple disease progression or drug hypersensitivity are summarized below.

| Feature | Type 1 (reversal) reaction | Dapsone hypersensitivity | Treatment failure |
| --- | --- | --- | --- |
| Skin changes | Existing patches become red, swollen, painful | Generalized rash, fever, lymphadenopathy | New lesions or slowly enlarging old lesions without acute inflammation |
| Nerve involvement | New nerve pain, tenderness, or functional loss | Not typical | Gradual, not acute |
| Onset | Often during first 6–12 months of MDT | Usually within first 6 weeks of dapsone | Any time, but without acute flare |
| MDT management | Continue MDT | Stop dapsone immediately | Evaluate adherence and resistance |
| Additional treatment | Urgent corticosteroids | Supportive care, stop offending drug | May require regimen change |

Key point! A leprosy reaction is an immune flare, not a sign that MDT is failing. The antimicrobial therapy must continue while the inflammatory component is suppressed with corticosteroids.

Nursing role in the RHU setting

The nurse should perform a focused neurological assessment of the affected ulnar nerve distribution, checking for sensory loss, muscle weakness, or clawing of the ring and little fingers. High-resolution ultrasonography can detect dynamic inflammatory changes in peripheral nerves during MDT, but clinical examination remains the first-line screening tool in most RHU settings . The client should be referred urgently for initiation of prednisolone, with clear documentation of the reaction type, nerve involvement, and MDT adherence.

Watch out! Never wait for the next scheduled monthly visit when new nerve pain appears during MDT. Nerve damage from leprosy neuritis can become irreversible within days to weeks if corticosteroids are delayed [2][3].References (research sources)

- [1]"Reactions in Leprosy: Updated Insights Into Pathophysiology, Clinical Spectrum, and Therapeutic Approaches-A Narrative Review".Research articleGupta B, Singh M, Goldust M, Das K, Gorai S, Pudasaini P, Sitaula S, Pokhrel A, Thapa E, Jaiswal S. (2026) · DOI: 10.1002/hsr2.72519

- [2]Case report: Injected corticosteroids for treating leprosy isolated neuritis.Case reportSpitz CN, Pitta IJR, Andrade LR, Sales AM, Sarno EN, Villela NR (2023) · DOI: 10.3389/fmed.2023.1202108

- [3]The Neurological Impact of Leprosy: Manifestations and Treatment Approaches.Research articleCalderone A, Aloisi MC, Casella C, Fiannacca S, Cosenza B, Quartarone A (2024) · DOI: 10.3390/neurolint16060111

## 임상 시나리오

Leprosy Type 1 Reaction: Continue MDT, Refer UrgentlyRed swollen patches plus new nerve pain is an immune flare, not treatment failure
During month 4 of multidrug therapy, pre-existing patches that become red, swollen, and painful with new ulnar nerve pain indicate a type 1 (reversal) reaction. This is an acute increase in cell-mediated immunity against M. leprae antigens, not drug resistance.

The priority is to continue MDT and refer urgently for corticosteroids such as prednisolone, along with nerve assessment. MDT reduces the bacterial antigen load and should not be stopped during a reaction.

CautionNew nerve pain signals acute neuritis, which can cause irreversible nerve damage if treatment is delayed. Do not wait until the next monthly dose to reassess.

## 핵심 개념

- **Type 1 (reversal) reaction** — Acute immune-mediated inflammatory episode in leprosy caused by increased cell-mediated immunity against M. leprae antigens; presents with inflamed skin patches and neuritis.
- **Multidrug therapy (MDT)** — Combination antimicrobial regimen for leprosy that should be continued during reactional episodes because it reduces the bacterial antigen load.
- **Neuritis** — Inflammation of a peripheral nerve; in leprosy reactions it can cause acute pain and rapidly progress to irreversible nerve damage if untreated.
- **Corticosteroids** — Anti-inflammatory drugs such as prednisolone used urgently to suppress the immune reaction and prevent nerve damage in leprosy reactions.
- **Dapsone hypersensitivity** — Adverse drug reaction to dapsone, typically presenting with fever, rash, and systemic symptoms; distinct from a leprosy type 1 reaction.

## 같은 주제 문제

- [Situation: A public health nurse at a Rural Health Unit (RHU) in an agricultural municipal…](https://mymerci.kr/pages/nclex_q.php?qn_id=627011)
- [Situation: A public health nurse at a Rural Health Unit (RHU) in an agricultural municipal…](https://mymerci.kr/pages/nclex_q.php?qn_id=627012)
- [Situation: A public health nurse at a Rural Health Unit (RHU) manages clients enrolled in …](https://mymerci.kr/pages/nclex_q.php?qn_id=627024)
- [Situation: A public health nurse at a Rural Health Unit (RHU) manages clients enrolled in …](https://mymerci.kr/pages/nclex_q.php?qn_id=627025)
- [Situation: A public health nurse at a Rural Health Unit (RHU) manages clients enrolled in …](https://mymerci.kr/pages/nclex_q.php?qn_id=627026)
- [Situation: A public health nurse at a Rural Health Unit (RHU) manages clients enrolled in …](https://mymerci.kr/pages/nclex_q.php?qn_id=627027)
- [Situation: Dengue cases are being reported in a densely populated barangay during the rain…](https://mymerci.kr/pages/nclex_q.php?qn_id=627028)
- [Situation: Dengue cases are being reported in a densely populated barangay during the rain…](https://mymerci.kr/pages/nclex_q.php?qn_id=627029)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._