{"id":36872,"date":"2026-05-27T11:10:48","date_gmt":"2026-05-27T05:40:48","guid":{"rendered":"https:\/\/atsixty.com\/?p=36872"},"modified":"2026-05-27T11:11:55","modified_gmt":"2026-05-27T05:41:55","slug":"leprosy-hansens-disease","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/27\/05\/2026\/leprosy-hansens-disease\/","title":{"rendered":"Leprosy &#8211; Hansen\u2019s Disease"},"content":{"rendered":"\n\n\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n\/* All styles namespaced to #lep01 -- no bleed into WordPress theme *\/\n#lep01 *,#lep01 *::before,#lep01 *::after{box-sizing:border-box;margin:0;padding:0}\n#lep01{\n  --ter:#8B3D20;--ter-light:#B85A38;--ter-pale:#FDF0EB;--ter-dark:#6B2D14;\n  --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n  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.mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<div id=\"lep01\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; Daily Clinical Quiz<\/div>\n    <div class=\"mr-title\">\n      Leprosy<br><em>Hansen&rsquo;s Disease &mdash; Classification, Nerve &amp; Reactions<\/em>\n    <\/div>\n    <div class=\"mr-subtitle\">Five high-yield clinical cases &middot; +4 \/ &minus;1 scoring &middot; NEET-PG and INI-CET<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"lep01-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"lep01-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"lep01-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"lep01-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"lep01-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"lep01-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"lep01-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"lep01-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"lep01-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"lep01-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"lep01-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"lep01-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"lep01-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"lep01-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'lep01';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  \/* ================================================================\n     QUESTION BANK -- Leprosy (Hansen's Disease)\n     NEET-PG level. Not superspeciality.\n     ================================================================\n\n     Q1  CLASSIFICATION -- Ridley-Jopling & WHO (Easy-Medium)\n         Ridley-Jopling spectrum: TT, BT, BB, BL, LL.\n         TT: strong CMI, few bacilli, well-defined lesions,\n             lepromin positive.\n         LL: absent CMI, numerous bacilli, diffuse lesions,\n             lepromin negative, leonine facies, saddle nose,\n             madarosis, glove-stocking anaesthesia.\n         WHO operational: PB (<=5 skin lesions, <=1 nerve trunk)\n                          MB (>5 skin lesions, >1 nerve trunk)\n         Slit-skin smear: BI (bacterial index) 0 in TT\/BT,\n                          6+ in LL.\n         Answer: Lepromatous leprosy (LL) -- absent cell-mediated\n                 immunity, numerous bacilli, lepromin negative\n\n     Q2  LEPROMIN TEST (Medium)\n         Mitsuda reaction: read at 3-4 weeks; nodule formation;\n                           indicates granuloma formation (CMI).\n                           Positive in TT; negative in LL.\n         Fernandez reaction: read at 48-72 hours; erythema\/induration;\n                             indicates prior sensitisation (DTH).\n         NOT a diagnostic test -- tests immune status only.\n         Positive in healthy BCG-vaccinated individuals too.\n         Answer: Mitsuda reaction at 3-4 weeks indicates intact\n                 cell-mediated immunity; not a diagnostic test\n\n     Q3  NERVE INVOLVEMENT -- MOST COMMONLY AFFECTED (Medium)\n         Most common nerve overall: Ulnar nerve\n           => claw hand (ring and little fingers)\n           => loss of sensation over medial 1.5 fingers\n         Others in order: Common peroneal (foot drop),\n                          Posterior tibial (plantar anaesthesia,\n                          trophic ulcers), Radial cutaneous,\n                          Facial (lagophthalmos -- most common\n                          cause of blindness in leprosy),\n                          Greater auricular, Lateral popliteal.\n         Pure neuritic leprosy: nerve involvement without skin\n         lesions -- more common in India.\n         Answer: Ulnar nerve is most commonly affected, causing\n                 claw hand deformity\n\n     Q4  LEPRA REACTIONS (Hard -- but NEET-PG level)\n         Type 1 (Reversal reaction):\n           - Borderline forms (BT, BB, BL) only\n           - Type IV hypersensitivity (cell-mediated)\n           - Existing lesions become erythematous and oedematous\n           - Nerve involvement common -- can cause sudden nerve\n             function impairment\n           - Treatment: prednisolone (mainstay)\n           - Can be upgrading (towards TT) or downgrading (to LL)\n         Type 2 (Erythema Nodosum Leprosum, ENL):\n           - LL and BL only\n           - Type III hypersensitivity (immune complex)\n           - Tender erythematous nodules -- new lesions, NOT\n             existing ones\n           - Systemic features: fever, iritis, orchitis,\n             dactylitis, nephritis\n           - Treatment: thalidomide (drug of choice) or steroids\n           - Clofazimine also used for chronic\/recurrent ENL\n         Answer: Type 1 reaction affects borderline forms, Type IV\n                 CMI; Type 2 (ENL) affects LL\/BL, Type III immune\n                 complex, treat with thalidomide\n\n     Q5  MDT -- NEET-PG REGIMEN (Easy-Medium)\n         PB leprosy (<=5 lesions):\n           Rifampicin 600mg once monthly (supervised)\n           + Dapsone 100mg daily (unsupervised)\n           Duration: 6 months\n         MB leprosy (>5 lesions):\n           Rifampicin 600mg once monthly (supervised)\n           + Clofazimine 300mg once monthly (supervised)\n             + 50mg daily (unsupervised)\n           + Dapsone 100mg daily (unsupervised)\n           Duration: 12 months\n         Clofazimine: causes reddish-brown skin discolouration\n                      (often distressing to fair-skinned patients);\n                      also anti-inflammatory (useful in ENL).\n         Dapsone: check G6PD; causes haemolytic anaemia in\n                  G6PD deficiency (same as DH management).\n         Rifampicin: only bactericidal drug in MDT.\n         Answer: MB MDT -- Rifampicin + Clofazimine + Dapsone\n                 for 12 months; Rifampicin is the only\n                 bactericidal component\n     ================================================================ *\/\n\n  var QS = [\n\n    \/* ---- Q1 : Classification ---- *\/\n    {\n      id:      1,\n      tag:     'Leprosy &mdash; Classification',\n      stem:    'A <strong>45-year-old man<\/strong> from a rural area presents with a <strong>diffuse, symmetrical infiltration of the skin<\/strong>, loss of eyebrows (<em>madarosis<\/em>), thickened ear lobes, and a saddle-nose deformity. Sensation is lost in a <strong>glove-and-stocking distribution<\/strong>. Slit-skin smear shows a <strong>bacterial index of 6+<\/strong>. Lepromin test is <strong>negative<\/strong>. Which statement best describes the immunological basis of this presentation?',\n      correct: 'Lepromatous leprosy: absent cell-mediated immunity allows uncontrolled bacillary multiplication; humoral immunity is intact but ineffective',\n      opts: [\n        'Lepromatous leprosy: absent cell-mediated immunity allows uncontrolled bacillary multiplication; humoral immunity is intact but ineffective',\n        'Tuberculoid leprosy: strong cell-mediated immunity limits bacillary multiplication to a few well-defined lesions',\n        'Borderline tuberculoid leprosy: partial cell-mediated immunity with moderate bacillary load and asymmetric lesions',\n        'Pure neuritic leprosy: selective nerve involvement without skin lesions due to neurotropism of Mycobacterium leprae'\n      ],\n      exp:     'This is classic <strong>lepromatous leprosy (LL)<\/strong> &mdash; the anergic pole of the Ridley-Jopling spectrum. <strong>Cell-mediated immunity (CMI) is completely absent<\/strong>: Th1 response fails, macrophages cannot kill bacilli, and <em>M. leprae<\/em> multiplies unchecked. <strong>Humoral immunity is paradoxically robust<\/strong> but ineffective against an intracellular pathogen, producing high antibody titres (including anti-PGL-1 IgM). Clinical hallmarks: <em>diffuse symmetric infiltration<\/em>, madarosis, <em>leonine facies<\/em> (lion-like face), saddle-nose (septal destruction), gynaecomastia, and glove-stocking anaesthesia. Bacterial index (BI) of 6+ indicates &gt;1000 bacilli per field. Lepromin (Mitsuda) test is negative because there is no CMI. <strong>WHO classification:<\/strong> LL falls under <strong>multibacillary (MB)<\/strong> leprosy (&gt;5 skin lesions or &gt;1 nerve trunk involved). <strong>Extra point:<\/strong> the Ridley-Jopling spectrum has five types &mdash; TT, BT, BB, BL, LL &mdash; with the borderline forms (BT, BB, BL) being immunologically unstable and prone to lepra reactions. Pure neuritic leprosy, more common in India than elsewhere, has nerve involvement without skin lesions and is classified as PB or MB based on nerve count.'\n    },\n\n    \/* ---- Q2 : Lepromin Test ---- *\/\n    {\n      id:      2,\n      tag:     'Leprosy &mdash; Lepromin Test',\n      stem:    'A <strong>12-year-old child<\/strong> with a single hypopigmented anaesthetic patch on his forearm undergoes a lepromin test as part of his evaluation. At <strong>48&ndash;72 hours<\/strong>, a 10&nbsp;mm area of erythema and induration is noted at the injection site. At <strong>3&ndash;4 weeks<\/strong>, a 6&nbsp;mm indurated nodule has formed. Which of the following correctly interprets these findings?',\n      correct: 'The 48-72 hour reaction (Fernandez) indicates prior sensitisation; the 3-4 week reaction (Mitsuda) indicates intact cell-mediated immunity; the test is not diagnostic of leprosy',\n      opts: [\n        'The 48-72 hour reaction (Fernandez) indicates prior sensitisation; the 3-4 week reaction (Mitsuda) indicates intact cell-mediated immunity; the test is not diagnostic of leprosy',\n        'Both reactions together confirm active lepromatous leprosy with high bacillary load',\n        'The 3-4 week Mitsuda reaction alone is sufficient to diagnose tuberculoid leprosy in this child',\n        'A positive lepromin test at any reading time indicates the patient is non-infectious and requires no treatment'\n      ],\n      exp:     'The lepromin test has <strong>two components<\/strong> read at different times. The <strong>Fernandez reaction<\/strong> (early, 48&ndash;72 hours): erythema and induration &mdash; a delayed-type hypersensitivity response indicating <em>prior sensitisation<\/em> to <em>M. leprae<\/em> antigens, similar to a Mantoux reaction. The <strong>Mitsuda reaction<\/strong> (late, 3&ndash;4 weeks): a granulomatous nodule &mdash; indicates <em>intact cell-mediated immunity<\/em> and the ability to mount a granulomatous response. <strong>Critical point: the lepromin test is NOT a diagnostic test<\/strong>. It tests immune status, not infection. It is positive in healthy individuals vaccinated with BCG (cross-reactivity). It is <em>positive<\/em> in tuberculoid leprosy (TT) and <em>negative<\/em> in lepromatous leprosy (LL). Its clinical value is <strong>prognostic<\/strong> &mdash; a positive Mitsuda predicts a favourable immune response and paucibacillary disease course. <strong>Extra point:<\/strong> the single hypopigmented anaesthetic patch in a child in an endemic area is the most common presentation of early leprosy in India and is classified as <strong>indeterminate leprosy<\/strong> or early PB leprosy. It may resolve spontaneously or progress along the spectrum depending on host immunity.'\n    },\n\n    \/* ---- Q3 : Nerve Involvement ---- *\/\n    {\n      id:      3,\n      tag:     'Leprosy &mdash; Nerve Involvement',\n      stem:    'A <strong>38-year-old man<\/strong> with known borderline tuberculoid leprosy develops progressive <strong>weakness and wasting of the intrinsic muscles of his right hand<\/strong>. Examination reveals clawing of the ring and little fingers, with <strong>loss of sensation over the medial one-and-a-half fingers<\/strong> and the medial palm. The nerve most likely involved, and the deformity that results from its damage, are:',\n      correct: 'Ulnar nerve; claw hand deformity (hyperextension at MCP joints, flexion at IP joints of ring and little fingers)',\n      opts: [\n        'Ulnar nerve; claw hand deformity (hyperextension at MCP joints, flexion at IP joints of ring and little fingers)',\n        'Median nerve; ape hand deformity with loss of thenar eminence and opposition of thumb',\n        'Radial nerve; wrist drop with loss of extension at wrist and fingers',\n        'Common peroneal nerve; foot drop with loss of dorsiflexion and eversion of the foot'\n      ],\n      exp:     'The <strong>ulnar nerve<\/strong> is the <em>most commonly affected nerve<\/em> in leprosy overall. It is thickened and palpable above the medial epicondyle. Damage produces <strong>claw hand<\/strong> &mdash; hyperextension at the MCP joints and flexion at the IP joints of the ring and little fingers (the lateral two fingers are spared because they are supplied by the median nerve via the lumbricals). Sensory loss covers the medial one-and-a-half fingers and medial palm. <strong>Order of nerve involvement in leprosy<\/strong> (NEET-PG favourite): <strong>Ulnar &gt; Common peroneal &gt; Posterior tibial &gt; Radial cutaneous &gt; Facial &gt; Greater auricular<\/strong>. <strong>Common peroneal<\/strong>: foot drop (loss of dorsiflexion, steppage gait). <strong>Posterior tibial<\/strong>: plantar anaesthesia, trophic ulcers on the sole. <strong>Facial nerve<\/strong>: lagophthalmos (inability to close the eye) &mdash; the most common cause of <em>blindness<\/em> in leprosy, from exposure keratitis. <strong>Extra point:<\/strong> <em>Pure neuritic leprosy<\/em> &mdash; nerve involvement without any skin lesion &mdash; is more common in India than in any other country. Diagnosis requires nerve biopsy. It is classified as PB or MB based on the number of nerve trunks involved (&le;1 = PB; &gt;1 = MB).'\n    },\n\n    \/* ---- Q4 : Lepra Reactions ---- *\/\n    {\n      id:      4,\n      tag:     'Leprosy &mdash; Lepra Reactions',\n      stem:    'A <strong>30-year-old woman<\/strong> on multidrug therapy for borderline lepromatous (BL) leprosy develops multiple <strong>tender, erythematous, raised nodules<\/strong> on her limbs and face, along with <strong>fever, joint pains, and red painful eyes<\/strong>. Her existing skin patches have <em>not<\/em> changed in character. The type of reaction, its immunological basis, and the drug of choice for management are:',\n      correct: 'Type 2 reaction (Erythema Nodosum Leprosum); Type III hypersensitivity (immune complex); thalidomide is the drug of choice',\n      opts: [\n        'Type 2 reaction (Erythema Nodosum Leprosum); Type III hypersensitivity (immune complex); thalidomide is the drug of choice',\n        'Type 1 reaction (reversal reaction); Type IV hypersensitivity (cell-mediated); prednisolone is the drug of choice',\n        'Type 2 reaction (Erythema Nodosum Leprosum); Type I hypersensitivity (IgE-mediated); antihistamines are the drug of choice',\n        'Type 1 reaction (reversal reaction); Type III hypersensitivity (immune complex); clofazimine is the drug of choice'\n      ],\n      exp:     '<strong>Type 2 reaction (Erythema Nodosum Leprosum, ENL)<\/strong> occurs only in <strong>LL and BL<\/strong> leprosy (high bacillary load necessary). It is a <strong>Type III hypersensitivity<\/strong> reaction &mdash; immune complexes (antigen + antibody) deposit in tissues, activating complement and causing systemic inflammation. Key feature: <em>new<\/em> erythematous tender nodules appear, while <em>existing<\/em> patches are unchanged (distinguishing it from Type 1). Systemic features: fever, iritis\/uveitis, orchitis, nephritis, dactylitis. <strong>Treatment: thalidomide<\/strong> is the drug of choice for ENL in men and postmenopausal women (absolutely contraindicated in women of childbearing potential due to severe teratogenicity). Steroids are used when thalidomide is contraindicated. Clofazimine has anti-inflammatory properties and is used for chronic\/recurrent ENL. <strong>Type 1 reaction (reversal reaction)<\/strong>, by contrast, occurs in <em>borderline forms only (BT, BB, BL)<\/em>, is <strong>Type IV<\/strong> (cell-mediated), causes <em>existing lesions<\/em> to become inflamed and oedematous, causes sudden nerve function impairment, and is treated with <strong>prednisolone<\/strong>. <strong>Extra point:<\/strong> MDT is <em>continued<\/em> through both types of reactions &mdash; reactions are immune events, not signs of treatment failure, and stopping MDT is never the correct response.'\n    },\n\n    \/* ---- Q5 : MDT Regimen ---- *\/\n    {\n      id:      5,\n      tag:     'Leprosy &mdash; Multidrug Therapy',\n      stem:    'A <strong>25-year-old man<\/strong> presents with <strong>eight hypopigmented anaesthetic patches<\/strong> on his trunk and limbs, and two thickened nerve trunks. Slit-skin smear is positive. He is classified as multibacillary leprosy and commenced on WHO multidrug therapy. Which of the following correctly describes the MB-MDT regimen, the duration, and the only bactericidal drug in the combination?',\n      correct: 'Rifampicin 600mg monthly + Clofazimine 300mg monthly and 50mg daily + Dapsone 100mg daily; 12 months; Rifampicin is the only bactericidal drug',\n      opts: [\n        'Rifampicin 600mg monthly + Clofazimine 300mg monthly and 50mg daily + Dapsone 100mg daily; 12 months; Rifampicin is the only bactericidal drug',\n        'Rifampicin 600mg monthly + Dapsone 100mg daily; 6 months; both drugs are bactericidal',\n        'Rifampicin 600mg daily + Clofazimine 100mg daily + Dapsone 100mg daily; 24 months; all three drugs are bactericidal',\n        'Rifampicin 600mg monthly + Clofazimine 50mg daily + Dapsone 100mg daily; 6 months; Clofazimine is the primary bactericidal drug'\n      ],\n      exp:     '<strong>MB-MDT (WHO regimen)<\/strong>: <strong>Rifampicin 600&nbsp;mg once monthly<\/strong> (supervised) + <strong>Clofazimine 300&nbsp;mg once monthly<\/strong> (supervised) and <strong>50&nbsp;mg daily<\/strong> (unsupervised) + <strong>Dapsone 100&nbsp;mg daily<\/strong> (unsupervised). Duration: <strong>12 months<\/strong>. <strong>PB-MDT<\/strong>: Rifampicin 600&nbsp;mg monthly + Dapsone 100&nbsp;mg daily for <strong>6 months<\/strong>. <strong>Rifampicin is the only bactericidal drug<\/strong> in both regimens; dapsone and clofazimine are bacteriostatic. The monthly supervised dose of rifampicin ensures compliance and prevents resistance. <strong>Clofazimine<\/strong>: causes <em>reddish-brown skin discolouration<\/em> and ichthyosis, particularly noticeable in fair-skinned patients &mdash; a common cause of poor compliance; also has anti-inflammatory properties useful in ENL. <strong>Dapsone<\/strong>: check G6PD before starting &mdash; causes haemolytic anaemia in G6PD-deficient patients (same caution as in dermatitis herpetiformis). <strong>Extra point:<\/strong> India accounts for approximately <strong>50% of global leprosy burden<\/strong> and was declared to have eliminated leprosy as a public health problem (prevalence &lt;1 per 10,000) in 2005, though new case detection continues. The National Leprosy Eradication Programme (NLEP) delivers MDT free of cost. Elimination is not eradication &mdash; a distinction that has appeared in PSM papers.'\n    }\n\n  ];\n  \/* ================================================================\n     END OF CONTENT -- engine logic below, do not edit\n     ================================================================ *\/\n\n  var answers  = {};\n  var answered = 0;\n  var shuffled = {};\n  var done     = false;\n\n  function byId(id) { return document.getElementById(id); }\n  function gid(sfx) { return byId(NS + '-' + sfx); }\n\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, t;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      t = a[i]; a[i] = a[j]; a[j] = t;\n    }\n    return a;\n  }\n\n  function countVal(val) {\n    var k, n = 0;\n    for (k in answers) {\n      if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n    }\n    return n;\n  }\n\n  function buildPips() {\n    var cont = gid('pips'), i, q, wl, wp, line, pip;\n    if (!cont) return;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wl = document.createElement('div'); wl.className = 'mr-pip-wrap';\n        line = document.createElement('div'); line.className = 'mr-pip-line';\n        line.id = NS + '-pl' + q.id;\n        wl.appendChild(line); cont.appendChild(wl);\n      }\n      wp = document.createElement('div'); wp.className = 'mr-pip-wrap';\n      pip = document.createElement('div'); pip.className = 'mr-pip';\n      pip.id = NS + '-pip' + q.id; pip.textContent = String(q.id);\n      wp.appendChild(pip); cont.appendChild(wp);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, nd, meta, tg, st,\n        rule, od, ed, lb, tx, j, oe, ls, ts;\n    cont = gid('cases');\n    if (!cont) return;\n    cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    if (gid('score')) gid('score').style.display = 'none';\n    buildPips();\n    for (i = 0; i < QS.length; i++) {\n      q    = QS[i];\n      opts = shuffleArr(q.opts);\n      shuffled[q.id] = opts;\n      card = document.createElement('div'); card.className = 'mr-case';\n      top  = document.createElement('div'); top.className  = 'mr-case-top';\n      nd   = document.createElement('div'); nd.className   = 'mr-num';\n      nd.textContent = q.id < 10 ? 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'correct' : 'wrong');\n    if (qid > 1) { var pl = gid('pl' + qid); if (pl) pl.className = 'mr-pip-line done'; }\n  }\n\n  function showScore() {\n    var c, w, s, net, pct, disp, vlist, vi, sc;\n    if (done) return;\n    done = true;\n    c = countVal('c'); w = countVal('w'); s = TOTAL - answered;\n    net  = c * 4 - w;\n    pct  = Math.max(0, Math.round((net \/ MAX) * 100));\n    disp = Math.min(100, Math.max(0, pct));\n    var rg = gid('ring');\n    if (rg) rg.style.background = 'conic-gradient(#8B3D20 ' + disp + '%, #E8DDD8 0%)';\n    var pe = gid('pct'); if (pe) pe.textContent = pct + '%';\n    var ne = gid('net'); if (ne) ne.textContent = 'Net Score: ' + net + ' \/ ' + MAX;\n    vlist = [\n      [5, 'Perfect round. Hansen would be proud.'],\n      [4, 'Strong \\u2014 one reaction type to revisit before exam day.'],\n      [3, 'Solid base \\u2014 the nerve order and MDT regimen reward a second read.'],\n      [2, 'Halfway there \\u2014 the debrief panels have everything you need.'],\n      [0, 'Leprosy rewards persistence. 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