A 19-year-old male, on treatment for MDR-TB, presented with complaints of localized swelling over face, reddish discoloration of limbs, and hypopigmented patches over body since 1 month. He was on Category IV directly observed treatment, short-course chemotherapy for the last 5½ months on the basis of sputum line probe assay report from Revised National Tuberculosis Control Program (RNTCP) accredited laboratory, which showed M. tuberculosis isolates, resistant to drugs isoniazid and rifampicin. The patient was taking kanamycin, ethionamide, pyrazinamide, ethambutol, levofloxacin, and cycloserine regularly. There was a history of leprosy 6 years back, for which the patient was treated for 6 months. The patient had a history of TB 5 years back which was treated with 9 months of daily regimen antitubercular therapy. Clinical examination revealed hypopigmented, dry, scaly plaque over upper arms [], hypoanesthetic plaque over right palm [], and erythematous plaque over right side cheek and nose []. Respiratory system examination revealed bilateral infraclavicular crepts.\nRoutine investigations were normal. Chest radiograph was suggestive of fibrotic lesions, bilateral upper lobes []. Sputum culture from RNTCP accredited laboratory at 4th month was positive for growth of M. tuberculosis.\nDermatology review was taken for skin lesions. The patient was diagnosed as multibacillary (MB) leprosy and started on multidrug therapy regimen (MB-MDT) consisting of rifampicin 600 mg once monthly, dapsone 100 mg daily, and clofazimine 300 mg once monthly and 50 mg daily. Biopsy of skin lesions was suggestive of mid-borderline leprosy. Two weeks later, the patient presented with increased erythema and pain over the skin lesions and appearance of new lesions []. The patient was diagnosed with Type I lepra reaction and started on analgesics and steroids (prednisolone). Prednisolone was given in the dose of 30 mg/day orally for the first 2 weeks and then gradually tapered over the next 4 weeks. It was thus stopped after a total duration of 6 weeks. MB-MDT was continued as per the National Leprosy Eradication Programme guidelines.\nThus, final diagnosis of MDR-TB with mid-borderline leprosy and Type I lepra reaction was made. Skin lesions markedly improved with treatment []. Patient's subsequent sputum cultures were negative and MDR-TB was thereafter managed as per the RNTCP guidelines.
A 59-year-old Sinhalese man presented with nonhealing ulcers and deformities of both upper and lower limbs and indurations of his face (Fig. ) for many years. He was clinically diagnosed to have borderline lepromatous leprosy, which was subsequently confirmed with slit-skin smears and histology. He was a laborer from poor social background and did not have a significant past medical history. He was emaciated with low BMI; a neurological examination did not reveal neuropathy. There was no contact history of leprosy or TB. He had received a BCG vaccination. He did not smoke tobacco and he drank alcohol occasionally. During his initial evaluation he was also found to have high ESR (> 100 mm/hour) with positive Mantoux test (21 mm) and sputum was positive for AFB. A CXR and contrast-enhanced computer tomography scan of his chest revealed the focus of pulmonary TB; bronchoalveolar lavage for TB culture revealed growth of AFB, but GeneXpert did not reveal rifampicin resistance. His HIV status was negative and repeated blood sugar levels remained within normal range. Other basic investigations are given in Table . He was commenced on multibacillary leprosy treatment (dapsone 100 mg/day and clofazimine 50 mg/day and 300 mg/once a month) and subsequently added TB treatment (isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 800 mg/day, and pyrazinamide 1500 mg/day) for 6 months. At 6 months, his ESR came down, sputum was negative for AFB, and skin lesions and ulcers improved.