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.
A 65-year-old non-hypertensive, non-diabetic man presented with history of left sided chest pain associated with productive cough and breathlessness for seven days. There was no history of fever, haemoptysis and exertional increase in breathlessness. The patient was referred to our teaching hospital from Green Pastures Hospital (GPH), a tertiary care referral centre for leprosy. The patient was treated for leprosy with WHO multidrug therapy for multibacillary leprosy. The patient was currently on treatment for ulnar neuritis with prednisolone 30 mg once a day for last three months. There was no past history of tuberculosis as per GPH records or information provided by the patient.\nClinical examination revealed numerous hypopigmented skin lesions varying in size from 2 to 10 centimeters over the trunk. The left ulnar nerve was thickened. There was dullness and decreased breath sounds in the left infrascapular and axillary areas.\nThe laboratory investigations revealed hemoglobin: 14.4 mg/dl; total leukocyte count: 19.5×103; erythrocyte sedimentation rate: 60 mm at the end of first hour; serum creatinine: 1.4 mg/dl; and random blood sugar: 91 mg/dl.\nOne out of three sputum samples tested was positive for acid fast bacilli and the chest radiograph showed loculated pleural effusion suggesting long standing pleural collection in left hemi thorax with infiltrations bilaterally, more on left side.\nA diagnosis of borderline leprosy with concomitant pulmonary tuberculosis was made. The patient was referred to DOTS clinic of our teaching hospital and started on category-I treatment according to the guidelines of national tuberculosis programme of Nepal. The oral prednisolone was subsequently tapered and stopped. The patient's general condition improved and was on regular follow up.