A 29-year-old male, born to nonconsanguineous parents, presented with multiple skin coloured nodules and hyperkeratotic scaly lesions of 3-month duration. He initially developed asymptomatic skin coloured raised lesions over both the ear lobes. Over the next 2 months he developed multiple similar lesions over the trunk and both the extremities. He also gave history of generalised burning sensation for 15-day duration with low grade fever. There was no history of burning sensation in the eyes, nasal stuffiness, and sensory or motor weakness. The patient denied any drug intake, fever, myalgia, spontaneous blistering or ulceration, neuritic pain, and testicular pain. None of the family members or neighbours had suffered from leprosy. He denied any past history of infectious diseases but there was no history of immunization including Bacillus Calmette et Guérin (BCG) vaccination. He was a chronic alcoholic.\nHis general physical examination was normal with no madarosis or lymphadenopathy. Cutaneous examination revealed multiple, soft, succulent, nontender, skin coloured superficial nodules present bilaterally on the forehead, cheeks, ear lobes, forearms, back, and chest with sparing of palms and soles (). The surface of these nodules showed follicular plugging. Multiple verrucous plaques were seen over the right ankle (). Skin surrounding the plaques was erythematous. Neurological examination revealed thickened bilateral greater auricular, right common peroneal nerve, and tender left posterior tibial nerve. The rest of the musculoskeletal and neurological examination was normal. Routine haematological and biochemical investigations including urine, renal, and liver function test revealed no abnormality. His retroviral serology was negative. Chest X-ray was normal. Slit skin smear from the lesion showed a bacteriological index (BI) of 5+ and the perilesional skin had a BI of 2+.\nHistopathological examination of the wedge biopsy done from the forearm and back nodules revealed sheets of histiocytes aggregates along with lymphocytes and few polymorphs in perivascular and periadnexal location (Figures and ). There was collection of epithelioid cells (). Fite Faraco stain was strongly positive (). A diagnosis of borderline lepromatous leprosy with type 2 reaction was made.\nA wedge biopsy from the verrucous lesion on the right ankle was taken. Epidermis showed hyperkeratosis and parakeratosis with irregular acanthosis (). Dermis showed epithelioid cell granulomas along with lymphocytes and plasma cells (Figures and ). Zeihl-Neelsen stain for acid fast bacilli was positive (). GeneXpert MTB/RIF test based on Nucleic Acid Amplification, which detects MTB-specific region of the rpoB gene and uses real time-PCR (RT-PCR), was done on skin biopsy specimen. The result was positive. However, a culture was not done. Based on clinical and histopathological findings, a diagnosis of tuberculosis verrucosa cutis (TVC) was made.\nThe patient was treated with rifampicin, isoniazid, pyrazinamide, and ethambutol, in addition to dapsone and clofazimine along with a monthly supervised dose of clofazimine and rifampicin for first 2 months. Then rifampicin and isoniazid with dapsone and clofazimine were continued for further 4 months. After 6 months, treatment of leprosy was continued as for multibacillary leprosy. Type 2 reaction was treated with oral anti-inflammatory drugs. The patient tolerated the drugs well with control of type 2 reaction and regression of the TVC lesion.
A 25-year-old man was admitted with complaints of fever, which was mainly in the evening, of nearly 1-week duration associated with cough, breathlessness, and generalized fatigue. He was on standard multidrug therapy (Rifampicin, Clofazamine, Dapsone) for lepromatous leprosy, for the last 2 years, but he was not very compliant with drug intake. He developed ENL for which he was started on steroids for the last 6 months. He did not have any addictions.\nOn examination he was sick looking, and had severe pallor, generalized lymph node enlargement, diffuse erythematous lesions, and nodular tender lesions of varying size all over the body. The scalp and oral mucosa were not involved. At the time of admission his temperature was 40°C, blood pressure was 120/70 mm of Hg and pulse rate was 114/m and respiratory rate was 38/m. Respiratory system examination revealed bilateral scattered crepitations and rhonchi. He had a hepatomegaly of 5 cm below the costal margin in the right midclavicular line and splenomegaly of 3 cm.\nInvestigations revealed Hb 6 g%, total leucocyte count 1000/mm3 (P 85%, L 15%), ESR 130 mm in the first hour, platelet count 3.2 lakhs/mm3, renal and liver function tests within normal limits, MCV 80, MCH 24, MCHC 30, reticulocyte count 3.5%. Peripheral smear showed normocytic normochromic cells with no evidence of hemolysis; WBCs were increased in number with predominance of neutrophils; and platelets were adequate. CRP was 160 mg/l, and slit-skin smear from the ear lobe was tested positive for lepra bacilli, BI 6%, MI 0%. X-ray chest was normal, sputum was positive for AFB, and HIV status was negative.\nWith the clinical scenario and investigation results the diagnosis of Hansen's disease, ENL, pulmonary tuberculosis, SIRS was made. He went into hypotension which was corrected with fluid replacement. Spo2 was maintained at 98%, without supplemental o2. He was started on broad spectrum antibiotics and DOTS CAT I ATT. The treatment for leprosy was continued. Fever subsided in 3 days and he was discharged.