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 49-year-old man, nonsmoker, was admitted to dermatology department and followed up for diffuse lepromatous leprosy. He was vaccinated with BCG and he had no past history of tuberculosis. Diagnosis of leprosy was documented based on histological and bacteriologic evidence: a slit skin smear from the ear lobe was positive for lepra bacilli (BI3+), histopathology from the lesion on the face showed granulomas consisting of epithelioid histiocytes and lymphocytes with central caseous surrounding vessels and nerves, and PCR of biopsy specimens were positive for Mycobacterium leprae. After successful treatment using dapsone (100 mg/day), rifampicin (600 mg/month), and clofazimine (300 mg/month and 50 mg/day) during twelve months, hypopigmented skin lesions on the trunk and congestive rhinitis disappeared and the slit skin smear was negative. One month after the end of the treatment, he presented with diffuse papulonodular lesions on the face and trunk, fever, and alteration of general status. On the basis of his symptoms, diagnosis of leprosy reaction (type II) was made and the patient was treated using prednisone at a dose of 40 mg/kg/day. Outcome was unfavorable after two months of corticotherapy, and we had to wait for two supplementary months before we could get clofazimine to add corticoid. After 1 month of this treatment, he presented with fever, weight loss, and asthenia. Clinical examination revealed fever of 39°C, nodular lesions over face, trunk, forearms, and dorsum of hands (Figures , , and ). He presented no neurologic impairment. Biological examination showed inflammatory syndrome: CRP 393 mg/L, total leukocyte count 16,2 × 109/L, neutrophilia 15,3 × 109/L, and lymphopenia 0,48 × 109/L. Serum creatinine and alanine aminotransferase were normal. HIV status was negative. Two out of three sputum samples were positive for acid fast bacilli. Chest tomography showed alveolar-interstitial opacities at the left lower lobe (). Bronchoscopy detected thickening of lower lobar bronchi, without malignancy in histopathology of biopsy specimens. The patient was treated by antitubercular treatment. One month after the onset of this treatment, there were only two nodular lesions on the trunk, fever disappeared, and general status improved.