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.
A 34-year-old, non- smoker male was admitted, in September 2007, to the Department of Pulmonary Medicine, as a follow through case of border line lepromatous leprosy. He had complaints of breathlessness, loss of appetite with cough with expectoration for last two and half months and skin lesions over face, forearm and dorsum of hands with exfoliative skin lesions over fore arm for last two months and recurrent haemoptysis for last 25 days. He was on medication, tab. Dapsone 100 mg daily, tab. Clofazimine 500 mg daily and cap, Rifampicin 600 mg, once a month, for the last nine months. He had also taken oral Prednisolone for more than three months duration about six months back, for neurological complications. There was no past history of tuberculosis as per information provided by the patient. Clinical examination revealed multiple hypo pigmented skin lesions varying in size from 2 to 4 cms over the trunk with thickened left ulnar nerve and nodular lesions over face, forearm and dorsum of hands [Figure and ] and exfoliative skin lesions over fore arm []. His resting pulse rate was 102/min and blood pressure was 112/74 mmHg and his respiratory rate was 26/min. His general examination revealed no significant abnormality. His respiratory system examination revealed coarse crepts localized to left infraclavicular and axillary areas. Initially he was put on symptomatic treatment for hemoptysis. Subsequently, his chest X-ray showed a large cavity with a mass filled opacity confined to left upper zone and fibrotic changes in right upper zone []. Computed tomography of thorax revealed fibro-consolidation with cavitation in the anterior segment of left upper lobe, fibrotic nodule in both anterior and posterior segments of right the upper lobe []. Thus a possibility of aspergilloma with other possibilities was raised. The clinical examination of the rest of the system revealed no abnormality.\nHis blood biochemistry revealed total leucocyte count: 10,200/cmm, DLC: P 66 %, L 34 %. His PPD was 2219 mm induration. His sputum for AFB on three consecutive days was positive. Thus a diagnosis of pulmonary tuberculosis was confirmed. For leprosy, patient consulted the skin department, was diagnosed with borderline lepromatous leprosy (on the basis of slit skin smear) with type-II Lepra reaction (biopsy of nodular lesion revealed diffuse sheets of foamy macrophages centered around adenexal structures with heavy infiltration of lepra bacilli suggestive of Erythema Nodosum Leprosum). He was advised to stop Dapsone and started oral Prednisolone, Thaliodomide and Clofazimine.\nThus a final diagnosis of borderline leprosy with type-II lepra reaction with concomitant pulmonary tuberculosis was made. The patient was referred to DOTS clinic and started on category-I treatment. The oral prednisolone was subsequently tapered and stopped while the other antileprotic drugs continued. The patient's general condition improved and was on regular follow-up.