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.
A 47-year-old Tamil woman with poorly controlled long-standing diabetes mellitus presented with facial infiltration, multiple ichthyotic patches, and peripheral neuropathy associated with Charcot joints and trophic ulcers (Fig. ). She was a homemaker with poor social background and there was no contact history of TB or leprosy. She did not smoke tobacco or drink alcohol. She had received a BCG vaccination. She had a low BMI and a respiratory examination revealed B/L coarse crepitations. There was no peripheral neuropathy. A clinical diagnosis of lepromatous leprosy was made which was later confirmed with histology and slit-skin smears: bacteriological index (BI) of 5; morphological index (MI) of 2%. Initial investigations revealed persistently elevated ESR (100–122 mm/hour) and inflammatory shadows in a CXR. Two consecutive sputum smears were positive for AFB and the result of a Mantoux test was positive (18 mm). Her liver and renal functions were normal (Table ). She was negative for HIV screening. She was commenced on both TB (isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 800 mg/day, and pyrazinamide 1500 mg/day) and multibacillary leprosy treatment (dapsone 100 mg/day and clofazimine 50 mg/day and 300 mg/once a month) without a monthly loading dose of rifampicin. She had poor compliance and defaulted treatment several times and ultimately succumbed to the illness. An autopsy was not performed.