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.
A 50-year-old non-diabetic, non-hypertensive man who had completed treatment for lepromatous leprosy two years back, was admitted at Green Pastures Hospital for type-2 lepra reaction (erythema nodosum leprosum). There was a past history of lepra reactions for which he underwent treatment. Currently the patient was again being treated for the same with prednisolone 30 mg once daily, thalidomide 100 mg twice daily and clofazimine 50 mg once daily. However, information about initial screening of tuberculosis was not available.\nThe patient was referred to our teaching hospital with complaints of fever, productive cough and dyspnoea of three months duration. The patient also complained of pain and distension of abdomen and decreased appetite for three months.\nClinical examination revealed tense abdomen with shifting dullness, respiratory system with bilateral crackles with bronchial breath sounds predominantly in the left infra clavicular area, and skin showed no active lesions of erythema nodosum leprosum. The laboratory investigations revealed hemoglobin: 11.8 mg/dl; total leukocyte count: 5900/mm3; erythrocyte sedimentation rate: 110 mm in first hour; random blood sugar: 109 mg/dl; serum electrolytes, sodium: 135 meq/L and potassium: 3.2 meq/L.\nTwo out of three sputum samples were positive for acid fast bacilli. Chest radiograph showed multiple heterogeneous opacities in bilateral lung fields and a cavitary lesion in left upper zone. A diagnosis of pulmonary tuberculosis and provisional diagnosis of peritoneal tuberculosis were made.\nDermatologist's opinion was sought for the lepra reaction. The patient was advised to stop prednisolone as no active lesions persisted. He was subsequently referred to DOTS clinic and was started on category-I treatment.