A 50-year-old Sinhalese man with poorly controlled diabetes mellitus presented with facial infiltration (Fig. ) and erythematous painful nodules over his lower limbs and trunk suggestive of lepromatous leprosy with erythema nodosum leprosum. He was a manual laborer with low BMI. The rest of the general and neurological examination was normal. He had received a BCG vaccination. He did not smoke tobacco and drank alcohol occasionally. A skin biopsy revealed evidence of foamy macrophages with well-developed grenz zone. He was commenced on multidrug treatment-multibacillary treatment for leprosy (dapsone 100 mg/day, clofazimine 50 mg/day and 300 mg/once a month, and rifampicin 600 mg/month) with prednisolone 40 mg daily for type 2 reaction. Twelve months later he developed generalized lymphadenopathy with low-grade evening pyrexia and elevated ESR (80–100 mm/hour). Both Mantoux and QuantiFERON Gold test were positive. A CXR remained persistently normal. He was negative for HIV and diabetes. Basic investigations are given in Table . A lymph node excision biopsy revealed suppurative inflammation with focal foamy histiocytes; a TB culture from the lymph node biopsy later showed growth of AFB. GeneXpert did not reveal rifampicin resistance. Therefore, he was started on TB treatment (isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 800 mg/day, and pyrazinamide 1500 mg/day) by the respiratory physician for the treatment of extrapulmonary TB. At 6 months, he had improved clinically and biochemically.
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.