A 59-year-old male patient was admitted to our university hospital (Botucatu, SP, Brazil) complaining of a perianal suppurative ulcer developed two months before the first medical consultation. He was under therapy with prednisone 40 mg/day for six months due to a presumed diagnosis of a drug reaction. On physical examination, a clean 10-cm diameter phagedenic perianal ulcer (Figure ) and two longitudinal suppurative ulcers on the inguino-crural region were observed. During investigation, and soon after reducing the corticosteroid dose, disseminated erythematous papules and nodules were observed in the upper limbs (Figure ).Histopathology of the perianal ulcer revealed a dense histiocytic dermal infiltrate and a granulomatous inflammatory response with central caseous necrosis (Figure ). Fite-Faraco staining showed a few acid-fast bacilli and the hypothesis of cutaneous tuberculosis was raised. The histopathology of upper limbs papular and nodular lesions showed foamy macrophages with globi of bacilli, suggesting lepromatous leprosy (Figure ). The perianal and inguinal ulcers were considered uncommon manifestations of type 2 leprosy developed when corticosteroid was gradually diminished. The patient was treated as for multibacillary leprosy with multidrug therapy and thalidomide.\nFour weeks later, the patient had fever, weight loss, asthenia and worsening of the perianal ulcer (Figure ), but without erythema nodosum leprosum. With this clinical picture, new investigation was developed. The tuberculin skin test was positive (20 × 20 mm) and culture of M. tuberculosis – using a biopsy sample from the perianal ulcer – on Löwenstein-Jensen medium was positive (Figure ). Polymerase chain reaction (PCR) and DNA analysis from upper limb skin samples were positive for M. leprae (Figure ). With the new information the patient was finally diagnosed as presenting simultaneously lepromatous leprosy – type 2 reaction – and cutaneous tuberculosis expressed by the perianal ulcer. Screening for HIV, HBV or HCV infection as well as lung, renal or colon compromising were negative. Hence, the patient was treated with isoniazid, ethambutol and rifampin for nine months with complete healing of the perianal and inguinal lesions after two months (Figure ). After the tuberculosis treatment, the patient was submitted to additional multidrug therapy for 12 months with dapsone, rifampin and clofazimine with complete cure of leprosy.
A 72-year-old Tamil man presented with a 2-year history of trophic ulcers, auto-amputated fingers, and facial infiltration (Fig. ). He was a retired mason from a poor social back ground with low income and did not have any other medical diseases. A general examination and neurological examination was normal. There was no significant contact history of leprosy or TB. He had received a BCG vaccination. He was an ex-smoker of tobacco and an ex-drinker of alcohol. His evaluation confirmed the clinical diagnosis of leprosy with highly positive slit-skin smears and histological evidence of lepromatous leprosy. He also gave a history of constitutional symptoms, evening pyrexia, and loss of weight and appetite. His ESR was 113 mm/hour and a sputum examination revealed AFB along with positive Mantoux test of 14 mm and CXR evidence of pulmonary TB. Basic investigations are given in Table . He was evaluated for both congenital and acquired immunodeficiency status, which did not reveal any abnormality. Although treatment for both conditions was commenced (isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 800 mg/day, and pyrazinamide 1500 mg/day and dapsone 100 mg/day and clofazimine 50 mg/day and 300 mg/once a month) in liaison with a respiratory team, he was lost to follow up.