A 59-year-old Sinhalese man presented with nonhealing ulcers and deformities of both upper and lower limbs and indurations of his face (Fig. ) for many years. He was clinically diagnosed to have borderline lepromatous leprosy, which was subsequently confirmed with slit-skin smears and histology. He was a laborer from poor social background and did not have a significant past medical history. He was emaciated with low BMI; a neurological examination did not reveal neuropathy. There was no contact history of leprosy or TB. He had received a BCG vaccination. He did not smoke tobacco and he drank alcohol occasionally. During his initial evaluation he was also found to have high ESR (> 100 mm/hour) with positive Mantoux test (21 mm) and sputum was positive for AFB. A CXR and contrast-enhanced computer tomography scan of his chest revealed the focus of pulmonary TB; bronchoalveolar lavage for TB culture revealed growth of AFB, but GeneXpert did not reveal rifampicin resistance. His HIV status was negative and repeated blood sugar levels remained within normal range. Other basic investigations are given in Table . He was commenced on multibacillary leprosy treatment (dapsone 100 mg/day and clofazimine 50 mg/day and 300 mg/once a month) and subsequently added TB treatment (isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 800 mg/day, and pyrazinamide 1500 mg/day) for 6 months. At 6 months, his ESR came down, sputum was negative for AFB, and skin lesions and ulcers improved.
A 54-year-old Sinhalese man, an intravenous substance abuser, a tobacco smoker, and alcoholic, who was a garbage truck worker by occupation, with a close contact history of leprosy (his daughter), presented with leonine face and asymptomatic infiltrated papules and plaques over his earlobes of 5 months’ duration and hypopigmented hypoanesthetic patches all over his body for a similar duration (Fig. ). His skin smear and skin biopsy were compatible with borderline lepromatous leprosy. He had a normal BMI; a neurological examination was normal. He had received a BCG vaccination. He was commenced on multibacillary treatment for leprosy (dapsone 100 mg/day, clofazimine 50 mg/day and 300 mg/once a month and rifampicin 600 mg/month) with tailing-off of dose of prednisolone starting from 40 mg daily. Six months later, he presented with productive cough with nocturnal pyrexia; an evaluation revealed high ESR (130 mm/hour), CXR evidence of active pulmonary TB, and positive sputum smear for AFB. Immune function studies carried out to evaluate his immunodeficiency status did not reveal any congenital or acquired immunodeficiency conditions, including diabetes and HIV. Table gives the basic investigations. He was commenced on TB (isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 800 mg/day, and pyrazinamide 1500 mg/day) treatment. He defaulted treatment several times with regards to both leprosy and TB and later died due to TB. An autopsy was not performed.