A 65-year-old non-hypertensive, non-diabetic man presented with history of left sided chest pain associated with productive cough and breathlessness for seven days. There was no history of fever, haemoptysis and exertional increase in breathlessness. The patient was referred to our teaching hospital from Green Pastures Hospital (GPH), a tertiary care referral centre for leprosy. The patient was treated for leprosy with WHO multidrug therapy for multibacillary leprosy. The patient was currently on treatment for ulnar neuritis with prednisolone 30 mg once a day for last three months. There was no past history of tuberculosis as per GPH records or information provided by the patient.\nClinical examination revealed numerous hypopigmented skin lesions varying in size from 2 to 10 centimeters over the trunk. The left ulnar nerve was thickened. There was dullness and decreased breath sounds in the left infrascapular and axillary areas.\nThe laboratory investigations revealed hemoglobin: 14.4 mg/dl; total leukocyte count: 19.5×103; erythrocyte sedimentation rate: 60 mm at the end of first hour; serum creatinine: 1.4 mg/dl; and random blood sugar: 91 mg/dl.\nOne out of three sputum samples tested was positive for acid fast bacilli and the chest radiograph showed loculated pleural effusion suggesting long standing pleural collection in left hemi thorax with infiltrations bilaterally, more on left side.\nA diagnosis of borderline leprosy with concomitant pulmonary tuberculosis was made. The patient was referred to DOTS clinic of our teaching hospital and started on category-I treatment according to the guidelines of national tuberculosis programme of Nepal. The oral prednisolone was subsequently tapered and stopped. The patient's general condition improved and was on regular follow up.
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.