A 49-year-old man, nonsmoker, was admitted to dermatology department and followed up for diffuse lepromatous leprosy. He was vaccinated with BCG and he had no past history of tuberculosis. Diagnosis of leprosy was documented based on histological and bacteriologic evidence: a slit skin smear from the ear lobe was positive for lepra bacilli (BI3+), histopathology from the lesion on the face showed granulomas consisting of epithelioid histiocytes and lymphocytes with central caseous surrounding vessels and nerves, and PCR of biopsy specimens were positive for Mycobacterium leprae. After successful treatment using dapsone (100 mg/day), rifampicin (600 mg/month), and clofazimine (300 mg/month and 50 mg/day) during twelve months, hypopigmented skin lesions on the trunk and congestive rhinitis disappeared and the slit skin smear was negative. One month after the end of the treatment, he presented with diffuse papulonodular lesions on the face and trunk, fever, and alteration of general status. On the basis of his symptoms, diagnosis of leprosy reaction (type II) was made and the patient was treated using prednisone at a dose of 40 mg/kg/day. Outcome was unfavorable after two months of corticotherapy, and we had to wait for two supplementary months before we could get clofazimine to add corticoid. After 1 month of this treatment, he presented with fever, weight loss, and asthenia. Clinical examination revealed fever of 39°C, nodular lesions over face, trunk, forearms, and dorsum of hands (Figures , , and ). He presented no neurologic impairment. Biological examination showed inflammatory syndrome: CRP 393 mg/L, total leukocyte count 16,2 × 109/L, neutrophilia 15,3 × 109/L, and lymphopenia 0,48 × 109/L. Serum creatinine and alanine aminotransferase were normal. HIV status was negative. Two out of three sputum samples were positive for acid fast bacilli. Chest tomography showed alveolar-interstitial opacities at the left lower lobe (). Bronchoscopy detected thickening of lower lobar bronchi, without malignancy in histopathology of biopsy specimens. The patient was treated by antitubercular treatment. One month after the onset of this treatment, there were only two nodular lesions on the trunk, fever disappeared, and general status improved.
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.