A 57-year-old Sinhalese woman presented to the dermatology unit of the National Hospital of Sri Lanka with extensive seborrheic dermatitis and tender facial induration (Fig. ) of 1-year duration. She was a homemaker from an urban area with poor social background. She did not have diabetes or hypertension. She had received a Bacillus Calmette–Guérin (BCG) vaccination. She did not smoke tobacco or drink alcohol. A skin biopsy taken from indurated facial plaque revealed evidence of borderline tuberculoid leprosy with type 1 reaction. She did not have hypopigmented anesthetic patches or thickened peripheral nerves in the rest of her body. She was commenced on multibacillary treatment for leprosy. A year later, she developed fever, loss of appetite, loss of weight, and widespread skin abscesses all over her body. Her body mass index (BMI) was within normal range and the rest of the general examination was normal. A respiratory examination revealed bilateral (B/L) coarse crepitations; a neurological examination was normal. Her erythrocyte sedimentation rate (ESR) remained persistently elevated at more than 120 mm/hour. She had inflammatory shadows in a chest X-ray (CXR). A sputum examination for AFB was positive and GeneXpert confirmed rifampicin resistance. At that time, she revealed a diagnosis of human immunodeficiency virus (HIV) infection and tuberculous lymphadenitis, which was made 5 years back, where she had taken 6-month TB treatment but had defaulted on antiretroviral therapy. During this presentation, her CD4+ count was 57/μL. The rest of the investigations are summarized in Table . There was no contact history of leprosy or TB. She was started on a multidrug treatment regime, which included intravenously administered kanamycin (15 mg/kg per day), orally administered ethambutol (800 mg/day), orally administered levofloxacin (750 mg/day), isoniazid (300 mg/day), orally administered ethionamide (500 mg/day), orally administered cycloserine (750 mg/day), and orally administered pyridoxine (10 mg/day). A repeated split skin smear was negative and she continued with multidrug treatment-multibacillary therapy (dapsone 100 mg/day and clofazimine 50 mg/day and 300 mg/once a month) for leprosy without rifampicin. Highly active antiretroviral treatment was restarted subsequently. At 6 months she had clinically, hematologically, and radiologically improved.
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.