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 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.