A 29-year-old male, born to nonconsanguineous parents, presented with multiple skin coloured nodules and hyperkeratotic scaly lesions of 3-month duration. He initially developed asymptomatic skin coloured raised lesions over both the ear lobes. Over the next 2 months he developed multiple similar lesions over the trunk and both the extremities. He also gave history of generalised burning sensation for 15-day duration with low grade fever. There was no history of burning sensation in the eyes, nasal stuffiness, and sensory or motor weakness. The patient denied any drug intake, fever, myalgia, spontaneous blistering or ulceration, neuritic pain, and testicular pain. None of the family members or neighbours had suffered from leprosy. He denied any past history of infectious diseases but there was no history of immunization including Bacillus Calmette et Guérin (BCG) vaccination. He was a chronic alcoholic.\nHis general physical examination was normal with no madarosis or lymphadenopathy. Cutaneous examination revealed multiple, soft, succulent, nontender, skin coloured superficial nodules present bilaterally on the forehead, cheeks, ear lobes, forearms, back, and chest with sparing of palms and soles (). The surface of these nodules showed follicular plugging. Multiple verrucous plaques were seen over the right ankle (). Skin surrounding the plaques was erythematous. Neurological examination revealed thickened bilateral greater auricular, right common peroneal nerve, and tender left posterior tibial nerve. The rest of the musculoskeletal and neurological examination was normal. Routine haematological and biochemical investigations including urine, renal, and liver function test revealed no abnormality. His retroviral serology was negative. Chest X-ray was normal. Slit skin smear from the lesion showed a bacteriological index (BI) of 5+ and the perilesional skin had a BI of 2+.\nHistopathological examination of the wedge biopsy done from the forearm and back nodules revealed sheets of histiocytes aggregates along with lymphocytes and few polymorphs in perivascular and periadnexal location (Figures and ). There was collection of epithelioid cells (). Fite Faraco stain was strongly positive (). A diagnosis of borderline lepromatous leprosy with type 2 reaction was made.\nA wedge biopsy from the verrucous lesion on the right ankle was taken. Epidermis showed hyperkeratosis and parakeratosis with irregular acanthosis (). Dermis showed epithelioid cell granulomas along with lymphocytes and plasma cells (Figures and ). Zeihl-Neelsen stain for acid fast bacilli was positive (). GeneXpert MTB/RIF test based on Nucleic Acid Amplification, which detects MTB-specific region of the rpoB gene and uses real time-PCR (RT-PCR), was done on skin biopsy specimen. The result was positive. However, a culture was not done. Based on clinical and histopathological findings, a diagnosis of tuberculosis verrucosa cutis (TVC) was made.\nThe patient was treated with rifampicin, isoniazid, pyrazinamide, and ethambutol, in addition to dapsone and clofazimine along with a monthly supervised dose of clofazimine and rifampicin for first 2 months. Then rifampicin and isoniazid with dapsone and clofazimine were continued for further 4 months. After 6 months, treatment of leprosy was continued as for multibacillary leprosy. Type 2 reaction was treated with oral anti-inflammatory drugs. The patient tolerated the drugs well with control of type 2 reaction and regression of the TVC lesion.
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.