A 50-year-old Sinhalese man with poorly controlled diabetes mellitus presented with facial infiltration (Fig. ) and erythematous painful nodules over his lower limbs and trunk suggestive of lepromatous leprosy with erythema nodosum leprosum. He was a manual laborer with low BMI. The rest of the general and neurological examination was normal. He had received a BCG vaccination. He did not smoke tobacco and drank alcohol occasionally. A skin biopsy revealed evidence of foamy macrophages with well-developed grenz zone. He was commenced on multidrug treatment-multibacillary treatment for leprosy (dapsone 100 mg/day, clofazimine 50 mg/day and 300 mg/once a month, and rifampicin 600 mg/month) with prednisolone 40 mg daily for type 2 reaction. Twelve months later he developed generalized lymphadenopathy with low-grade evening pyrexia and elevated ESR (80–100 mm/hour). Both Mantoux and QuantiFERON Gold test were positive. A CXR remained persistently normal. He was negative for HIV and diabetes. Basic investigations are given in Table . A lymph node excision biopsy revealed suppurative inflammation with focal foamy histiocytes; a TB culture from the lymph node biopsy later showed growth of AFB. GeneXpert did not reveal rifampicin resistance. Therefore, he was started on TB treatment (isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 800 mg/day, and pyrazinamide 1500 mg/day) by the respiratory physician for the treatment of extrapulmonary TB. At 6 months, he had improved clinically and biochemically.
A 50-year-old non-diabetic, non-hypertensive man who had completed treatment for lepromatous leprosy two years back, was admitted at Green Pastures Hospital for type-2 lepra reaction (erythema nodosum leprosum). There was a past history of lepra reactions for which he underwent treatment. Currently the patient was again being treated for the same with prednisolone 30 mg once daily, thalidomide 100 mg twice daily and clofazimine 50 mg once daily. However, information about initial screening of tuberculosis was not available.\nThe patient was referred to our teaching hospital with complaints of fever, productive cough and dyspnoea of three months duration. The patient also complained of pain and distension of abdomen and decreased appetite for three months.\nClinical examination revealed tense abdomen with shifting dullness, respiratory system with bilateral crackles with bronchial breath sounds predominantly in the left infra clavicular area, and skin showed no active lesions of erythema nodosum leprosum. The laboratory investigations revealed hemoglobin: 11.8 mg/dl; total leukocyte count: 5900/mm3; erythrocyte sedimentation rate: 110 mm in first hour; random blood sugar: 109 mg/dl; serum electrolytes, sodium: 135 meq/L and potassium: 3.2 meq/L.\nTwo out of three sputum samples were positive for acid fast bacilli. Chest radiograph showed multiple heterogeneous opacities in bilateral lung fields and a cavitary lesion in left upper zone. A diagnosis of pulmonary tuberculosis and provisional diagnosis of peritoneal tuberculosis were made.\nDermatologist's opinion was sought for the lepra reaction. The patient was advised to stop prednisolone as no active lesions persisted. He was subsequently referred to DOTS clinic and was started on category-I treatment.