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 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.