A 19-year-old male, on treatment for MDR-TB, presented with complaints of localized swelling over face, reddish discoloration of limbs, and hypopigmented patches over body since 1 month. He was on Category IV directly observed treatment, short-course chemotherapy for the last 5½ months on the basis of sputum line probe assay report from Revised National Tuberculosis Control Program (RNTCP) accredited laboratory, which showed M. tuberculosis isolates, resistant to drugs isoniazid and rifampicin. The patient was taking kanamycin, ethionamide, pyrazinamide, ethambutol, levofloxacin, and cycloserine regularly. There was a history of leprosy 6 years back, for which the patient was treated for 6 months. The patient had a history of TB 5 years back which was treated with 9 months of daily regimen antitubercular therapy. Clinical examination revealed hypopigmented, dry, scaly plaque over upper arms [], hypoanesthetic plaque over right palm [], and erythematous plaque over right side cheek and nose []. Respiratory system examination revealed bilateral infraclavicular crepts.\nRoutine investigations were normal. Chest radiograph was suggestive of fibrotic lesions, bilateral upper lobes []. Sputum culture from RNTCP accredited laboratory at 4th month was positive for growth of M. tuberculosis.\nDermatology review was taken for skin lesions. The patient was diagnosed as multibacillary (MB) leprosy and started on multidrug therapy regimen (MB-MDT) consisting of rifampicin 600 mg once monthly, dapsone 100 mg daily, and clofazimine 300 mg once monthly and 50 mg daily. Biopsy of skin lesions was suggestive of mid-borderline leprosy. Two weeks later, the patient presented with increased erythema and pain over the skin lesions and appearance of new lesions []. The patient was diagnosed with Type I lepra reaction and started on analgesics and steroids (prednisolone). Prednisolone was given in the dose of 30 mg/day orally for the first 2 weeks and then gradually tapered over the next 4 weeks. It was thus stopped after a total duration of 6 weeks. MB-MDT was continued as per the National Leprosy Eradication Programme guidelines.\nThus, final diagnosis of MDR-TB with mid-borderline leprosy and Type I lepra reaction was made. Skin lesions markedly improved with treatment []. Patient's subsequent sputum cultures were negative and MDR-TB was thereafter managed as per the RNTCP guidelines.
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.