A 47-year-old Tamil woman with poorly controlled long-standing diabetes mellitus presented with facial infiltration, multiple ichthyotic patches, and peripheral neuropathy associated with Charcot joints and trophic ulcers (Fig. ). She was a homemaker with poor social background and there was no contact history of TB or leprosy. She did not smoke tobacco or drink alcohol. She had received a BCG vaccination. She had a low BMI and a respiratory examination revealed B/L coarse crepitations. There was no peripheral neuropathy. A clinical diagnosis of lepromatous leprosy was made which was later confirmed with histology and slit-skin smears: bacteriological index (BI) of 5; morphological index (MI) of 2%. Initial investigations revealed persistently elevated ESR (100–122 mm/hour) and inflammatory shadows in a CXR. Two consecutive sputum smears were positive for AFB and the result of a Mantoux test was positive (18 mm). Her liver and renal functions were normal (Table ). She was negative for HIV screening. She was commenced on both TB (isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 800 mg/day, and pyrazinamide 1500 mg/day) and multibacillary leprosy treatment (dapsone 100 mg/day and clofazimine 50 mg/day and 300 mg/once a month) without a monthly loading dose of rifampicin. She had poor compliance and defaulted treatment several times and ultimately succumbed to the illness. An autopsy was not performed.
A 54-year-old Sinhalese man, an intravenous substance abuser, a tobacco smoker, and alcoholic, who was a garbage truck worker by occupation, with a close contact history of leprosy (his daughter), presented with leonine face and asymptomatic infiltrated papules and plaques over his earlobes of 5 months’ duration and hypopigmented hypoanesthetic patches all over his body for a similar duration (Fig. ). His skin smear and skin biopsy were compatible with borderline lepromatous leprosy. He had a normal BMI; a neurological examination was normal. He had received a BCG vaccination. He was commenced on multibacillary treatment for leprosy (dapsone 100 mg/day, clofazimine 50 mg/day and 300 mg/once a month and rifampicin 600 mg/month) with tailing-off of dose of prednisolone starting from 40 mg daily. Six months later, he presented with productive cough with nocturnal pyrexia; an evaluation revealed high ESR (130 mm/hour), CXR evidence of active pulmonary TB, and positive sputum smear for AFB. Immune function studies carried out to evaluate his immunodeficiency status did not reveal any congenital or acquired immunodeficiency conditions, including diabetes and HIV. Table gives the basic investigations. He was commenced on TB (isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 800 mg/day, and pyrazinamide 1500 mg/day) treatment. He defaulted treatment several times with regards to both leprosy and TB and later died due to TB. An autopsy was not performed.