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 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.