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 65-year-old non-hypertensive, non-diabetic man presented with history of left sided chest pain associated with productive cough and breathlessness for seven days. There was no history of fever, haemoptysis and exertional increase in breathlessness. The patient was referred to our teaching hospital from Green Pastures Hospital (GPH), a tertiary care referral centre for leprosy. The patient was treated for leprosy with WHO multidrug therapy for multibacillary leprosy. The patient was currently on treatment for ulnar neuritis with prednisolone 30 mg once a day for last three months. There was no past history of tuberculosis as per GPH records or information provided by the patient.\nClinical examination revealed numerous hypopigmented skin lesions varying in size from 2 to 10 centimeters over the trunk. The left ulnar nerve was thickened. There was dullness and decreased breath sounds in the left infrascapular and axillary areas.\nThe laboratory investigations revealed hemoglobin: 14.4 mg/dl; total leukocyte count: 19.5×103; erythrocyte sedimentation rate: 60 mm at the end of first hour; serum creatinine: 1.4 mg/dl; and random blood sugar: 91 mg/dl.\nOne out of three sputum samples tested was positive for acid fast bacilli and the chest radiograph showed loculated pleural effusion suggesting long standing pleural collection in left hemi thorax with infiltrations bilaterally, more on left side.\nA diagnosis of borderline leprosy with concomitant pulmonary tuberculosis was made. The patient was referred to DOTS clinic of our teaching hospital and started on category-I treatment according to the guidelines of national tuberculosis programme of Nepal. The oral prednisolone was subsequently tapered and stopped. The patient's general condition improved and was on regular follow up.